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 Villa Las Palmas Healthcare Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and mobility limitations used the call light during the night to request a brief change and reported waiting about two hours before a CNA responded. When the CNA arrived, the resident, described by staff as usually alert, oriented, and compliant, questioned the delay and may have raised her voice out of frustration. The CNA reportedly told the resident not to yell and stated she would change the resident when the resident was "ready," then proceeded to change the roommates first before returning and repeatedly asking if the resident was ready. The resident reported feeling belittled and angry after this interaction. In interviews, the CNA acknowledged changing the roommates while the resident calmed down and recognized this could be considered disrespectful, while facility leadership and policy confirmed expectations for prompt response to call lights, immediate changing of soiled briefs, and respectful communication to preserve resident dignity.
A resident with impaired cognition and multiple health conditions reported sexual harassment and inappropriate contact by a staff member, which was recognized as abuse by facility staff. However, the DON and abuse coordinator failed to report the allegation to the required authorities or initiate an investigation, contrary to facility policy.
A resident receiving IV antibiotics for pneumonia and UTI had two missed entries for PIV line flushing by LNs, as required by physician order. The DON confirmed the missed documentation and could not explain the omissions, leaving it unclear whether the flushes were performed as ordered.
A resident with severe cognitive impairment and a high risk for falls experienced multiple falls, including one resulting in a head injury, due to the facility's failure to revise and implement an individualized fall prevention plan. The care plan contained only general interventions and did not address the resident's specific needs related to cognitive deficits.
Surveyors found that food items in a resident refrigerator and freezer were not properly labeled, dated, or discarded within the required timeframe, with some items showing signs of spoilage. Staff interviews revealed inconsistent practices and understanding of the facility's food safety policy, resulting in improper storage and monitoring of resident food items.
A resident with a history of anxiety and PTSD was diagnosed with major depressive disorder after admission, but staff did not update the PASRR to reflect this new diagnosis. Interviews with the Admissions Director, MDS Coordinator, and DON confirmed that the required process for resubmitting a PASRR after a new mental health diagnosis was not followed, resulting in the resident not being referred for a level II PASRR as required.
Staff failed to follow a physician's order to hold a diuretic medication when a resident's systolic blood pressure was below a specified threshold, resulting in multiple administrations of the medication outside of ordered parameters. Nursing staff either overlooked or disregarded the hold order, and facility leadership confirmed that orders regarding vital sign parameters were expected to be followed.
A resident experienced verbal and mental abuse when a CNA made disparaging and humiliating comments about the resident's weight and ability to move in bed, causing the resident to cry and feel unsafe. The incident was witnessed by another CNA and reported to facility leadership, with documentation showing the CNA had a history of unprofessional conduct. The resident suffered emotional distress and was referred for psychological support.
A CNA verbally and emotionally abused a resident by making humiliating comments about the resident's weight and abilities, causing emotional distress. The charge nurse on duty did not gather sufficient information or escalate the incident, allowing the CNA to continue working. Facility policies and training did not adequately prepare staff to distinguish between rudeness and abuse or to conduct thorough investigations, despite prior warnings about the CNA's behavior.
Two residents identified as high risk for falls upon admission did not have baseline care plans developed within 48 hours, despite facility policy and fall risk assessments indicating the need for immediate interventions. Staff interviews confirmed that the lack of timely care plans resulted in fall prevention measures not being communicated to the care team.
The facility employed an SSD who did not meet federal qualifications, including lacking a bachelor's degree in social work or a related field and the required supervised social work experience. This was confirmed by the DON, HRA, and the SSD herself, following an anonymous complaint and subsequent investigation. All 151 residents were affected by the absence of a qualified SSD.
Failure to Maintain Resident Dignity During Delayed Toileting and Brief Care
Penalty
Summary
The deficiency involves a failure to treat a resident with dignity during toileting and brief care. The resident had diagnoses including polyneuropathy and osteomyelitis of the vertebrae and a BIMS score of 12, indicating moderate cognitive impairment. Staff interviews described the resident as alert, oriented, able to make her needs known, generally compliant, and easygoing. On the night in question, the resident reported that at approximately 3:00 a.m. she used her call light to request a brief change because she was wet and then waited until about 5:00 a.m. before a CNA responded. When the CNA finally arrived, the resident, who stated she was frustrated by the two-hour delay, asked why it had taken so long for the call light to be answered. According to the resident, the CNA did not provide an explanation, and when the resident may have raised her voice, the CNA told her, "Don't yell at me. When you are ready for me to change you, I will change you." The resident reported that the CNA then proceeded to change the other two residents in the room first, even though she was the one who had called for assistance, and only returned to her afterward, repeatedly asking, "Are you ready now?" The resident stated she felt belittled and angry following this interaction because she was in a vulnerable position and unable to care for herself independently. In a subsequent interview, the CNA involved acknowledged remembering the incident and stated that when she entered the room the resident was very angry and yelling. The CNA said she told the resident she would give her a few minutes to calm down, referencing a prior experience of being hit by a resident, and that while in the room she offered to change the roommates while the resident calmed down. The CNA further stated she had never been in the resident’s situation and recognized that changing the other residents before attending to the angry resident could be considered disrespectful. Facility leadership, including the DSD and ADON, stated that call lights were expected to be answered as soon as possible, soiled briefs were to be changed immediately, and that delaying toileting assistance and not responding promptly to such requests was disrespectful and a dignity issue. The facility’s dignity policy required prompt response to toileting requests, respectful communication, and prohibited demeaning practices that compromise dignity.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with impaired cognition and multiple diagnoses, including alcoholic cirrhosis, major depressive disorder, anxiety disorder, and unspecified dementia. The incident began when the resident called 911 to report that a staff member had engaged in flirtatious and inappropriate physical contact, which the resident described as sexual harassment. The Assistant Director of Nursing (ADON) and a Licensed Nurse (LN) were present during the police interview, during which the resident identified a staff member as the alleged perpetrator. Both the ADON and LN recognized the resident's statements as an allegation of abuse. Despite the clear identification of the incident as abuse, the Director of Nursing (DON) did not report the allegation to the State Licensing Agency or the Ombudsman, nor did she initiate an investigation, citing a desire to train the ADON in handling such incidents. The Director of Operations, who was the designated abuse coordinator, also acknowledged that the allegation was not reported as required. A review of the facility's policy confirmed that all allegations of abuse must be reported to the appropriate authorities within specified timeframes, which was not followed in this case.
Missed Documentation of PIV Line Flushing for Resident Receiving IV Antibiotics
Penalty
Summary
A deficiency was identified during an investigation of two complaints related to the administration of IV fluids and line care for a resident with pneumonia and a urinary tract infection. The resident was readmitted to the facility with physician's orders for antibiotic administration and for the PIV (peripheral intravenous) line to be flushed every shift by licensed nurses. Review of the resident's IV medication administration record for July revealed that documentation of PIV line flushing was missing for two specific shifts: the evening shift on 7/18 and the night shift on 7/19. During a joint review of the clinical record and interview with the DON, it was confirmed that there were two missed entries for PIV flushes, and the DON could not provide an explanation for the missing documentation. The facility's policy requires frequent monitoring of residents receiving IV fluids, including monitoring catheter patency and insertion site complications. The absence of documentation left uncertainty as to whether the PIV flushes were performed as ordered.
Failure to Individualize Fall Prevention Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to revise and implement an individualized fall prevention plan for a resident with a known history of falls and severe cognitive impairment. The resident, who had diagnoses including vascular dementia, metabolic encephalopathy, muscle weakness, and gait instability, was assessed as high risk for falls with a fall risk evaluation score of 20. Despite having a care plan that noted a history of self-transferring and poor safety awareness, the interventions listed were general, such as anticipating and meeting needs, and reminding the resident to call for assistance, without specific strategies tailored to the resident's severe cognitive impairment. The resident experienced two falls during their stay, with the most recent resulting in a one-inch skin tear on the back of the head after being found on the floor in their room. The care plan was not updated with individualized interventions following these incidents, and the facility did not implement specific fall prevention measures that addressed the resident's significant cognitive deficits. The deficiency was identified during an unannounced visit and through interviews and record reviews with facility staff.
Failure to Label, Date, and Discard Resident Food Items per Policy
Penalty
Summary
The facility failed to ensure that food items stored in the residents' refrigerator were properly labeled, dated, and discarded within the timeframe specified by facility policy. During an observation with a registered nurse, surveyors found a pizza with a gray substance in an unsealed, unlabeled, and undated container in the freezer, as well as chicken and rice with a gray substance and a date, a container of spaghetti labeled only with a room number, and a blue bowl of beans with no label or date in the refrigerator. The registered nurse acknowledged that the food items should have been labeled and dated, and stated that kitchen and dietary staff were responsible for maintaining refrigerator cleanliness. Interviews with facility staff, including the Dietary Director, DON, and Director of Operations, revealed inconsistent understanding and enforcement of the policy regarding food labeling, dating, and timely disposal. The Dietary Director expected foods to be labeled with a resident's name and date and stated that dietary aides were responsible for checking the refrigerator, while the DON and Director of Operations both indicated that food should be labeled, dated, and discarded within two days, and that management staff should ensure compliance. The presence of unlabeled, undated, and potentially spoiled food items indicated a failure to follow established procedures for food safety.
Failure to Update PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a level II Pre-Admission Screening and Resident Review (PASRR) after the resident received a new diagnosis of major depressive disorder. The resident was originally admitted with diagnoses of generalized anxiety disorder and post-traumatic stress disorder, and the initial PASRR did not include major depressive disorder. When the new diagnosis was made, there was no evidence in the medical record that a level II PASRR was resubmitted to the appropriate state-designated authority. Interviews with facility staff, including the Admissions Director, MDS Coordinator, and DON, confirmed that the process for updating PASRR screenings after a new mental health diagnosis was not followed. Staff acknowledged that the new diagnosis should have triggered another PASRR screening to ensure the resident's information was accurate and to determine if a level II screening was necessary. The facility policy required screening for mental disorders prior to admission and evaluation for care in the most appropriate setting, but this was not adhered to in this case.
Failure to Hold Diuretic Medication per Blood Pressure Parameters
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors by not adhering to a physician's order regarding the administration of spironolactone, a diuretic prescribed for congestive heart failure. The physician's order specified that the medication should be held if the resident's systolic blood pressure (SBP) was less than 120 mmHg. Despite this, the medication administration record (MAR) showed that spironolactone was given on multiple occasions when the resident's SBP was below the specified threshold. The resident involved had a history of acute on chronic systolic heart failure, pulmonary hypertension, and essential hypertension, and was assessed as having moderate cognitive impairment. The care plan directed staff to administer medications as ordered, and the facility's policy required verification of vital signs prior to medication administration when necessary. However, nursing staff administered the medication without consistently checking or adhering to the SBP parameter outlined in the order. Interviews with nursing staff revealed a lack of awareness or attention to the hold parameter in the physician's order. One nurse stated she did not see the order to hold the medication, while another acknowledged administering the medication despite the low SBP, relying on subsequent blood pressure readings and familiarity with the resident. Facility leadership, including the DON and Director of Operations, confirmed the expectation that staff follow physician orders regarding vital sign parameters for medication administration.
Verbal and Mental Abuse of Resident by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) verbally and mentally abused a resident by making disparaging and humiliating comments about the resident's weight and ability to perform bed mobility. The incident took place after the resident requested assistance to be repositioned in bed. The CNA entered the room, loudly commented on the resident's size, and stated she did not want to break her back helping the resident, while laughing and pointing at the resident. These actions were witnessed by another CNA, who reported that the resident began to cry during the incident and that the abusive comments continued despite the resident's distress. The resident, who required a two-person assist for bed mobility, experienced significant emotional distress as a result of the incident, including crying, feeling unsafe, and expressing feelings of worthlessness. The resident's husband confirmed the negative impact on his wife's emotional well-being. The incident was also corroborated by the assigned CNA and the charge nurse, both of whom identified the behavior as verbal and mental abuse based on their training. The housekeeper also reported hearing from other residents about the CNA's rude behavior, though she did not report it at the time. A review of the CNA's employee file revealed a history of disciplinary actions for unprofessional conduct, including rudeness to residents and staff, and a recent termination following the internal investigation of this incident. Facility staff, including the Director of Staff Development, Director of Operations, and Director of Nursing, all acknowledged that the incident constituted verbal and mental abuse, and facility policy prohibits such conduct. The resident was referred to psychiatric and psychological services following the event due to the emotional impact.
Failure to Identify and Respond to Verbal and Emotional Abuse
Penalty
Summary
The facility failed to ensure that staff were fully trained to correctly identify and respond to mental, emotional, and verbal abuse. A certified nursing assistant (CNA) yelled at a resident, made disparaging comments about the resident's ability to perform bed mobility, and humiliated the resident regarding her weight and size. The incident occurred late at night when the resident was alone and in a vulnerable state. The resident reported feeling unsafe, worthless, and emotionally distressed, and was observed crying during the interview. The resident's husband confirmed the negative impact of the incident on his wife. Other staff, including a housekeeper, were aware of the CNA's rude behavior but did not report it. The charge nurse (CN) on duty at the time was not adequately trained to collect pertinent information to make an accurate determination of abuse. When the incident was reported, the CN only received vague information and did not clarify the details or escalate the situation for further guidance. As a result, the CNA involved was allowed to finish her shift and continue providing care to residents after the incident. The director of staff development (DSD) and other leadership staff later acknowledged that the incident constituted verbal and mental abuse, and that the CN should have gathered more information and reported the incident appropriately. A review of facility policies and staff interviews revealed that while abuse prevention training was provided, it did not sufficiently cover the distinction between rudeness and abuse or equip staff in charge with the skills to thoroughly investigate and report abuse allegations. The CNA involved had a documented history of negative behavior, including previous written warnings. The failure to properly identify, report, and respond to the abuse incident resulted in the potential for other residents to experience similar mistreatment.
Failure to Develop Baseline Fall Risk Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan to address fall risk within 48 hours of admission for two residents. Both residents were admitted with conditions that included unsteadiness on their feet and a history of repeated falls, as documented in their admission records. Fall risk assessments conducted upon admission identified both residents as high risk for falls, with scores of 22 and 26, respectively. Despite these findings, there was no evidence in the clinical records that a baseline care plan for fall risk was created for either resident within the required timeframe. Interviews with facility staff, including a licensed nurse and the Director of Nursing (DON), confirmed that the purpose of the admission fall risk assessment is to identify high-risk residents and develop interventions to prevent falls. The DON acknowledged that interventions should have been in place immediately and that the absence of a baseline care plan meant that necessary fall prevention measures were not communicated to the care team. A review of facility policy further indicated that a baseline plan of care must be developed within 48 hours of admission to address immediate health and safety needs.
Unqualified Social Services Director Employed
Penalty
Summary
The facility failed to employ a qualified Social Services Director (SSD) on a full-time basis as required for facilities with more than 120 beds. An anonymous complaint was received regarding the SSD's qualifications, prompting an unannounced site visit by the California Department of Public Health. During interviews and record reviews, it was determined that the current SSD had only an associate's degree in nursing, was not a licensed nurse, and did not possess a bachelor's degree in social work or a related human services field as required by federal regulations. The SSD also lacked the necessary supervised social work experience in a health care setting. Both the Director of Nursing (DON) and the Human Resources Administrator (HRA) confirmed that the SSD did not meet the educational or experiential requirements outlined in the facility's job description and federal regulations. The SSD reported being placed in the position by a former administrator, who incorrectly informed her that she was qualified for the role. The current administrator was unavailable for interview, and the former administrator was no longer employed at the facility. This deficiency affected all 151 residents, as the facility did not have a qualified individual to provide medically-related social services necessary for residents' well-being.
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 581 citations issued within 25 miles in the last 12 months — including the 3 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 El Cajon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Victoria Post Acute Care | 0 mi | ★★★★★ | 12 | 0 |
| Magnolia Post Acute Care | 0.6 mi | ★★★★★ | 15 | 0 |
| Stillwater Post-acute | 0.6 mi | ★★★★★ | 2 | 0 |
| Somerset Post Acute Care | 0.7 mi | ★★★★★ | 2 | 0 |
| San Diego Post-acute Center | 0.9 mi | ★★★★★ | 13 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Villa Las Palmas Healthcare Center.
100% money-back within 48 hours.
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.