Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sharp Chula Vista Med Ctr Snf during CMS and state inspections, most recent first.
Missing Documentation of Advance Directive Education: The facility failed to document that advance directive information was provided to multiple residents or their representatives, and LNs reviewing the records confirmed there was no charted evidence of any advance directive discussion for several sampled residents. The DON and AC stated admitting staff did not document this information during the admission process, and the facility policy did not address a requirement to document that the information was provided.
The facility's QAA/QAPI committee failed to identify, develop, and implement action plans related to advance directives. The DON stated admissions staff missed documenting that advance directives information was provided to all residents, and that this documentation should have been completed. The DON also stated advance directives should have been identified as a QAPI project.
A resident was prescribed hydroxyzine 25 mg PRN for anxiety for 54 days, exceeding the 14-day limit for a PRN psychotropic. The DON acknowledged the medication was being used as a psychotropic, but the psychiatry consult note did not address hydroxyzine therapy or provide documentation supporting the extended PRN use.
Failure to notify the Ombudsman of resident transfers: a resident with DVT was transferred to the hospital twice for worsening symptoms, another resident with generalized weakness and HTN was transferred for poor appetite and dehydration, and a third resident left AMA; staff and the DON confirmed there was no documented written notice to the Ombudsman for these transfers.
Missing Care Plans for Anticoagulant Medications: Two residents receiving anticoagulants had no specific care plans to monitor for medication complications. One resident was ordered Xarelto and the other Eliquis for Afib, but staff found no care plan addressing bleeding-related monitoring such as bruising, blood in stools, or bleeding gums. The DON stated care plans should have been developed for residents on anticoagulant medications.
Feeding Tube Not Flushed Between Medications: A nurse administered 11 medications through a resident’s feeding tube, flushing before and after the medications but not between each one. The DON stated staff were expected to flush with 10 mL of water between medications, and the facility policy also required flushing before, between, and after enteral medication administration.
Medication carts contained improperly labeled and expired items. An LPN found a bag of albuterol inhaler mouthpieces for a resident with the top of the label missing, an expired Breo Ellipta inhaler mouthpiece for the same resident, and an expired tube of white petrolatum in a treatment cart. The DON stated the expired items should not have been in the carts, and the facility policy required missing or illegible labels to be returned to the pharmacy and outdated medications to be removed from stock.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found the facility’s medication error rate was above the allowed limit during observed med passes. An LPN gave doxycycline with magnesium oxide to one resident and administered levothyroxine after breakfast to another resident, while also giving levothyroxine via feeding tube without flushing between meds as expected. The DON and RPH were interviewed, and record review showed the medication orders, meal timing, and tube-med administration practices involved in the errors.
An LPN failed to perform hand hygiene after touching a resident’s bed while administering medications through a feeding tube under EBP. The nurse used the same gloves to adjust the bed and continue medication administration, and later acknowledged she may have missed hand hygiene. The IP stated that touching the resident’s surroundings could harbor microorganisms, and facility policy required hand hygiene after contact with inanimate objects in the resident’s immediate vicinity.
The facility failed to accommodate residents' preferences for bus outings, which were discontinued during the COVID-19 pandemic. Despite receiving a grant for outings, the facility was unable to secure suitable transportation for residents in wheelchairs. Residents expressed a strong desire for group outings to maintain their independence and experience the outside world, but the facility did not fulfill these needs.
The facility failed to monitor and document target behaviors and side effects for psychotropic medications for four residents, leading to potential unnecessary medication use and adverse effects. A resident was not monitored for behaviors and side effects related to antidepressants and anti-anxiety medication, while two other residents lacked proper monitoring for antidepressant medications. Another resident's antidepressant use lacked appropriate target behavior monitoring, with discrepancies between care plans and physician orders.
The facility's kitchen was found to have multiple deficiencies, including dented and expired food items, improper labeling and storage, unsanitary conditions, and inadequate personal hygiene practices. These issues were acknowledged by the facility's management and pose a risk of foodborne illnesses to residents.
A resident with arteriosclerotic cardiovascular disease transitioned from skilled to custodial care without receiving an Advanced Beneficiary Notice (ABN), despite having remaining Medicare days. The facility issued a Notice of Medicare Non-Coverage (NOMNOC) instead, failing to inform the resident of private pay options or appeal rights. Interviews revealed staff were unaware of the ABN requirement, and the facility's policy was not followed.
A resident with a history of stroke was readmitted to an LTC facility with a new stroke diagnosis, resulting in a decline in ADLs and dependence on tube feeding. Despite these changes, the facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days, as required. Staff interviews confirmed the oversight, noting that the resident's condition had significantly declined and was not expected to return to baseline within two weeks.
The facility failed to implement care plans for three residents regarding RNA ROM exercises. A resident with a traumatic brain injury received fewer passive ROM exercises than prescribed, leading to contractures. Another resident with weakness and confusion did not receive the required active and passive ROM exercises, risking contractures and decline. A third resident with stroke-related hemiparesis received fewer ROM exercises than ordered, risking further decline. Staff interviews and observations confirmed these deficiencies.
A facility failed to provide ordered ROM exercises for three residents, leading to potential worsening of contractures. One resident with a traumatic brain injury received fewer passive ROM exercises than ordered due to staffing issues. Another resident with weakness and confusion did not receive any ROM exercises despite orders. A third resident with stroke-related hemiparesis received fewer exercises than prescribed. The facility's policy emphasized adherence to the written plan for maintaining residents' independence.
The facility failed to properly store and label insulin aspart, with bottles not labeled with open dates, leading to potential interchanging and compromised medication integrity. The DON confirmed that without proper labeling, LNs could not ensure the correct use of insulin, which has a 28-day expiration upon opening.
The facility did not address transportation concerns for outdoor activities raised by the resident council in their QAPI program. Although the DON acknowledged the issue and its potential impact on residents' quality of life, it was not documented or formalized in the QAPI plan. Efforts to restore transportation options post-pandemic were ongoing, but the issue remained unaddressed in the QAPI activities.
The facility failed to implement proper infection prevention and control practices for two residents. A CNA entered a resident's room on contact precautions without PPE, and an LN did not wear a gown or change gloves during high-contact care for a resident on enhanced barrier precautions. These actions violated the facility's infection control policies, posing a risk of infection spread.
The facility failed to implement an effective antibiotic stewardship program, as the Infection Preventionist and pharmacy staff did not adequately track and monitor antibiotic use. A resident was coded for antibiotic use on the MDS but not on the MAR, indicating a gap in oversight. Interviews revealed inconsistencies in tracking processes, and there was no documented evidence of a comprehensive tracking list, contrary to the facility's policy.
A resident reported to their Responsible Party that a CNA had pulled their arm and spoken hurtfully. The Social Worker informed management, but the DON and Clinical Lead were unaware of the abuse allegation. The Clinical Lead investigated other concerns but did not address the abuse allegation, thinking it was an old incident, contrary to the facility's policy requiring immediate investigation.
A resident with a potential malignancy diagnosis was not protected from unauthorized visitors despite an APS case indicating financial exploitation concerns. The facility failed to create a care plan or communicate restrictions to staff, allowing restricted individuals to visit the resident multiple times.
Missing Documentation of Advance Directive Education
Penalty
Summary
The facility failed to document that residents were informed of their right to formulate advance directives and failed to document that advance-directive information had been provided in the medical record for 9 of 18 sampled residents reviewed, including Residents #17, 95, 11, 38, 6, 52, 60, 42, and 32. During concurrent interviews and record reviews, multiple LNs reviewed the records for these residents and stated there was no documentation regarding advance directive discussion or that advance directive information had been provided to the resident or the resident's representative, and that such documentation should have been present. The DON stated that admitting staff did not document in the medical record when advance directive information was provided to the resident or the resident's representative, and that this should have been done. The AC also stated that admitting staff did not document advance directive information was provided to all residents or resident representatives during the admitting process and that her expectation was that it should have been. A review of the facility's policy titled Advanced Directives and Physician Orders for Life Sustaining Treatment (POLST), approved 3/5/25, did not address a requirement to document that advance directive information was provided upon admission.
QAA/QAPI Committee Failed to Address Advance Directives Documentation
Penalty
Summary
The facility's QAA/QAPI committee failed to identify, develop, and implement action plans related to advance directives, with the deficiency cross-referenced to F578. During an interview, the DON stated that admissions staff missed the opportunity to document that advance directives information was provided to all residents, and he stated that this documentation should have been completed. The DON also stated that the facility's QAPI committee reviewed issues affecting a high number of residents, and that advance directives should have been identified as a project for the QAPI committee. Record review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan and Adverse Events Policy showed that the plan included performance improvement activities to reduce the risk of failure and improve reliability of systems and processes, as well as monitoring and improving compliance with state and national regulatory, accreditation, and certification standards.
PRN Psychotropic Ordered Beyond 14 Days Without Documented Rationale
Penalty
Summary
The facility failed to ensure that one of five sampled residents, Resident 52, was free from unnecessary psychotropic medication when hydroxyzine was prescribed as needed for anxiety for more than 14 days. The medical record showed an active order for hydroxyzine 25 mg every six hours as needed for anxiety, dated 1/10/26, with a duration of 54 days and prescribed by a physician. During interviews on 2/26/26, the DON acknowledged that hydroxyzine for anxiety was being used as a psychotropic medication. When the DON and pharmacist reviewed the order and were asked for documentation supporting the prescriber's rationale for exceeding the 14-day duration for a PRN psychotropic, the DON later referenced a psychiatry consult note dated 1/23/2026. That note stated the resident's breakthrough anxiety appeared to be addressed with as needed medication and that medication adjustment was discussed, but the note did not address hydroxyzine therapy. The facility policy titled, Assessment of Psychotropic Medications, indicated residents who receive psychotropic medication are assessed to determine the need or continued need of the medication for the ordered indication as mandated by State and Federal law.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide written notice of transfer to the Long-Term Care Ombudsman for three sampled residents. Resident #7, who had a history of DVT, was transferred to the hospital on 12/10/25 after being assessed with dark discoloration to the right foot and severe pain, and was later transferred again on 12/13/25 after being assessed with abdominal distension and pain. Licensed Nurse 3 stated that written notification to the Ombudsman was not documented for either transfer. Resident #89, admitted with generalized weakness and HTN, was assessed on 12/21/25 for poor appetite and dehydration and was transferred to the hospital; Licensed Nurse 3 stated that written notification to the Ombudsman was not documented. Resident #91 was admitted on [DATE] and left the facility against medical advice on 1/11/26, and Licensed Nurse 11 stated there was no documentation of notification to the Ombudsman. The DON reviewed the records and stated that the Ombudsman was not notified of Residents #89 and #91 transfers and that written notice should have been done.
Missing Care Plans for Anticoagulant Medications
Penalty
Summary
A deficiency was cited because the facility did not develop a care plan for anticoagulant medications for 2 of 5 sampled residents. Resident 95 was admitted to the facility and had a physician order dated 2/19/26 for Xarelto 20 mg daily with the evening meal. During a concurrent interview and record review on 2/25/26, the resident’s clinical record did not contain a care plan to monitor for complications of anticoagulant medication, and LN 11 stated that such a care plan should have been developed. Resident 60 was admitted with a diagnosis that included atrial fibrillation and had a physician order for Eliquis 5 mg twice daily for Afib. During an interview and record review on 2/24/26, LN 1 stated there was no specific care plan for monitoring the negative side effects of the blood thinner and that there should have been one. LN 1 identified monitoring concerns such as blood in stools, bruising, and bleeding gums. The DON later stated that care plans should have been developed for any residents on anticoagulant medications. The facility policy titled Care Plan/interdisciplinary Care Conference stated care plans are to be developed and implemented by the IDT, and the drug reference provided listed side effects including vomiting blood, blood in urine, black, red or tarry stools, and bleeding gums.
Feeding Tube Not Flushed Between Medications
Penalty
Summary
The facility failed to provide medication therapy in accordance with professional standards of practice for one resident when a licensed nurse did not flush the resident’s feeding tube between medications during administration of 11 medications. During a concurrent observation and interview, the nurse flushed the tube with 30 mL of water before starting the medications, administered each medication separately, and then flushed the tube again after all medications were given, but no flushing was observed between the individual medications. The nurse stated she flushed only before and after the medication administration and not between each medication. The Director of Nursing stated nursing staff were expected to flush with 10 mL of water in between each medication, in addition to flushing with 30 mL before and 30 mL after medication administration. The facility’s policy for enteral tube medication administration also stated the feeding tube should be flushed with 30 mL of water prior to medication administration, flushed between individual liquids and solids with a minimum of 10 mL of water, and flushed with 30 mL of water following medication administration.
Medication Labeling and Expired Stock in Carts
Penalty
Summary
Safe and effective pharmaceutical services were not maintained when East Wing Medication Cart 2 contained a bag of three albuterol inhaler mouthpieces for Resident 85 with the top portion of the prescription label missing. The remaining label did not show the resident’s name, the drug name, or part of the directions for use. Licensed Nurse 10 stated the outer bag should have had a label in addition to the labels on the individual inhalers, and the individual inhaler labels only showed the resident’s name and medication name, not the directions for use. Resident 85’s record showed an active order for albuterol 90 mcg, 1 puff every 4 hours as needed for wheezing. The same medication cart also contained an expired Breo Ellipta inhaler mouthpiece for Resident 85, with stickers on both the inhaler and outer bag showing an expiration date that had passed. Licensed Nurse 10 confirmed the medication was expired, and the DON stated it should not have been in the medication cart and should have been disposed of or returned to the pharmacy. In addition, East Wing Treatment Cart 2 contained a tube of white petrolatum with an expiration date of 10/23, which Licensed Nurse 10 confirmed was expired. The DON stated the tube should have been disposed of before the expiration date. The facility policy stated that containers with worn, illegible, or missing labels shall be returned to the pharmacy, and outdated medications are to be immediately removed from stock and disposed of according to procedure.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. Surveyors determined the medication error rate was 11.43 percent, with four medication errors occurring out of 35 opportunities during medication administration for three of six randomly observed residents. The errors were identified through observation, interview, and record review during medication pass observations involving Residents 92, 94, and 1. For Resident 92, LN 14 administered doxycycline, magnesium oxide, and levothyroxine during the morning medication pass. Resident 92 stated she had already eaten breakfast when the medications were being given. The doxycycline label stated not to give milk, iron products, or antacids containing aluminum, calcium, or magnesium within 2 hours before or at least 4 hours after the dose, and LN 14 stated doxycycline and magnesium should not have been given together. The DON stated nursing should have followed the directions on the doxycycline order because it could impact the dose. For Resident 94, LN 12 administered levothyroxine at 9 A.M. during the observed medication pass, and later stated levothyroxine had been given on an empty stomach in the morning around 6:30 A.M. before the orders were changed to 9 A.M. The DON stated levothyroxine orders were changed from before breakfast to 9 A.M. for patient satisfaction, while the facility’s breakfast was at 7 A.M. and Resident 94 had consumed 100 percent of breakfast at 8 A.M. For Resident 1, LN 14 administered levothyroxine through a feeding tube during the delayed morning medication pass, flushed the tube before and after administration, but did not flush between medications. The DON stated staff were expected to flush with 10 mL of water in between each medication, in addition to flushing before and after administration.
Hand Hygiene Not Performed During Feeding Tube Medication Administration
Penalty
Summary
The facility failed to implement proper infection control practices when a Licensed Nurse did not perform hand hygiene after touching a potentially contaminated surface during medication administration through a resident’s feeding tube. During a concurrent observation and interview, the nurse was seen preparing and administering 11 medications through the feeding tube while wearing gown and gloves for Enhanced Barrier Precautions. The nurse elevated the resident’s head of bed while wearing gloves and then continued medication administration using the same pair of gloves, and acknowledged she used the same gloves to adjust the bed and for medication administration. She stated she may have missed performing hand hygiene after adjusting the bed. The resident had a sign outside the room indicating Enhanced Barrier Precautions. The Infection Preventionist stated nursing staff were to give medications immediately after performing hand hygiene and donning gloves, and that touching the resident’s surroundings, such as the bed, could harbor microorganisms and defeated the purpose of Enhanced Barrier Precautions. The facility policy on Enhanced Barrier Precautions identified feeding tube care as a high-contact resident care activity requiring gown and gloves, and the hand hygiene policy required hand hygiene after contact with inanimate objects in the immediate vicinity of the patient.
Failure to Provide Resident Outings
Penalty
Summary
The facility failed to accommodate the activity preferences of its residents, specifically regarding bus outings, which were previously available before the COVID-19 pandemic. During a confidential group meeting, six residents expressed dissatisfaction with the discontinuation of these outings, which included trips to stores, parks, and other recreational locations. The facility's bus and driver were no longer available, and efforts to find alternative transportation had been unsuccessful due to cost and capacity issues. The residents emphasized their desire for group outings to experience the outside world and maintain their independence. The facility's records from February to September 2024 indicated ongoing attempts to secure transportation, but no progress was made. Interviews with staff members revealed that the facility had received a grant for bus outings, but they were still unable to find suitable transportation for residents in wheelchairs. The Director of Nursing acknowledged the residents' rights to outings and the facility's failure to accommodate these needs. The facility's policy on activities emphasized the importance of community outings and accommodating residents' preferences, which was not fulfilled in this case.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to appropriately monitor and document the target behaviors and side effects for psychotropic medications for four residents, leading to potential unnecessary medication use and adverse effects. Resident 274 was not monitored for behaviors and side effects related to two antidepressants and one anti-anxiety medication. Interviews revealed that the monitoring was subjective and lacked objective measures, and side effects were not documented in the medication administration record (MAR). The facility's policy required monitoring for suspected adverse drug reactions, which was not adhered to in this case. Residents 35 and 58 also lacked proper monitoring for behaviors and side effects associated with their antidepressant medications. For Resident 35, there was no measurement of sleep hours to evaluate the effectiveness of Trazodone, and the MAR showed zeros for a month of use. Similarly, Resident 58's record did not include a way to measure the behavior for Trazodone, and the MAR also showed zeros for a month's use. The facility's policy emphasized the importance of monitoring for adverse drug reactions, which was not followed. Resident 51's use of antidepressant medication lacked appropriate target behavior monitoring. The care plan and physician's orders did not align, leading to confusion about the target behavior for monitoring. Interviews indicated that there was no clear method to measure depressive behavior, such as continuous crying or refusal of care. The facility's policy required documentation of the necessity for medication and monitoring of its effects, which was not adequately implemented for Resident 51.
Multiple Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in its kitchen, leading to multiple deficiencies. Observations revealed dented cans of thyme and hoisin sauce, which were acknowledged by the Food Service Manager (FSM) and Food Operations Manager (FOM) as potentially hazardous due to the risk of botulism. Additionally, expired food items such as wonton chips, split peas, corn starch, barley, beans, dried red chili peppers, mango mousse, parmesan cheese, and shredded zucchini were found, which the FSM and FOM agreed should be discarded to ensure food safety. Further deficiencies were noted in the labeling and storage of food items. Unlabeled and improperly sealed food items, including pasta, graham crumbs, chili peppers, bread, hash browns, and various vegetables, were observed. The FSM and FOM acknowledged the importance of labeling to ensure freshness and prevent contamination. The facility's policy on food storage was not adhered to, as evidenced by cracked and loose container lids, dust, and spilled food on container lids, which could lead to contamination. Additional unsanitary conditions included the presence of moldy strawberries, wilted produce, dirty rugs, trash in storage areas, and improper storage of ready-to-eat food above raw meat. Kitchen utensils were found with crusted food debris, and personal items such as employee drinks and belongings were improperly stored in food preparation areas. A Nutrition Assistant was observed preparing food without a hair covering, increasing the risk of contamination. These findings indicate a failure to comply with professional standards and the facility's own policies, potentially exposing residents to foodborne illnesses.
Failure to Provide Advanced Beneficiary Notice for Custodial Care Transition
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to a resident, identified as Resident 282, who transitioned from skilled services to custodial care. Resident 282 was admitted with a history of arteriosclerotic cardiovascular disease and had remaining Medicare days when skilled services were discontinued. The facility's Assistant Director (AD 1) acknowledged that a Notice of Medicare Non-Coverage (NOMNOC) was issued instead of an ABN, despite the resident not exhausting Medicare skilled days. This oversight resulted in Resident 282 not being informed of the option to continue services under private pay or the associated costs, nor having the opportunity to appeal the decision. Interviews with facility staff, including AD 1, AD 2, and the Director of Nursing (DON), revealed a lack of awareness and proper procedure regarding the issuance of the ABN. AD 2 confirmed that the ABN provided was unsigned and that the business office had not issued an ABN document before September 2024. The DON expressed that it was crucial for the resident and their responsible party to be notified about the transition to custodial care and the implications of non-coverage. The facility's policy required an ABN to be completed and signed when services were believed to be non-covered, which was not adhered to in this case.
Failure to Complete SCSA for Resident with Significant Change
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days for a resident who experienced a significant change in condition. The resident, who had a history of stroke, was readmitted to the facility with a new stroke diagnosis and exhibited a decline in activities of daily living (ADLs), becoming dependent on tube feeding and unable to participate in the Brief Interview for Mental Status (BIMS). Despite these changes, the facility did not conduct the required SCSA, which is necessary to update the resident's plan of care based on their current health status. Interviews with facility staff, including MDS Coordinators and the Director of Nursing (DON), confirmed that the resident's condition had significantly declined in multiple areas, including mental status, nutrition, and ADLs. The staff acknowledged that an SCSA should have been completed as the resident was not expected to return to their prior levels of function within two weeks. The failure to conduct the SCSA was attributed to the completion of another comprehensive admission MDS instead, which did not adequately reflect the resident's current health status and needs.
Failure to Implement ROM Exercises as per Care Plans
Penalty
Summary
The facility failed to implement care plans for three residents concerning Restorative Nursing Assistant (RNA) range of motion (ROM) exercises. Resident 1, who had a traumatic brain injury and was in a vegetative state, was supposed to receive passive ROM exercises daily to prevent further contractures. However, the RNA weekly summary indicated that Resident 1 only received these exercises five times a week instead of the prescribed seven times. Observations showed that Resident 1's hands were contracted, and interviews with staff confirmed the lack of adherence to the care plan. Resident 45, who was admitted with weakness and confusion, required assistance with activities of daily living and was supposed to receive both active and passive ROM exercises five times a week. However, interviews with staff revealed that these exercises were not being provided as per the care plan. The care plan aimed to prevent contractures and decline in ROM, but it was not implemented, as confirmed by the staff and the Director of Nursing (DON). Resident 51, who had a stroke with right-sided hemiparesis, was dependent on staff for most activities and was supposed to receive daily ROM exercises. The RNA weekly summary showed that Resident 51 received these exercises only five times a week instead of daily. Interviews with staff and the DON confirmed that the care plan was not followed, which was necessary to prevent contractures and decline in performing activities of daily living. The facility's policies did not clearly indicate the implementation of care plans, contributing to the deficiency.
Failure to Provide Ordered ROM Exercises
Penalty
Summary
The facility failed to consistently provide Restorative Nursing Assistant (RNA) services for range of motion (ROM) exercises as per physician's orders for three residents with limited ROM. Resident 1, who had a traumatic brain injury and was in a vegetative state, was supposed to receive passive ROM exercises seven times a week to prevent worsening of contractures. However, due to insufficient RNA staffing, Resident 1 only received these exercises five times a week, which was not in compliance with the physician's orders. Resident 45, who was admitted with weakness and confusion, was ordered to receive both active and passive ROM exercises five times a week. Despite this, there were no records of ROM exercises being provided to Resident 45 since the order was given. This oversight was confirmed by the staff, who acknowledged that Resident 45 was not enrolled in the RNA program and did not receive the necessary exercises to prevent the development of contractures. Resident 51, who had a stroke with right-sided hemiparesis, was ordered to receive daily ROM exercises. However, the facility only provided these exercises five times a week, contrary to the physician's orders. The staff confirmed the discrepancy, acknowledging that the exercises were not provided as frequently as required. The facility's policy on the Restorative Nursing Program emphasized the importance of following the written plan to help residents achieve and maintain the highest possible levels of independence, which was not adhered to in these cases.
Improper Storage and Labeling of Insulin Aspart
Penalty
Summary
The facility failed to properly store and label house supply/stock medications, specifically insulin aspart, with open dates. During an observation and interview, it was found that two boxes of insulin aspart were stored in a medication refrigerator, each containing one bottle. One box was labeled with an open date, but the bottle inside was not labeled. The other box was labeled with an expiration date, but again, the bottle inside was not labeled with an open date. This lack of labeling could lead to the interchanging of bottles, compromising the integrity of the medication. The Director of Nursing (DON) confirmed that insulin has a 28-day expiration upon opening and acknowledged that without proper labeling, Licensed Nurses (LNs) would not be able to determine which bottle corresponded to the correct box with the open date. This oversight could result in the use of ineffective medication. The facility's policy on drug storage and security requires all medications to be accurately labeled with expiration dates and stored in a manner that reduces the likelihood of error.
Failure to Address Resident Council Concerns in QAPI
Penalty
Summary
The facility failed to identify and address concerns raised in the residents council minutes regarding transportation for outdoor activities within their Quality Assurance and Performance Improvement (QAPI) program. During an interview with the QAPI program members, it was revealed that the team utilized various sources of information, including family and resident feedback, to track performance and make necessary changes to policies and procedures. However, the Director of Nursing (DON) admitted that while concerns from the resident council were discussed, they were not documented or formalized into the QAPI plan. The DON further explained that transportation for activities had been halted during the pandemic, and efforts were being made to restore these options. Despite recognizing that the lack of transportation could affect residents' quality of life, the facility did not formally address the issue in their QAPI activities. A review of the facility's QAPI policy indicated that the program should encompass all segments of care and services impacting clinical care, quality of life, and resident choice, yet the transportation issue was not included.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two residents, leading to deficiencies in care. For Resident 52, who was on contact precautions due to a history of methicillin-resistant Staphylococcus aureus (MRSA), a CNA entered the resident's room without performing hand hygiene or wearing the required personal protective equipment (PPE), such as a gown and gloves. The CNA admitted to not knowing why the resident was on contact precautions and acknowledged the importance of following these precautions to prevent the spread of infection. Additionally, the Infection Prevention nurse did not have a complete list of residents on infection control precautions, which contributed to the oversight. For Resident 1, who was in a vegetative state and on enhanced barrier precautions (EBP) due to the use of a gastrostomy tube, a licensed nurse (LN) failed to wear a gown and did not change gloves between procedures while administering tube feeding. The LN incorrectly believed that wearing a gown was discretionary and admitted to not changing gloves after touching a potentially contaminated curtain. The Director of Nursing (DON) confirmed that the expectation was for staff to wear a gown and gloves during high-contact activities with residents on EBP to prevent infection spread. The facility's policies on standard and transmission-based precautions, as well as enhanced barrier precautions, were not followed by the staff, leading to potential risks of infection spread among residents, staff, and visitors. The lack of adherence to these protocols highlights a significant deficiency in the facility's infection control practices.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as per its own policy and procedure. During an interview and record review, the Infection Preventionist (IP) acknowledged that while the pharmacy assisted with logging and tracking antibiotics, there was no comprehensive tracking system in place. The IP was responsible for tracking urinary tract infections (UTIs), but there was no documented evidence of a line tracking list for antibiotics. This lack of documentation and oversight was further highlighted by the fact that a resident was coded for antibiotic use on the Minimum Data Set (MDS) but was not listed on the medication administration record (MAR), indicating a gap in tracking and monitoring antibiotic use. Interviews with pharmacy staff revealed further inconsistencies in the antibiotic tracking process. Pharm 1 stated that he did not track the antibiotic line list and suggested that another pharmacist might be responsible. Pharm 2 mentioned the use of antibiotic escalation but emphasized the need for a collaborative process to ensure all information is available and accessible to the healthcare team. The facility's long-term care policy on antimicrobial stewardship indicated the need for a designated committee to monitor antimicrobial use, but this was not effectively implemented, leading to a deficiency in the facility's antibiotic stewardship program.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse for one of the sampled residents, leading to an increased risk of abuse for the resident. The resident was admitted to the facility and later reported to their Responsible Party (RP) that a Certified Nursing Assistant (CNA) had pulled their arm and spoken to them in a hurtful manner. The RP communicated these concerns to the facility's Social Worker (SW), who then informed the facility's management. However, the Director of Nursing (DON) and the Clinical Lead (CL) were not aware of the abuse allegation. The CL conducted an investigation into the RP's concerns but did not investigate the abuse allegation, mistakenly believing it was related to an old incident. This oversight was contrary to the facility's policy, which mandates immediate investigation of any abuse charges.
Failure to Implement Care Plan for Resident Safety
Penalty
Summary
The facility failed to develop a care plan to ensure the safety of a resident who was at risk due to financial exploitation concerns. The resident was admitted with a diagnosis that included an ill-defined liver mass concerning for malignancy. An Adult Protective Services (APS) case was opened after a family member expressed concerns about the resident's financial transactions with neighbors. Despite the APS report and a psychiatrist's determination that the resident lacked the capacity for financial decision-making, the facility did not create a care plan to restrict certain visitors, leading to unauthorized visits by individuals suspected of exploiting the resident. Interviews with facility staff, including the Director of Nursing (DON), Licensed Nurses (LN), and Certified Nurse Assistants (CNA), revealed a lack of awareness and communication regarding the restricted visitors. The visitor logs showed that the restricted individuals visited the resident multiple times after the APS report was filed. The facility's policy required care plans to be reviewed and revised as needed, but no such plan was created for the resident, and there was no documentation of restricted visitors in the resident's records.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 381 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chula Vista
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Veterans Home Of California - Chula Vista | 0.7 mi | ★★★★★ | 10 | 0 |
| South Bay Post Acute Care | 4.3 mi | ★★★★★ | 1 | 0 |
| Reo Vista Healthcare Center | 4.4 mi | ★★★★★ | 6 | 0 |
| Ridgeview Skilled Nursing Facility | 4.7 mi | ★★★★★ | 3 | 0 |
| National City Post Acute | 5.6 mi | ★★★★★ | 26 | 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 October 2026) and official state health department websites.