Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kearny Mesa Convalescent And Nursing Home during CMS and state inspections, most recent first.
A resident admitted with anxiety did not receive a prescribed pregabalin dose and later found medications on the floor after a 9 p.m. medication pass. An LN reported dropping the resident’s prepared medications, being unable to locate them, and then re-preparing the medications but omitting pregabalin. The DON later noted that the LN should have verified the orders and searched for the dropped medications. Facility policy requires medications to be administered in accordance with prescriber orders.
A resident with intact cognition and a diagnosis of acute pyelonephritis had a POLST and MDS assessment indicating DNR status, but the care plan continued to list Full Code. Staff confirmed the care plan was not updated to match the resident's documented wishes.
A resident with chronic heart failure was admitted with a hospital recommendation to continue CPAP therapy, but the facility did not obtain physician orders for the device until several weeks later. The resident's care plan and records did not reflect CPAP use, and staff were unaware of the missing orders, resulting in a lack of appropriate monitoring and documentation.
A resident with chronic heart failure had their CPAP equipment improperly stored on multiple occasions, with the mask found on the bed, behind the bed, and on the floor, and no storage bag provided. Nursing staff interviews revealed inconsistent practices and a lack of adherence to protocols for cleaning and storing respiratory equipment.
A resident with hydronephrosis and osteomyelitis was left outside an IR clinic in cold weather for nearly an hour due to the facility's failure to verify the necessity of an appointment. Despite the catheter being removed and no further treatment needed, staff did not confirm the appointment, resulting in unnecessary transportation costs for the family. The resident had moderate cognitive impairment and was dependent on daily living activities.
A resident with Alzheimer's and dementia, who exhibited wandering behavior, entered another resident's room and caused an altercation. The facility failed to conduct a wandering assessment for the resident, despite known behavioral issues, leading to inadequate supervision and the incident.
Missed Pregabalin Dose and Unattended Medications Left on Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered and that unattended medications were not accessible to residents. Resident 1, admitted with diagnoses including anxiety, had no progress notes documented on 3/11/26. On the following day at 9:45 A.M., the DON documented in a progress note that during a bedside visit, the resident handed over two capsules the resident stated were pregabalin and gabapentin. The facility’s controlled drug record for pregabalin showed one dose signed out as given at 9 P.M. on 3/11/26, with no additional doses removed from the package that night. During an interview, Resident 1 reported finding medications on the floor one morning and realizing that not all medications from the previous night had been taken. In a later telephone interview, LN 2 stated that on 3/11/26 she prepared the 9 P.M. medications for the resident, dropped the medications on the floor, and was unable to find them. LN 2 reported that she then re-prepared the medications but forgot to include pregabalin, resulting in that medication not being administered. LN 2 also stated she should have asked for help locating the dropped medications. In a separate interview, the DON stated that LN 2 should have double-checked the medication orders before administration and should have searched for the dropped medications. The facility’s “Administering Medications” policy states that medications are to be administered in accordance with prescriber orders.
Care Plan Not Updated to Reflect Resident's DNR Status
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised to accurately reflect the resident's code status as documented in the comprehensive assessment and the Physician Orders for Life-Sustaining Treatment (POLST). The resident, who was admitted with a primary diagnosis of acute pyelonephritis and demonstrated intact cognition, had a POLST form and MDS assessment indicating a Do Not Attempt Resuscitation (DNR) status. However, the care plan intervention continued to list the resident as Full Code, which was inconsistent with the resident's expressed wishes and documented orders. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that the care plan should have been updated to match the resident's current POLST. The discrepancy was identified during a review of the resident's records, and staff acknowledged that the care plan did not reflect the resident's actual code status as required by facility policy and assessment findings.
Failure to Obtain Timely Orders for CPAP Use
Penalty
Summary
The facility failed to obtain timely physician orders for the use of a non-invasive mechanical ventilator (CPAP) for a resident with a history of chronic diastolic congestive heart failure. Upon admission, the resident's hospital discharge records indicated the need to continue CPAP therapy, but there was no evidence of a physician order for the CPAP machine from the time of admission until several weeks later. The resident's care plan and Minimum Data Set did not reflect the use of a CPAP machine, and the medication and treatment administration records showed no related orders during this period. Observations revealed the presence of a CPAP machine in the resident's room, and the resident reported using the device for years, though not in the days prior to the survey. Nursing staff were unaware of the absence of orders for the CPAP and did not consistently monitor or assist with its use. The DON confirmed that orders for CPAP use, including settings and equipment care, were required but had not been obtained at admission. The administrator acknowledged the need for communication among staff and medical providers to confirm respiratory equipment orders.
Failure to Ensure Proper Storage of CPAP Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment, specifically a CPAP machine, for a resident with chronic diastolic congestive heart failure. Observations over several days revealed that the CPAP mask and tubing were not stored appropriately when not in use. The mask was found on the bed above a pillow, hanging down behind the bed, and on the floor at the head of the bed. The humidifier chamber was observed to be full of water, and there was no designated bag or container for storing the mask. The resident confirmed long-term use of the CPAP machine. Interviews with nursing staff indicated a lack of consistent protocol for the storage and handling of CPAP equipment. One LVN acknowledged that the mask should be stored in a bag, but none was available. Another LVN described her role as limited to assisting with water refills and mask application, with no further involvement in equipment storage. The administrator confirmed that staff were expected to follow appropriate protocols for cleaning and storing CPAP equipment, which was not observed in practice.
Failure to Verify Appointment Leads to Resident Left in Cold
Penalty
Summary
The facility failed to perform an abdominal assessment and verify a resident's appointment before sending them to an Interventional Radiology (IR) clinic. This oversight resulted in the resident being left outside the clinic in cold weather for nearly an hour, despite not needing to be seen at the clinic. The resident, who was admitted with conditions including hydronephrosis and osteomyelitis, had previously undergone an IR drainage procedure, and the catheter was removed. The family member of the resident reported that the appointment was unnecessary, and they had to pay for the transportation to the clinic. Interviews with facility staff revealed a lack of verification of the resident's appointment. Licensed nurses and the unit clerk were responsible for verifying orders, scheduling appointments, and arranging transportation, but failed to confirm the necessity of the appointment with the IR clinic. The Director of Nursing acknowledged the oversight, and the resident's family was upset about the unnecessary transportation cost. The resident's medical records indicated moderate cognitive impairment and dependency on activities of daily living, with no current treatment needed for the resolved drain site.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision for a resident with wandering behavior, leading to an altercation with another resident. Resident 1, who has chronic pain syndrome and uses a wheelchair, was involved in an incident where Resident 2, diagnosed with Alzheimer's disease and dementia, entered Resident 1's room and hit her on the back of the head. Resident 1 reported the incident to the staff, who then separated the two residents and informed the licensed nurses. Resident 2's Minimum Data Set (MDS) indicated a BIMS score of 8, showing severe cognitive impairment, and noted wandering episodes and resistance to care. Despite these behaviors, the facility did not conduct a wandering assessment for Resident 2, as they were not exhibiting exit-seeking behaviors upon admission. The Director of Nursing acknowledged Resident 2's behavioral issues, including grabbing cookies from other residents, and mentioned that a behavior care plan was initiated. However, the lack of a wandering assessment and adequate supervision contributed to the incident with Resident 1.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Diego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Helen Bernardy Center D/p Snf | 1.2 mi | ★★★★★ | 8 | 0 |
| The Shores Post-acute | 1.3 mi | ★★★★★ | 6 | 0 |
| Hillcrest Heights Healthcare Center | 3.5 mi | ★★★★★ | 1 | 0 |
| Mission Hills Post Acute Care | 3.8 mi | ★★★★★ | 0 | 0 |
| Balboa Nursing & Rehabilitation Center | 4.1 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.