Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 The Springs At Pacific Regent during CMS and state inspections, most recent first.
Unsafe food storage, labeling, and temperature monitoring practices were observed in the dietary area. The DS found a cracked cambro container, dirty serving dishes, and wet mixing bowls on the clean dish rack; spoiled produce was stored with unspoiled produce; and peeled cucumbers were unlabeled and undated. In the prep area, a container labeled as olives held melted margarine, the prep cart and utensils had food particles and grease, the cook did not visualize the thermometer probe touching the food when checking tray line temperatures, and soup was served without a documented temperature check.
Baseline Care Plan Missing Mealtime Assistance for a Blind Resident: A resident with legal blindness and Pigmentary Retinal Dystrophy reported needing help with meal tray setup, food identification, and locating items on the plate, but staff repeatedly had to be reminded at meals. Interviews and record review showed CNAs were not informed of the resident’s blindness, the care plan lacked mealtime setup assistance, and the DON acknowledged no baseline care plan had been developed for this need.
MAR and CMCS records did not reconcile for two residents receiving controlled pain medications. One resident had an oxycodone order for post-surgery pain, but a dose removed from locked supply had no MAR entry, and another resident had multiple unreconciled hydrocodone-acetaminophen entries. The DON confirmed the discrepancies, and an LPN described the expected process for documenting controlled medication administration and accountability.
Hand Hygiene Not Performed During Wound Care: A resident with an unstageable coccyx pressure ulcer and a history of stroke and hemiplegia received wound care from an LPN and CNA, but the LPN changed gloves multiple times without performing hand hygiene between glove changes. The nurse cleaned the wound, applied ointment and powder, and placed dressings while repeatedly donning new gloves without hand hygiene, despite acknowledging the missed hand hygiene and the IP and DON stating it was expected.
A resident with diabetes and a recent amputation did not receive necessary wound care due to lapses in treatment administration and documentation. Despite being on isolation for COVID-19, the resident's daily wound treatments were not consistently performed, leading to a deficiency in care. Interviews with staff revealed confusion and miscommunication regarding the resident's care needs.
The facility failed to report a COVID-19 outbreak to health officials in a timely manner and did not review infection control policies annually. The IP nurse delayed reporting the outbreak due to being off duty, despite the facility's policy requiring prompt reporting. Additionally, the IP nurse was unaware of the responsibility to review and update infection control policies, which had not been revised since October 2022.
A resident with diabetes type 1, end-stage renal disease, and cirrhosis of the liver received Insulin Lispro via injection instead of an insulin pump, as ordered by the physician. The licensed nurse administering the medication was unaware of what an insulin pump was and did not verify the order, leading to a significant drop in the resident's blood sugar levels.
Unsafe Food Storage, Labeling, and Temperature Monitoring Practices
Penalty
Summary
The facility failed to maintain safe and sanitary kitchen conditions during dietary operations. On observation of the clean dish storage rack, the Dietary Supervisor identified a cracked 7.5-quart plastic cambro container, two serving dishes with food particles stuck on them, and four wet mixing bowls stacked on a shelf with water in the bottoms of the bowls. The Dietary Supervisor removed those items from the clean storage rack during the observation. In the produce walk-in refrigerator, spoiled produce was stored with non-spoiled produce. Observed items included two cantaloupes that were brown, soft, and indentable, a container of blueberries with a fuzzy white substance growing on multiple berries, multiple soft brown apples, and yellow squash with brownish color, slimy soft spots, and visible fuzzy white growth. Two refrigerated peeled and cut cucumbers were also found wrapped in plastic without being labeled or dated. The Dietary Supervisor stated the spoiled items should be thrown away and that the cucumbers should have been labeled and dated. In the food prep area, a container in the warming oven labeled as olives contained a clear yellow liquid substance that the Dietary Supervisor identified as melted margarine. The utensil prep cart had food particles and crumbs in the drawers and on the shelves, a spatula had a slimy greasy coating, and there were grease smudges on the back of the plate dispenser. During tray line observation, the cook took temperatures of foil-covered food containers without visualizing the thermometer probe touching the food, and the probe was heard hitting the bottom of the metal container. Later, soup was placed on a meal tray for service without a temperature being taken, and the temperature log entry for the soup was blank.
Baseline Care Plan Missing Mealtime Assistance for a Blind Resident
Penalty
Summary
The facility failed to ensure that Resident 86’s baseline care plan included person-centered mealtime assistance within 48 hours of admission. Resident 86 was readmitted with a diagnosis of Pigmentary Retinal Dystrophy, and during interview stated she was legally blind and needed staff to help set up her meal tray, identify food items, and tell her where the food was located on the plate. She reported that she had to wait to eat and repeatedly call staff to remind them she needed help with tray setup almost every meal since admission. Interviews and record review showed that CNA 1 was not aware the resident was legally blind and had not been informed of her blindness. LN 1 stated he knew the resident was blind and needed mealtime setup assistance, and said this should have been included in the care plan. LN 3 reviewed the written care plans and found no intervention for mealtime setup assistance, stating it should have been part of the baseline care plan. The DON acknowledged there was no care plan developed for the resident’s mealtime assistance and stated the baseline care plan was intended to identify basic needs at the time of admission. The facility policy stated a baseline care plan would be developed and implemented within 72 hours of admission, and the ADON stated the policy did not align with the federal requirement for baseline care plan development within 48 hours.
MAR and CMCS Did Not Reconcile for Controlled Pain Medications
Penalty
Summary
The facility failed to provide proper pharmaceutical services when the Medication Administration Record (MAR) and Controlled Medication Count Sheet (CMCS) did not reconcile for two residents receiving controlled pain medications. One resident was admitted for post-surgery care after joint replacement surgery and osteoarthritis and had an order for oxycodone HCL 5 mg, one tablet by mouth every 4 hours as needed for moderate pain and two tablets by mouth every 4 hours as needed for severe pain. The MAR and CMCS showed that a dose of oxycodone 5 mg was removed from locked supply on 7/31/25, but the MAR had a blank entry for that date, so it could not be determined whether the medication was administered. A second resident was admitted with diagnoses including post-surgery care and had an order for hydrocodone-acetaminophen 10-325 mg, one tablet by mouth every 4 hours as needed for severe pain. Review of the MAR and CMCS for this resident showed multiple dates and times where the records did not reconcile. During interview, an LPN described the process for controlled medication administration as verifying pain level, removing the medication from locked storage, comparing the physician order to the MAR and CMCS, administering the medication, and documenting on both records. The DON reviewed both residents’ records and stated that the MAR and CMCS did not reconcile, and that they should reconcile because they document controlled medications, nursing communication, and staff accountability.
Hand Hygiene Not Performed During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to follow hand hygiene practices during wound care for a resident with an unstageable pressure ulcer on the coccyx. The resident was admitted with diagnoses including cerebral infarction and hemiplegia. During an observed wound treatment, a licensed nurse and a CNA cleaned the resident after stool was noted on both buttocks, and the CNA briefly left to get supplies while the nurse washed her hands. The nurse then returned, donned new gloves, and began wound care while the resident was turned to the left side. During the wound treatment, the nurse removed and replaced gloves multiple times without performing hand hygiene between glove changes. The nurse removed the foam dressing, cleansed the wound, pat-dried it, applied medicated ointment, applied medicated powder, and applied a special dressing and foam dressing, each time changing gloves without hand hygiene. The nurse later stated she should have performed hand hygiene between glove changes. The IP stated staff were expected to perform hand hygiene when donning new gloves, and the DON stated hand hygiene during wound care was expected and necessary before putting on a new pair of gloves to decrease the risk of infections.
Failure to Provide Necessary Wound Care
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice for a resident who required wound care and treatment. The resident, who had a history of type two diabetes mellitus and had undergone a right below-the-knee amputation, was at risk for poor wound healing and infection. The resident missed a surgical wound appointment due to a positive COVID-19 test and was on isolation precautions. Despite the need for daily wound treatments as per medical orders, there were lapses in the administration of these treatments. The treatment administration record for the resident's surgical wound was left blank, indicating that the wound treatment was not performed on certain days. Interviews with the infection prevention nurse, licensed nurses, and the assistant director of nursing revealed inconsistencies and confusion regarding the resident's wound care. Licensed nurses acknowledged that the wound treatments were not documented or performed as required, with one nurse mistakenly believing the resident was absent from the facility due to dialysis. The assistant director of nursing emphasized the importance of daily wound treatments to prevent complications such as infection and poor wound healing, especially given the resident's diabetes and compromised circulation. The facility's policy on wound management was reviewed, but the lack of adherence to this policy contributed to the deficiency.
Failure to Report COVID-19 Outbreak and Update Infection Control Policies
Penalty
Summary
The facility failed to maintain an effective infection control program by not reporting a COVID-19 outbreak to local/state public health officials in a timely manner. The infection preventionist (IP) nurse was aware of COVID-19 symptoms in two nursing staff members, who tested positive on subsequent days. The outbreak expanded with additional staff and residents testing positive, but the IP did not report the outbreak immediately due to being off duty. The outbreak was not reported until several days later, despite the facility's policy requiring prompt reporting of communicable diseases. The Director of Nursing (DON) acknowledged the delay in reporting and noted that other trained staff were available to report the outbreak. Additionally, the facility did not review its infection control policies and procedures on an annual basis during the COVID-19 outbreak. The IP nurse admitted to not knowing if he was responsible for the annual review and revision of these policies. The facility's policies had not been updated since October 2022, and the IP acknowledged that current policies could have minimized or prevented the outbreak. The DON expected the IP to conduct annual reviews of the infection control policies, which was not done.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that a medication was administered per the physician's order for a resident with diabetes type 1, end-stage renal disease, and cirrhosis of the liver. The resident was supposed to receive Insulin Lispro via an insulin pump, but instead, a licensed nurse administered the insulin via injection. This error led to the resident's blood sugar level dropping significantly below the normal range, as documented in the progress notes and confirmed by interviews with the involved staff and the Director of Nursing. The incident occurred because the licensed nurse who administered the medication did not know what an insulin pump was and failed to double-check the physician's order or consult another nurse. The Director of Nursing acknowledged that the physician's order was not followed, and the facility's policy on medication administration was not adhered to. This failure had the potential to affect the resident's health, comfort, and well-being.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Vi At La Jolla Village | 0 mi | ★★★★★ | 22 | 0 |
| La Jolla Post-acute | 2.1 mi | ★★★★★ | 0 | 0 |
| The Cove At La Jolla | 3.7 mi | ★★★★★ | 0 | 0 |
| Kearny Mesa Convalescent And Nursing Home | 5.5 mi | ★★★★★ | 1 | 0 |
| Bayshire Torrey Pines Post-acute | 6.1 mi | ★★★★★ | 1 | 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.