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 University Care Center during CMS and state inspections, most recent first.
A resident with hypothyroidism and acid reflux did not receive morning medications on time due to multiple LNs splitting the tasks of preparing, administering, and documenting the medications, with one LN signing the MAR before the medications were actually given. This practice was not in accordance with facility policy, which requires the same licensed individual to prepare, administer, and document medication administration, creating the potential for medication errors.
A cook was observed placing a used mixing spoon with clean utensils during the preparation of pureed meals for multiple residents. Both the registered dietician and DON confirmed that this practice was inappropriate and contrary to facility policy, which requires measures to prevent cross-contamination during food preparation.
Three residents with complex medical conditions had incomplete POLST forms, missing key information such as effective dates and the relationship of the signer to the resident. This incomplete documentation was confirmed by a nurse and could lead to confusion among care providers.
Surveyors identified infection control lapses, including clean linens stored in contact with outside packages, trash cans and debris in clean linen closets, and a nurse administering medications to a resident with a gastrostomy tube under Enhanced Barrier Precautions without wearing a required gown. Facility staff acknowledged these practices did not meet infection control standards.
Two residents did not receive care in accordance with professional standards: one with a PICC line did not have required catheter length measurements performed or documented during dressing changes, and another with a gastrostomy tube had medications administered without verification of tube placement. Nursing staff and the DON confirmed these omissions, which were contrary to facility policy and physician orders.
A resident with severe cognitive impairment, total dependence for ADLs, and high risk for pressure ulcers was not consistently turned and repositioned every two hours as required by their care plan and facility policy. Multiple observations and staff interviews confirmed the lack of regular repositioning, despite the resident's significant risk factors for skin breakdown.
A resident with dysphagia and aphasia who was receiving enteral nutrition via a gastrostomy tube had their tube feeding formula administered without a required label. Observation and interviews with a per diem nurse and the DON confirmed the formula was not labeled, contrary to facility policy, which mandates labeling for safety and accuracy.
Nine rooms housing three residents each did not meet the required minimum of 80 sq ft per resident, with each room measuring between 206 and 211 sq ft. No residents expressed concerns, and no negative impacts on quality of care or quality of life were observed.
A resident with hypothyroidism did not receive Levothyroxine as per the prescribed schedule, with doses administered later than the ordered 6 AM time. The facility's care plan policy, which requires timely and person-centered interventions, was not followed, as confirmed by the LN and DON.
A resident with hypothyroidism did not receive Levothyroxine at the prescribed time of 6 AM, as documented in the MAR. The medication was administered later than ordered on multiple occasions, potentially affecting its absorption and effectiveness. The LN was unaware of the specific reasons for the timing, and the DON emphasized the importance of timely administration. The facility's policy supports timely medication administration to enhance therapeutic effects.
A facility failed to ensure that agency staff had the necessary competency to document care, resulting in a CNA not documenting care for a resident who died, and an LN administering medications late. The resident had multiple diagnoses, including congestive heart failure and diabetes. The facility did not review the agency's skills checklists, and there was no documentation of a change in condition or physician notification regarding abnormal lab results.
A resident with multiple health issues, including open sores, was found in a room with old food and numerous insects, posing infection risks. The resident had not received regular showers or clean clothing, contrary to facility policy. Staff interviews revealed a lack of awareness about the risks, and pest control issues were noted.
The facility failed to document proactive maintenance checks for room temperatures during extreme temperature changes. An unannounced visit revealed malfunctioning air conditioning in the east hallway, with residents reporting discomfort. The Director of Maintenance admitted to not documenting temperature checks for over a year, and the Administrator was unaware of the lack of temperature monitoring during the outage.
A resident with hemiplegia had a stage 1 pressure injury that was not documented weekly as required by the facility's policy. The Treatment Nurse confirmed the oversight, and the DON acknowledged the lapse in following the protocol for weekly monitoring and documentation of pressure injuries.
Failure to Follow Medication Administration Policy
Penalty
Summary
Licensed Nurses (LNs) at the facility failed to follow established policy and procedure regarding medication administration for a resident diagnosed with hypothyroidism and acid reflux. The resident, who was alert and oriented and had decision-making capacity, reported not receiving his morning medications on time. Upon inquiry, it was discovered that one LN had prepared the medications, another LN administered them, and a third LN had already signed the Medication Administration Record (MAR) as if the medications had been given, even though the resident had not yet received them. This process was confirmed through interviews with the involved LNs and review of the resident's clinical record. The facility's policy requires that the same licensed individual who prepares the medication must administer it and document the administration in the MAR. The Director of Nursing and Administrator confirmed that this expectation was not met in this instance, as the tasks were divided among three different LNs, contrary to policy. This deviation from professional standards of practice created the potential for medication errors, as the MAR did not accurately reflect the actual administration of medications.
Failure to Separate Clean and Used Utensils During Meal Preparation
Penalty
Summary
During the preparation of pureed meals for nine residents, a cook (CK) was observed placing used utensils, specifically a large mixing spoon that had been used to mix tortillas and turkey meat in a blender, into a tray containing clean mixing spoons and colored scoops. This action occurred in the presence of the registered dietician (RD) and was directly observed by surveyors. The CK acknowledged during an interview that it was important not to mix used and clean utensils to prevent possible contamination, and admitted to being nervous as it was her first time being observed during a survey. The RD confirmed witnessing the incident and stated that mixing clean and used utensils was not appropriate due to the risk of contamination. The Director of Nursing (DON) also stated in an interview that separating clean and used utensils is important to prevent cross-contamination and protect residents' health. A review of the facility's policy on food preparation and service indicated that appropriate measures must be used to prevent cross-contamination, which was not followed in this instance.
Incomplete POLST Documentation for Multiple Residents
Penalty
Summary
The facility failed to maintain complete Physician Orders for Life Sustaining Treatment (POLST) forms for three residents. During a review, it was found that the POLST forms for these residents were incomplete, lacking necessary information such as the date the form became effective and the relationship of the person signing the form to the resident. These omissions were confirmed during interviews with a licensed nurse, who acknowledged that the forms should have been fully completed to accurately reflect the residents' wishes regarding life-sustaining treatment. The residents involved had significant medical conditions, including dementia, muscle weakness, adult failure to thrive, hemiplegia, hemiparesis following a stroke, bacteremia, diabetes type 2, endocarditis, autistic disorder, and cognitive communication deficits. The incomplete documentation did not provide an accurate representation of the care provided and had the potential to cause confusion among care providers, as noted in the findings.
Infection Control Lapses in Linen Handling and Enhanced Barrier Precautions
Penalty
Summary
Surveyors observed multiple infection control deficiencies within the facility. Clean linens were found stored in direct contact with packages transported from an outside laundry service, with the Director of Environmental Services (DES) and Infection Preventionist Nurse (IP) confirming that packaging should be removed before linens are placed in closets. Additionally, trash cans, including one containing used gloves, were present inside clean linen closets, which both the DES and IP acknowledged should not occur. The clean linen closets also had visible dust and debris on the floor, contrary to facility policy and staff statements that these areas should be kept clean and free from trash and dust. A licensed nurse was observed administering medications to a resident with a gastrostomy tube (GT) who was under Enhanced Barrier Precautions (EBP) without wearing the required isolation gown. The nurse performed hand hygiene and wore a face mask but did not don a gown, later stating she was unaware of the requirement. EBP signage posted outside the resident's room clearly indicated that gown and gloves were required for high-contact activities such as device care, including feeding tubes. The Director of Nursing (DON) confirmed that all staff are expected to adhere to infection control procedures.
Failure to Follow Professional Standards for PICC and GT Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents. For one resident with a peripherally inserted central catheter (PICC line), physician orders and facility policy required that the external catheter length be measured with each dressing change and documented. However, review of the Medication Administration Record (MAR) and interviews with nursing staff and the Director of Nursing (DON) confirmed that these measurements were not performed or documented during April. The DON acknowledged that measuring and documenting the PICC line length was a standard of practice and should have been completed as ordered. In a separate incident, a resident with a gastrostomy tube (GT) did not have tube placement checked prior to medication administration. Observation of a licensed nurse administering medications revealed that the nurse flushed the GT and administered medications without verifying tube placement, as required by facility policy. The nurse admitted to not checking placement, and the DON confirmed that verifying GT placement before administering medications was necessary to prevent complications.
Failure to Consistently Reposition Resident at Risk for Pressure Ulcers
Penalty
Summary
A deficiency was identified when a resident, admitted with acute respiratory failure with hypoxia and dysphagia, was not consistently turned and repositioned every two hours as required by their care plan and facility policy. Multiple observations over two days showed the resident lying on their back for extended periods, with only minor adjustments such as a pillow under the left arm, and no evidence of repositioning. A family member also reported not seeing the resident turned or repositioned during their visit. Interviews with nursing staff confirmed the importance of regular turning and repositioning to prevent skin breakdown, especially given the resident's severe cognitive impairment, total dependence on activities of daily living, and high risk for pressure ulcers as indicated by their Braden score and care plan. Record reviews further confirmed that the resident was dependent for all ADLs, had a severely impaired mental status, and was at risk for skin breakdown due to immobility and contractures. Despite these risk factors and clear care plan interventions, the required two-hourly turning and repositioning was not consistently implemented. The facility's own policy also emphasized individualized repositioning schedules for residents at risk of pressure injuries, which was not followed in this case.
Failure to Label Tube Feeding Formula for Resident Receiving Enteral Nutrition
Penalty
Summary
A resident with diagnoses of dysphagia and aphasia was admitted to the facility and required a gastrostomy feeding tube. During an observation, it was noted that the resident's tube feeding formula, Fiber source HN, was being administered at a specified rate but was not labeled as required. The lack of labeling was confirmed during interviews with a per diem licensed nurse and the Director of Nursing, both of whom acknowledged the importance of labeling for safety, accuracy, and adherence to physician orders. A review of the facility's policy on enteral feedings indicated that the formula label should include the resident's name, ID, room number, type of formula, date and time prepared, and initials of the person who hung the formula. The policy also requires verification of the label against the order before administration. The failure to label the tube feeding formula was identified through observation, interview, and record review, and was found to be inconsistent with facility policy and standard safety practices.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in nine out of 39 resident rooms, as determined through review of the Client Accommodations Analysis form. Specifically, rooms 31, 33, 35, 36, 37, 38, 39, 40, and 41 each housed three residents but did not meet the square footage requirement, with each room measuring slightly above 206 to 211 square feet, resulting in less than 80 square feet per resident. Observations and a confidential resident group interview were conducted, and no residents expressed concerns about their rooms. Additionally, no quality of care or quality of life concerns were observed during the survey period for residents in these rooms.
Failure to Implement Care Plan for Medication Administration
Penalty
Summary
The facility failed to implement a care plan related to medication administration for a resident diagnosed with hypothyroidism. The resident was admitted with a physician's order to receive Levothyroxine at 6 AM, which should be administered on an empty stomach or before breakfast. However, a review of the medication administration record (MAR) revealed that the medication was administered at various times between 8:24 AM and 8:37 AM on multiple occasions, deviating from the prescribed schedule. During interviews, the Licensed Nurse (LN) confirmed that the medication was ordered to be given at 6 AM, and the Director of Nursing (DON) acknowledged that the medication should be administered within one hour before or after the scheduled time. The facility's policy on care plans emphasized the need for comprehensive, person-centered care plans with measurable objectives and timetables, which were not adhered to in this case, leading to the deficiency.
Failure to Administer Levothyroxine on Time
Penalty
Summary
The Licensed Nurses (LNs) at the facility failed to administer Levothyroxine to Resident 1 within the time frame ordered by the physician. Resident 1, who was admitted with a diagnosis of hypothyroidism, had a physician's order for Levothyroxine to be administered at 6 AM. However, the Medication Administration Record (MAR) showed that the medication was consistently given later than ordered, with times recorded at 8:24 AM, 8:31 AM, 8:37 AM, and 8:29 AM on various dates. This deviation from the prescribed schedule had the potential to affect the absorption and effectiveness of the medication. During interviews, LN 1 acknowledged the medication should be administered on an empty stomach or before breakfast, as per the physician's order, but was unaware of the specific reasons for this requirement. The Director of Nursing (DON) confirmed that medications should be administered on time, emphasizing the importance of adhering to the prescribed schedule due to potential medical reasons. The facility's policy on administering medications, revised in April 2019, also highlighted the need for timely administration to enhance therapeutic effects and prevent interactions. Despite these guidelines, the failure to administer Levothyroxine as ordered was identified as a deficiency during the survey.
Deficiency in Staff Competency and Documentation
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN) provided by an agency had the necessary competency to document care during their shift. As a result, the CNA did not document any care provided for a resident who was sampled for death, and the LN documented medications were given late. Additionally, there was no documentation of a change in condition or physician notification regarding abnormal laboratory results. Furthermore, no follow-up social services notes were documented for the resident's roommate who was present at the time of the resident's death. The facility was unable to provide requested evidence of the events prior to the resident's death. The resident involved had multiple diagnoses, including congestive heart failure, diabetes mellitus type two with chronic kidney disease stage three, acute respiratory failure with hypoxia, and pulmonary hypertension. The Director of Nursing (DON) acknowledged that the agency staff did not participate in facility training and that the facility did not review the agency's skills checklists before allowing them to work. The DON also noted that the insulin administration was documented late, and there was no documentation to clarify if two doses of Lispro were given within one hour of each other. The facility's policy indicated that medications should be administered within one hour of their prescribed time, but this was not adhered to in this case.
Inadequate Infection Control and Hygiene Practices
Penalty
Summary
The facility failed to maintain an adequate infection prevention and control program, as evidenced by the conditions observed in the room of a resident with multiple health issues, including severe protein-calorie malnutrition and open sores. During an unannounced visit, it was noted that the resident's room contained an accumulation of old food and beverage items, which attracted numerous small flying insects. These insects were observed landing on the resident's skin, food, and beverages, posing a risk of foodborne illness and infection to the resident's open wounds. The resident was also found wearing soiled clothing, with disheveled hair, and the surrounding area was notably dirty. Interviews with staff, including a CNA and the Infection Preventionist, revealed a lack of awareness and understanding of the risks associated with the presence of insects and old food in the resident's environment. Further investigation revealed that the resident had not received regular showers or bed baths, as required by the facility's policy, which mandates bathing twice per week. The resident's shower log indicated only one shower was provided over a period of several weeks, and nail care was not performed weekly as required. The Director of Nursing acknowledged the failure to provide adequate hygiene care, which is essential to prevent bacterial growth and potential infection. Additionally, the facility's pest control report indicated ongoing issues with fruit fly activity, which had not been adequately addressed. The facility's policies on infection prevention and control, as well as bathing procedures, were not effectively implemented, contributing to the observed deficiencies.
Failure to Document Temperature Checks During HVAC Malfunction
Penalty
Summary
The facility failed to provide documented evidence of proactive maintenance checks for room and facility temperatures during extreme temperature changes. An unannounced visit was conducted following a complaint about the air conditioner malfunctioning in the east hallway. Observations revealed that resident rooms in the east hallway had one or more fans, and a small air conditioner unit was present in one room. Ceiling fans were operational along the hallway. Resident 3 reported that her room had been hot for several days due to the broken air conditioner, and she was informed that a part was needed for repairs. The Director of Maintenance (DM) acknowledged that the air conditioner in the east hallway stopped working on a Sunday night and informed the Administrator (ADM) the following morning. A repair company was contacted, and the blower part was replaced, but another issue arose with the air conditioner in the north hallway. The DM admitted to routinely checking room temperatures weekly but had not documented these checks for at least a year. During the visit, room temperatures were measured, with some rooms exceeding the recommended range of 72-80 degrees Fahrenheit. The DM was unable to locate the binder where temperatures were previously recorded. The ADM, who started at the facility recently, was aware of the air conditioner issue but was not informed that temperature checks were not being performed during the outage.
Failure to Document Weekly Pressure Injury Assessments
Penalty
Summary
The facility failed to ensure that pressure injuries were documented in the medical record every week as per the facility's policy for one of the sampled residents. Resident 1, who was admitted with hemiplegia, had a stage 1 pressure injury to the sacral area documented in the progress notes. However, the required weekly wound assessments were not conducted, as confirmed by the Treatment Nurse during an interview. The Director of Nursing acknowledged that pressure injuries should be monitored weekly and documented in medical records, in accordance with the facility's policy and procedure. The policy, dated 2001, specifies that skin assessments should be repeated weekly and any skin issues should be described and documented. The failure to perform these assessments resulted in the inability to accurately assess the progression or deterioration of Resident 1's pressure injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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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) |
|---|---|---|---|---|
| Jacob Healthcare Center | 0.2 mi | ★★★★★ | 17 | 0 |
| Arroyo Vista Nursing Center | 1.4 mi | ★★★★★ | 7 | 0 |
| Brighton Place San Diego | 2 mi | ★★★★★ | 3 | 0 |
| La Mesa Healthcare Center | 2.3 mi | ★★★★★ | 3 | 0 |
| Bella Vista Health Center | 3 mi | ★★★★★ | 11 | 0 |
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