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 South Bay Post Acute Care during CMS and state inspections, most recent first.
A resident with DM, cognitive deficits, and an existing sacral pressure injury did not receive MD-ordered wound care as directed, including prescribed use of calcium alginate, Medihoney, foam dressings, daily dressing changes, and a low air-loss mattress. The wound nurse acknowledged that the Wound MD’s instructions were not followed for a period, and later treatment orders for cleansing with Dakin’s solution and daily dressing applications were in place. Over time, the sacral wound increased substantially in size and was documented by the Wound MD as an unstageable pressure injury. The DON confirmed that MD-ordered treatments were expected to be implemented per the facility’s wound management policy, which requires that physician-ordered treatments be used as ordered and that the physician be contacted if there is no improvement.
Surveyors found that two residents received controlled pain medications without clear indications documented in physician orders. Orders for oxycodone and hydrocodone-acetaminophen included dosage and pain level parameters but did not specify the medical reason for use. Medication administration records showed these drugs were given for various types and locations of pain, sometimes without any pain location documented. Nursing staff and leadership acknowledged the missing indications, and facility policy required this information in medication orders.
A resident with cellulitis received two tablets of oxycodone for severe pain, but the MAR incorrectly documented that only one tablet was given for moderate pain. The LPN later confirmed the error, and the DON acknowledged that accurate documentation was required by facility policy.
Failure to Implement Ordered Wound Care Leading to Worsening Sacral Pressure Injury
Penalty
Summary
The facility failed to implement MD-ordered wound care treatments for a resident with a sacral pressure injury. The resident, who had diabetes mellitus and documented cognitive deficits with confusion and poor decision-making, was re-admitted with an open sacral wound initially measured at 3 cm by 3 cm. Wound MD notes shortly after admission identified a deep tissue pressure injury on the sacrum and specified detailed weekly instructions, including application of calcium alginate, Medihoney gel, foam dressing, daily dressing changes, and use of a Group 2 low air-loss mattress. Despite these orders, the wound nurse acknowledged that the Wound MD’s instructions for February were not carried out as directed. Subsequent treatment orders for the sacral pressure ulcer included cleansing with quarter-strength Dakin’s solution, application of Medihoney, coverage with calcium alginate and foam dressing every day shift, and use of a low air-loss mattress with functioning and placement checked every shift. However, by late March, Wound MD measurements documented that the sacral wound had progressed to an unstageable pressure injury with a size of 13 cm by 10.5 cm and an area of 136.5. The DON stated that MD-ordered wound treatments were expected to be implemented as directed and confirmed that ordered treatments were still required even though the resident had been evaluated for palliative care prior to the first admission. The facility’s wound management policy stated that treatments ordered by the physician will be used as ordered and that the physician will be called if there is no improvement.
Lack of Clear Indications for Controlled Pain Medications
Penalty
Summary
The facility failed to provide clear indications for the use of controlled pain medications for two of three sampled residents. For one resident admitted with cellulitis of the right leg, physician orders for oxycodone included dosage and pain level parameters but did not specify the indication for use. Medication administration records showed oxycodone was given for various types and locations of pain, including lower back pain, buttock pain, generalized pain, and instances where no pain location was documented. Another resident, admitted with a right femur fracture, had physician orders for hydrocodone-acetaminophen that also lacked a specific indication for use. Administration notes indicated the medication was given for leg pain, reported pain scores, and in some cases, without documentation of the pain location. Interviews with nursing staff and leadership confirmed that the orders were missing clear indications and that this information was necessary to prevent medication misuse. The facility's policy required that medication orders include the reason or problem for which the medication is given, but this was not followed in the cases reviewed. The lack of specific indications in the orders and inconsistent documentation of pain location led to the deficiency, as staff could not confirm the intended use of the controlled medications for the residents involved.
Inaccurate Documentation of Pain Assessment and Controlled Medication Administration
Penalty
Summary
The facility failed to accurately document a pain assessment result and the administration of a controlled pain medication for a resident with a diagnosis that included cellulitis of the right leg. Physician orders specified that one tablet of oxycodone was to be given for moderate pain (level 4-6) and two tablets for severe pain (level 7-10). On a specific date and time, the Controlled Drug Record showed that two tablets of oxycodone were removed from the medication cart by a licensed nurse, but the Medication Administration Record (MAR) indicated that only one tablet was administered and documented a pain level of 4/10. During interviews, the licensed nurse confirmed that two tablets were actually administered for a pain level of 7, and acknowledged that the MAR documentation was incorrect. The Director of Nursing also stated that pain assessment and medication administration should have been documented accurately. The facility's policy requires an accurate account of resident care and status in the clinical record, which was not followed in this instance.
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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 Chula Vista
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| National City Post Acute | 1.8 mi | ★★★★★ | 25 | 0 |
| Hillcrest Manor Sanitarium | 2 mi | ★★★★★ | 20 | 0 |
| Reo Vista Healthcare Center | 2.9 mi | ★★★★★ | 6 | 0 |
| Friendship Manor Nursing & Rehab Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Paradise Valley Health Care | 3.2 mi | ★★★★★ | 2 | 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.