Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 La Jolla Post-acute during CMS and state inspections, most recent first.
Facility staff failed to keep the dumpster area clean and the dumpster lid closed, resulting in overflowing trash and debris scattered on the ground. Multiple staff interviews confirmed that the area was not maintained according to facility policy, potentially affecting all residents.
Quarterly MDS assessments were not completed or signed for ten residents with complex medical conditions, including those with COPD, heart failure, diabetes, and chronic kidney disease. Facility staff, including MDS Coordinators, the DON, and the ED, confirmed that these assessments were overdue and not submitted as required by policy and federal guidelines.
A resident with type 2 diabetes and chronic kidney disease did not have their annual MDS assessment completed or submitted within the required timeframe. Facility staff, including MDS Coordinators, the DON, and the ED, confirmed the assessment was overdue and not transmitted, contrary to facility policy and CMS requirements.
The facility did not ensure accurate MDS assessments for two residents. One resident's MDS failed to reflect a positive Level II PASARR status despite relevant diagnoses, while another resident's MDS did not document ongoing dialysis and tube feeding, even though these were present in the care plan and physician orders. Staff interviews confirmed these omissions.
The facility did not resubmit a required Level I PASRR screening for a resident with multiple mental health diagnoses who remained in the facility beyond 30 days, and failed to ensure the accuracy of a Level I PASRR screening for another resident with depression and schizophrenia. Staff interviews confirmed that the required processes for timely resubmission and accuracy review were not followed.
A deficiency was identified when a bubble pack card containing desmopressin tablets with a resident's name was found on the ground near the dumpster, rather than being destroyed according to facility policy. Staff interviews confirmed that medications should be disposed of in a designated destruction receptacle, not outside, and that the observed method did not follow established procedures.
Surveyors observed that two residents had medications left at their bedside without physician orders or care plans authorizing self-administration. One resident with intact cognition had an albuterol inhaler, Coricidin D, and a calcium supplement at the bedside, while another resident with moderate cognitive impairment had Coricidin HBP on the overbed table without a physician's order. Staff interviews confirmed that medications should not be left at the bedside unless specifically ordered and care planned, which was not done in these instances.
A facility failed to correctly document a resident's POLST, leading to an incorrect change from full code to DNR status. The error was acknowledged by staff during interviews, highlighting the importance of accurate documentation to honor residents' wishes.
The facility failed to securely store medications for three residents, leaving them at the bedside, which was confirmed through observations and interviews with the residents and staff. The DON and LN acknowledged that this practice could lead to adverse medication reactions or incorrect self-administration.
The facility failed to ensure that a resident's routine thyroid medication, levothyroxine, was consistently available and administered as prescribed. The resident did not receive her medication for four days, despite it being delivered to the facility. The DON acknowledged the medication should have been available and administered as ordered.
A resident with quadriplegia was not provided with a physician-prescribed condom catheter due to expired supplies, leading to the use of an indwelling catheter that was improperly inserted, causing pain and bleeding. The facility lacked a care plan for catheter use and did not conduct competency reviews or in-service training for staff on catheter insertion and care.
A facility failed to ensure nursing competency in catheter insertion, leading to improper insertion and subsequent bleeding in a resident. The nurse involved had not received adequate training or competency assessments upon hire or annually, as required by the facility's policy.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
The facility failed to maintain a clean and sanitary dumpster area as required by its own Environmental Maintenance - Grounds Maintenance policy. Observations on multiple days revealed that the dumpster lid was left open, the dumpster was overflowing with garbage bags, and various items such as disposable gloves, aluminum foil, food packaging, and empty boxes were scattered on the ground around the dumpster. The dumpster lid could not be closed due to the volume of trash, and the area was not kept free of debris as specified in facility policy. Interviews with facility staff, including the Dietary Manager, Director of Environmental Services, Registered Dietician, Executive Director, and Director of Nursing, confirmed that the expectation was for the dumpster area to be clean and the lid to be closed at all times. Staff acknowledged responsibility for maintaining the area and agreed that the observed conditions did not meet facility standards. This deficiency had the potential to affect all 140 residents residing in the facility.
Failure to Complete and Sign Quarterly MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete and sign quarterly Minimum Data Set (MDS) assessments for 10 out of 11 sampled residents, as required by federal regulations and the facility's own policy. The MDS assessments, which are mandated to be completed at least every 92 days and signed within 14 days after the Assessment Reference Date (ARD), were found to be unsigned and incomplete for multiple residents. This was confirmed through record review, document review, and interviews with facility staff. The residents affected had a range of significant medical conditions, including chronic obstructive pulmonary disease, atherosclerotic heart disease, heart failure, acute respiratory failure, type 2 diabetes mellitus with foot ulcer, essential hypertension, age-related osteoporosis, chronic kidney disease, hypertensive chronic kidney disease, anemia, and hypothyroidism. Admission records for each resident detailed their medical histories, and the corresponding quarterly MDS assessments with specific ARDs were found to be incomplete, lacking required signatures and dates to indicate completion. During interviews, both MDS Coordinators acknowledged that several MDS assessments had not been submitted and were considered late, confirming that the facility's expectation was for all assessments to be completed and submitted on time. The DON and Executive Director also stated their expectations that MDS assessments be completed and transmitted within the required timeframes, but acknowledged that this had not occurred for the residents in question.
Failure to Complete and Submit Annual MDS Assessment
Penalty
Summary
The facility failed to complete and submit an annual Minimum Data Set (MDS) assessment for one resident as required by federal regulations and facility policy. The policy and CMS guidelines specify that an annual MDS must be completed at least every 366 days, with the assessment reference date (ARD) set within this timeframe and the MDS finalized no later than 14 days after the ARD. For the resident in question, who had a medical history including type 2 diabetes and chronic kidney disease, the annual MDS with an ARD of 03/05/2025 was not signed or dated to indicate completion, and it had not been submitted as of the time of the survey. Interviews with the MDS Coordinators confirmed that the assessment was overdue and had not been transmitted, which was acknowledged as not meeting the facility's expectations for timely completion. The DON and Executive Director both stated that their expectation was for all MDS assessments to be completed and submitted within the required timeframes, but this did not occur for the resident identified in the sample.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents. For one resident with a history of schizoaffective disorder and anxiety disorder, the annual MDS did not accurately reflect the resident's positive Level II PASARR status, despite the resident having active diagnoses of anxiety disorder and schizophrenia. MDS coordinators confirmed during interviews that the resident's PASARR status should have been indicated on the MDS. For another resident with end stage renal disease, dependence on renal dialysis, dysphagia, and a gastrostomy, the quarterly MDS failed to document the presence of a feeding tube and dialysis treatment, even though the care plan and physician orders indicated the resident was receiving both tube feeding and dialysis. Interviews with the MDS coordinators, DON, and Executive Director confirmed that these treatments should have been coded on the resident's MDS. The facility's policy requires accurate coding and assessment as per CMS RAI MDS 3.0 Manual guidelines.
Failure to Timely Resubmit and Accurately Complete PASRR Screenings
Penalty
Summary
The facility failed to ensure compliance with PASRR (Preadmission Screening and Resident Review) requirements for residents with mental disorders or intellectual disabilities. For one resident with a history of bipolar disorder, schizoaffective disorder, anxiety disorder, major depressive disorder, and post-traumatic stress disorder, the facility did not resubmit a new Level I PASRR screening after the resident remained in the facility beyond 30 days, as required. The omission was confirmed by the MDS Coordinators, who acknowledged that the process for resubmission was not followed and the required screening was not completed within the specified timeframe. Both the Director of Nursing and the Executive Director stated their expectation that the Level I be resubmitted within the required period, but this did not occur. Additionally, for another resident with diagnoses of depression and schizophrenia, the facility failed to ensure the accuracy of the Level I PASRR screening. The resident's medical record and care plan documented active diagnoses of depression and schizophrenia, but the Level I screening incorrectly indicated the absence of serious mental disorders. The MDS Coordinator admitted the screening was inaccurate and should have been reviewed for correctness. The Director of Nursing and Executive Director both stated that it was their expectation for the Level I screening to be accurate and resubmitted if found to be incorrect, but this was not done.
Improper Disposal of Resident Medication Observed
Penalty
Summary
A deficiency occurred when the facility failed to properly dispose of medication for one resident. Facility policy required that discontinued medications and those left after a resident's discharge be destroyed in accordance with federal and state regulations, including the removal and shredding of identifying information and destruction of the medication in a designated receptacle. However, during an observation, a bubble pack card containing four desmopressin tablets with a resident's name was found on the ground near the facility's dumpster. Multiple staff interviews confirmed that medications should not be disposed of in this manner and should instead be placed in a destruction bucket or discard bin within the medication room. The resident involved had a diagnosis of overactive bladder and was cognitively intact, as indicated by a BIMS score of 13. The medication in question was an active order for desmopressin acetate tablets. Staff, including the Dietary Manager, RN, DON, and Executive Director, all acknowledged that the observed disposal method did not align with facility policy or safe medication destruction practices. The improper disposal was directly observed by surveyors and confirmed through staff interviews.
Medications Improperly Left at Bedside Without Orders or Care Plan
Penalty
Summary
Surveyors found that the facility failed to ensure medications and biologicals were not left at the bedside for two residents. For one resident with a history of protein-calorie malnutrition and bone disorders, medications including an albuterol inhaler, Coricidin D, and a calcium supplement were observed at the bedside. This resident had intact cognition but did not have a care plan or physician's order permitting self-administration of medications. Staff interviews confirmed that the resident was not authorized to self-administer and that medications should have been stored in the medication cart. For another resident with congestive heart failure and moderate cognitive impairment, Coricidin HBP was found on the overbed table without a physician's order. The resident stated they were waiting for physician approval for the medication. There was no care plan or order for self-administration. Multiple staff, including RNs, the Director of Staff Development, the Executive Director, and the DON, confirmed that medications should not be left at the bedside unless specifically care planned and ordered, and that this protocol was not followed in these cases.
Incorrect Documentation of POLST Leads to DNR Status Error
Penalty
Summary
The facility failed to ensure that the POLST (Physician Orders for Life-Sustaining Treatment) was correctly documented in a resident's medical record. This resulted in a change from a full code status to a Do Not Resuscitate (DNR) status, contrary to the resident's documented wishes. The resident was admitted with multiple fractures of the pelvis, and the POLST form, signed by the resident's wife and the physician, indicated a preference for full resuscitation and treatment. However, an order summary report showed a change to DNR status, which was acknowledged as incorrect by the facility staff. During interviews, a licensed nurse confirmed that the full code status was ordered according to the POLST form, but the DNR status was entered incorrectly during an audit process. The Director of Nursing and the Administrator emphasized the importance of accurately entering code status to honor residents' wishes. The facility's policy on self-determination and advanced healthcare directives underscores the necessity of providing care in accordance with residents' preferences, which was not adhered to in this instance.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure that medications for three residents were stored securely. Resident 1's medications were observed at the bedside, and both Resident 2 and Resident 3 reported that their medications were left at their bedsides. These actions were confirmed through observations and interviews with the residents and staff. Resident 1 had four pills left on the bedside table, including atorvastatin, which was supposed to be administered at night. Resident 3 stated that her morning thyroid medication was often left at her bedside for her to take later. Resident 2 also reported that her morning medications were sometimes left on her bedside table. During an interview, the Licensed Nurse (LN) confirmed that medications should not be left unsecured at the bedside, as this could lead to double dosing or missed doses. The Director of Nursing (DON) also stated that medications should not be left unattended at the residents' bedsides, as this could result in adverse medication reactions or incorrect self-administration. A review of the facility's policy on medication storage indicated that medications and biologicals should be stored safely, securely, and properly.
Failure to Administer Thyroid Medication Consistently
Penalty
Summary
The facility failed to ensure that Resident 3's routine thyroid medication, levothyroxine, was consistently available and administered as prescribed. Resident 3, who was admitted with a diagnosis of hypothyroidism, had a physician's order to receive levothyroxine 125 micrograms, two tablets daily at 6:30 A.M. However, during the first week of April 2024, Resident 3 did not receive her medication for four days. This was confirmed by both Resident 3 and Licensed Nurse (LN) 5, who admitted that the medication was unavailable and mistakenly documented that it had been administered on one of those days. The pharmacy records indicated that the medication had been delivered to the facility, but it was not available for administration when needed. The Director of Nursing (DON) acknowledged that Resident 3's medication should have been available and administered as ordered. A review of the facility's policy on medication orders, updated in August 2019, did not provide guidance related to the availability of medications and their administration as ordered. This lack of guidance contributed to the failure in ensuring that Resident 3 received her prescribed medication consistently, as required for her condition.
Failure to Provide Prescribed Condom Catheter and Improper Indwelling Catheter Insertion
Penalty
Summary
The facility failed to supply a physician-prescribed condom catheter for a resident with quadriplegia, leading to the inappropriate use of an indwelling catheter. Upon admission, the resident was informed that the facility's supply of condom catheters was expired, and a new order would take about a week to arrive. In the interim, the resident was placed in incontinence briefs, which led to skin irritation and redness. The resident eventually agreed to the insertion of an indwelling catheter, which was improperly placed, causing pain and bleeding upon removal. The resident was subsequently sent to the hospital for evaluation and returned with a condom catheter and additional supplies. The clinical record review revealed that the resident had a cognitive score indicating intact cognition and was dependent on staff for transfers and personal care. The facility's documentation showed no evidence of a care plan for the use of either indwelling or condom catheters. Additionally, there was no documented evidence of a physician's order for discontinuing the urinary catheter. Interviews with staff indicated a lack of competency reviews and in-service training related to urinary catheter insertion and care. The Licensed Nurse who inserted the catheter had not received any skills or performance checks upon hire and had limited experience with catheter insertion since graduating from nursing school in 2021. The central supply staff confirmed that the appropriate size of condom catheters was not available at the time of the resident's admission and that alternative arrangements, such as obtaining supplies from sister facilities or ordering them urgently, were not pursued. The facility's policy on catheter insertion and removal was not followed, as the Licensed Nurse encountered resistance while inflating the balloon but did not take appropriate corrective actions. The resident expressed significant distress and fear of future catheterizations due to the traumatic experience. The facility's failure to provide the prescribed condom catheter and the improper insertion of the indwelling catheter resulted in physical harm and emotional distress for the resident.
Failure to Ensure Nursing Competency in Catheter Insertion
Penalty
Summary
The facility failed to ensure that staff were competent upon hire for licensed nursing skills, specifically the insertion of a urinary catheter. This deficiency was identified during an unannounced visit in response to a complaint. The Director of Staff Development (DSD) admitted that no documented evidence of urinary catheter care training was provided to licensed nurses, and no annual competence skills evaluations had been conducted since she took over the position. The employee file of the nurse involved in the incident showed incomplete performance evaluations with no documented evidence of skills assessment by a supervisor or evaluator. The nurse confirmed that she had not received any in-service training related to urinary catheter insertion or care at the facility and had only performed the procedure a few times since nursing school. As a result of this lack of competency assessment and training, an indwelling urinary catheter was improperly inserted into a resident, causing bleeding when the catheter was removed the following day. The Assistant Director of Nursing (ADON) emphasized the importance of competency assessments upon hire and annually to identify staff strengths and weaknesses and ensure adherence to current nursing standards. The facility's policy on competency evaluations, dated October 2022, outlined the procedures for initial and annual competency assessments, but these were not followed in this case.
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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 La Jolla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Cove At La Jolla | 1.6 mi | ★★★★★ | 0 | 0 |
| The Springs At Pacific Regent | 2.1 mi | ★★★★★ | 0 | 0 |
| Vi At La Jolla Village | 2.1 mi | ★★★★★ | 22 | 0 |
| Kearny Mesa Convalescent And Nursing Home | 5.8 mi | ★★★★★ | 1 | 0 |
| Helen Bernardy Center D/p Snf | 6.8 mi | ★★★★★ | 8 | 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.