Barton Memorial Hospital
An acute care hospital in South Lake Tahoe, California 96150
2170 South Avenue, South Lake Tahoe, California 96150. (530) 541-3000.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 4of 5 patient survey rating
- 1 deficiency cited in the last three years
- 64 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Nov 7, 2024: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Nov 2024. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Nov 7, 2024: complaint inspection1 deficiency
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Patient Care Assignments
The inspectors’ words, 827 words
“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 44780 Based on interview and record review, the facility failed to ensure the nursing staff had proper training and competency to safely provide nursing services in accordance with standards of practice and facility policy for 1 of 20 patients (Patient 1) when: 1. Registered Nurse (RN)1, RN 2, and RN 3 lacked the specialized training and competency necessary to provide safe and competent care to Patient 1 who was on peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of abdomen, or belly, to filter blood); 2. RN 2 accessed Patient 1’s PD catheter (a tube that extends from the skin into the abdominal cavity and peritoneal membrane to perform PD) to collect fluid sample without any training and competency; and 3. RN 2 failed to follow the facility’s chain of command when she followed the Doctor’s order to collect fluid sample from Patient 1’s PD catheter and RN 2 was aware that she did not have the specialized training to carry out the Doctor’s order. These failures resulted in Patient 1 not receiving safe treatment and care leading to potential compromised patient outcomes. Findings: A review of Patient 1’s “ED [Emergency Department] notes”, dated 8/28/24, indicated Patient 1 had history including kidney failure and was on PD. Patient 1 came to the ED with chief complaint of abdominal pain. ED notes indicated that MD (Medical Doctor) 2 ordered “Fluid Culture w/Gram Stain [laboratory test that identifies bacteria in a fluid sample and determines the type of bacteria causing an infection]” to be collected from PD catheter on 8/28/24 at 8:46 a.m. 1. During an interview with RN 3 on 11/5/24 at 2:55 p.m., RN 3 stated that she had not received training on accessing PD catheters or collecting fluid sample from the catheters. During an interview with Emergency Department Director (EDD) on 11/6/24 at 10:00 a.m., EDD stated that if RN’s had order to obtain PD fluid sample, they cannot do it as they are not trained to do it. During an interview with RN 1 on 11/5/24 at 2:55 p.m., RN 1 stated that “ ...no official training, usually doctors do that, they draw specimen, and we assist. Doctor’s draw specimen off catheters, it’s a team effort ...” During review of personnel file for RN 1, RN 2, and RN 3 with Director Human Resources (DHR) on 11/6/24 at 11:15 a.m., there was no documented evidence of competencies for dialysis care. 2. During an interview with RN 2 on 11/7/24 at 9:15 a.m., RN 2 stated, “ .... yes, I collected the sample” and “ No, not trained on collecting specimen...” RN 2 further stated that she asked MD 2 to do it, he said, “No, you get the specimen”. RN 2 further stated that “we were too busy to ask help from charge nurse ...” 3. During a joint interview with Chief Nursing Officer (CNO) and EDD on 11/7/24 at 9:50 a.m., EDD stated that, “ ...we do not get dialysis patients, we have no policy related to dialysis... Nurses are not trained, and we transfer those patients.” EDD further stated that, “For chain of command, if nurses had concerns, nursing supervisor is available 24/7 [24 hours, 7 days a week], house supervisor and Charge Nurse (CN) are also available. Leadership takes calls everyday ...At that point, nurse should have gone to CN and CN could have talk to [the] Physician. If does not work, then CN could have gone to Supervisor or EDD.” A review of facility documented titled, “Job Description- Registered Nurse ER”, revised 7/2021, indicated, “ ...The Emergency Department Staff Nurse provides professional nursing care to patients within the Emergency department, utilizing established policies and procedures, ensuring safe and effective care ... Essential functions- Recognizes unusual conditions outside of his/her expertise and seeks guidance of coworkers or supervisors ...” A review of a facility policy titled, “ Chain of Command for Patients Safety/Quality of Care Concerns” approved 5/25/22, indicated, “Purpose: To establish an organized process and procedure to address concerns related to patient care ...Any employee who identifies a problem with regard to patient care and is unable to reconcile it with the attending physician or nurse supervisor/manager/director should present the issue to successively higher levels of authority within the organization’s chain of command until a satisfactory resolution is achieved ...Policy: [The Hospital] is committed to providing safe, quality patient care and to the timely resolution of quality of care and patient safety/potential harm concerns. All staff are responsible for ensuring that patients receive quality care at all times and should implement the chain of command procedure to address issues where quality of care or safety/harm of a patient is at question ...””
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Nov 7, 2024 | Complaint inspection | 1 deficiency cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 3 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 3; safety of care, 0 better and 0 worse of 2; readmission, 1 better and 1 worse of 5.
- Patients rate it 4 of 5 in CMS’s patient survey (366 surveys completed, Oct 1, 2024 to Sep 30, 2025): 79% rated it 9 or 10 out of 10, and 78% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): C. diff infections, no different than national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart failure 11.7%, pneumonia 13.7%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart failure 21.5%, pneumonia 17.3%, COPD 19.2%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 132 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 1% left before being seen.
- 66% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.87 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 3 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 4 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Jul 15, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Jul 15, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 4 of 5.
- 67% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Barton Healthcare System owns 100% directly since Dec 2, 2005.
- 7 owners or officers are people: Abby Killebrew (corporate director); Kelly Neiger (corporate officer); Kelly Neiger (runs it (operational or managerial control)); Clinton D Purvance (corporate officer); Clinton D Purvance (runs it (operational or managerial control)); Charles Scharer (corporate director); Kirk Ledbetter (corporate director).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Jul 15, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Barton Healthcare System | Owns 5% or more directly | 100% | Dec 2, 2005 |
How does it compare nearby?
- Of the 2 hospitals CMS lists in El Dorado County, 2 have an overall star rating from CMS: 1 rated 4 of 5, 1 rated 3 of 5.
- CMS rates this one 3 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Marshall Medical Center | 4 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Oct 27, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q2_2026.csv).
Released Jul 15, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.