Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Mission Hills Post Acute Care during CMS and state inspections, most recent first.
A resident in an LTC facility was physically abused by another resident, resulting in being kicked in the shins. The incident occurred during a confrontation when one resident entered another's room. Staff interviews revealed a lack of awareness and documentation of the aggressive resident's behaviors, and no formal monitoring system was in place to prevent further incidents.
The facility failed to conduct baseline care plan meetings within 48 hours for two residents, leading to potential care gaps. One resident with cardiomyopathy and prostate cancer had their IDT conference 28 days post-admission, while another with muscle injury and Alzheimer's had theirs 13 days later. The facility's policy lacked guidance on timely baseline care plans.
The facility failed to provide timely assistance and maintain dignity for three residents, leading to prolonged periods without necessary care. A resident reported waiting over nine hours for a brief change, while another experienced delays in call light responses post-surgery. A third resident was left in a wet brief overnight. Care plans lacked specific instructions for toileting assistance, and staff expectations for timely responses were not met.
The facility failed to provide adequate staffing, resulting in residents being left in soiled conditions for extended periods. A resident's brief was not changed for over nine hours, another resident had to hold her urine for an hour, and a third resident was left in a wet brief for over four hours. Staff interviews confirmed consistent short-staffing, leading to delays in responding to residents' needs.
A resident with a history of falls and orthostatic hypotension suffered a right femoral neck fracture after falling in the shower. The resident was not identified as a fall risk, and a CNA, unaware of the risk, showered the resident alone, leading to the fall. Staff interviews revealed inadequate communication and identification of fall risk residents, and the facility's fall prevention protocols were not followed.
The facility failed to provide adequate respiratory care for three residents using CPAP machines. Two residents did not receive ongoing assessments, and one resident's CPAP machine was not checked by staff. Another resident used a CPAP machine without a physician's order. The facility's policy did not provide guidance for ongoing assessment of CPAP use.
The facility failed to implement infection control standards when respiratory equipment for two residents was not stored appropriately. Both residents had CPAP machines with exposed tubing and masks, and one had undated oxygen tubing. Staff confirmed that the equipment should have been stored in plastic bags and dated to prevent contamination.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in an incident where one resident was kicked in the shins. The altercation occurred when one resident entered another's room and offered coffee to a roommate, leading to a confrontation. The resident who was kicked reported that this was the second altercation with the same individual. Interviews with staff revealed that the resident who initiated the altercation had a history of becoming irritated with other residents and had previously exhibited aggressive behaviors such as hitting, yelling, or throwing objects. The facility's staff, including CNAs and a licensed nurse, were not fully aware of the altercation or the resident's aggressive behaviors, and there was no formalized monitoring system in place to prevent further incidents. The care plans for the aggressive resident did not reflect the behaviors reported by staff, indicating a lack of communication and documentation. The facility's policy on abuse prevention emphasized the importance of immediate measures to prevent further abuse, but these measures were not effectively implemented, as evidenced by the repeated altercations.
Failure to Conduct Timely Baseline Care Plan Meetings
Penalty
Summary
The facility failed to conduct a baseline care plan meeting within 48 hours of admission for two residents, leading to potential gaps in care and communication. Resident 2, diagnosed with cardiomyopathy and prostate cancer, was admitted to the facility, but the interdisciplinary team (IDT) conference was not conducted until 28 days later. The family of Resident 2 reported that no care meeting was held, and a physician did not visit until they complained to the Director of Nursing. The IDT-Care Plan Review document lacked signatures from Resident 2 or their family, indicating they had not received any information. Similarly, Resident 6, with diagnoses including muscle injury and Alzheimer's Disease, experienced a delay in care planning. The IDT conference for Resident 6 was conducted 13 days after admission, and the family was not provided with a staff contact list until 13 days post-admission. The Director of Social Services stated that initial care plan meetings were offered within 7 days, but the policy did not specify guidelines for completing a baseline care plan. The Director of Nursing emphasized the importance of these meetings for communication about resident care, but the facility's policy lacked guidance on timely completion of baseline care plans.
Failure to Ensure Timely Assistance and Dignity for Residents
Penalty
Summary
The facility failed to ensure that three residents were provided care in a manner that promoted dignity and respect, as observed through interviews and record reviews. Resident 2, who was dependent on assistance for toileting hygiene, reported that certified nurse assistants (CNAs) were slow to respond, resulting in her brief not being changed for over nine hours, which left her feeling upset and dirty. Her care plan did not address her toileting needs, contributing to the deficiency. Resident 3, who required partial assistance with toileting hygiene and supervision for toilet transfer, experienced delays in call light responses. She reported waiting up to two hours for assistance, which was particularly distressing following her knee surgery. Her care plan also failed to address her toileting needs, leading to her feeling upset and considering leaving the facility. Resident 4, who required dependent assistance with toileting hygiene, was found sitting on a wet pad, having not been changed since the previous night. She reported multiple instances of delayed call light responses, resulting in discomfort and potential skin issues. Her care plan similarly lacked specific instructions for toileting assistance. Interviews with staff revealed expectations for call light responses within five to ten minutes, which were not met, contributing to the residents' experiences of indignity and discomfort.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, resulting in prolonged periods where residents were left in soiled conditions. Resident 2, who required assistance with personal care due to limited mobility, reported that her brief was not changed for over nine hours on one occasion. This incident was corroborated by her statement that the certified nurse assistants (CNAs) were often slow to respond to her needs. The care plan for Resident 2 did not adequately address her toileting needs, contributing to the deficiency. Resident 3, who had recently undergone knee surgery and required assistance with toileting, experienced a delay of one hour before staff responded to her call light. This delay forced her to hold her urine, causing significant distress. The care plan for Resident 3 also failed to address her specific needs for assistance with toileting and other activities of daily living (ADLs), highlighting a gap in the facility's care planning process. Resident 4, who required dependent assistance with toileting hygiene, was left in a wet brief for over four hours. The call light outside her room was on, indicating a request for assistance that went unanswered for an extended period. Interviews with staff, including CNAs and licensed nurses, revealed that the facility was consistently short-staffed, which contributed to the delays in responding to residents' needs. The facility's policy required call lights to be answered within five minutes, but this standard was not met, as evidenced by the resident council minutes documenting ongoing complaints about delayed responses.
Failure to Prevent Fall in Resident with Known Fall Risk
Penalty
Summary
The facility failed to prevent an avoidable fall for a resident with a known history of falls and orthostatic hypotension, resulting in a right femoral neck fracture. The resident was admitted with diagnoses including pathological fractures and recurrent falls. Despite these conditions, the resident was not identified as a fall risk upon admission, and no fall risk indicators such as wristbands or signage were used to alert staff. On the day of the incident, a CNA was unaware of the resident's fall risk status and proceeded to shower the resident alone. During the shower, the resident was asked to stand and hold onto a rail while the CNA turned to retrieve a brief, at which point the resident fell and appeared to pass out. The CNA called for help, and additional staff arrived to assist. Vital signs indicated low blood pressure, consistent with the resident's history of orthostatic hypotension. Interviews with staff revealed a lack of communication and proper identification of fall risk residents. The Director of Nursing confirmed that fall risk status was communicated verbally rather than through visible indicators. The facility's policy required two staff members for showering fall risk residents and the use of a shower chair, which was not followed in this case. The incident highlighted deficiencies in staff training and adherence to fall prevention protocols.
Failure to Provide Adequate Respiratory Care for Residents Using CPAP Machines
Penalty
Summary
The facility failed to provide adequate respiratory care services for three residents using CPAP machines. Resident 5 and Resident 6 did not receive ongoing assessments to evaluate their respiratory status and response to the CPAP machine. Resident 5's CPAP machine was not checked by staff, and the water chamber was empty when used. Additionally, Resident 5's medication administration record (MAR) was signed even when the CPAP machine was not available, and there was no follow-up on the missing part of the CPAP machine as per the physician's order. Resident 6 also reported that staff did not check if she applied the CPAP or checked the machine, and she had to fix the machine herself when it malfunctioned. Resident 7 used a CPAP machine without a physician's order. The progress notes indicated that Resident 7 was observed using the CPAP, but there was no corresponding physician's order for its use. The assistant director of nursing (ADON) confirmed that there should be a physician's order for CPAP use and that staff should document any follow-up needed to address CPAP problems. The facility's policy and procedure for CPAP-BiPAP monitoring and management did not provide guidance for ongoing assessment of residents using CPAP machines.
Inadequate Storage of Respiratory Equipment
Penalty
Summary
The facility failed to implement infection control standards of practice when respiratory equipment was not stored appropriately for two residents. Resident 5, who was admitted with obstructive sleep apnea (OSA), had a CPAP machine with tubing and a mask exposed on top of the machine, and an oxygen tank with undated tubing at her bedside. Resident 5 stated that no facility staff had checked the machine or ensured its proper application. Similarly, Resident 6, also diagnosed with OSA, had a CPAP machine with tubing and a nasal mask left on top of her bed. Resident 6 mentioned that she cleaned the mask herself and that facility staff did not check her CPAP machine. Licensed nurses and the assistant director of nursing confirmed that the CPAP masks and oxygen tubing should have been stored in plastic bags and dated to prevent contamination. The facility's policies indicated that oxygen tubing and masks should be replaced every seven days, but did not address infection control measures for CPAP masks. The failure to adhere to these standards had the potential to expose residents to infections.
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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) |
|---|---|---|---|---|
| Hillcrest Heights Healthcare Center | 0.3 mi | ★★★★★ | 1 | 0 |
| Balboa Nursing & Rehabilitation Center | 0.6 mi | ★★★★★ | 7 | 0 |
| St. Pauls Health Care Center | 1 mi | ★★★★★ | 9 | 0 |
| The Pavilion At Ocean Point | 3 mi | ★★★★★ | 24 | 0 |
| Golden Hill Post Acute | 3.4 mi | ★★★★★ | 54 | 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.