The Springs At Pacific Regent
3884 Nobel Drive, San Diego, CA 92122 · For profit - Limited Liability company · 59 certified beds · (858) 625-8700 Medicare only — no Medicaid
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.2% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.5% | 11.2% | 12.0% | better |
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
72.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 802 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 83.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 284 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 1.85 therapist hours per resident per day in 2026Q1 — more than 100% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 72.8%CMS range 69.6–75.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 7.6–10.7 | 10.7% | Oct 2022–Sep 2024 | better than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 83.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 73.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 62.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 99.2% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 99.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 4.6%CMS range 3.2–6.3 | 7.1% | Oct 2023–Sep 2024 | better than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 59 beds and averages 56.5 residents a day — about 96% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.12 hrs/resident/day on weekends vs 5.44 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.89 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · E2025-08-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when:1. On the clean dish rack there was a cracked 7.5 quart plastic cambro container, two serving dishes that had food particles stuck on them and four wet mixing bowls stacked on a shelf.2. Refrigerated food items had a white, fuzzy substance growing on them and were stored alongside unspoiled food products. Two refrigerated peeled and cut cucumbers were wrapped in plastic and not labeled or dated.3. A large cambro container in the warming oven had a yellow, clear, liquid substance in it that was labeled as olives. Food particles and crumbs were in the drawers and on the shelves of the prep cart. A spatula was covered with a slimy, greasy coating. There were grease smudges on the back of the plate dispenser. 4. The cook (CK) took temperatures of the food on the steam table without visualizing where the temperature probe was placed. 5. The temperature of soup was not taken prior to placing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-06 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the baseline care plan included person-centered care during mealtimes for one of fourteen residents (Resident 86) within 48 hours of the resident's admission. This failure to develop the baseline care plan within 48 hours of admission for mealtime assistance resulted in the resident calling to request mealtime set ups multiple times a day continuously since admission. Findings:A review of the facility's admission Record indicated Resident 86 was readmitted to the facility on [DATE] with diagnosis including Pigmentary Retinal Dystrophy (an inherited eye disorder that causes loss of sight). On 8/3/25 at 9:10 A.M., an interview was conducted with Resident 86. Resident 86 stated that she was legally blind and needed help with meal tray set up. Resident 86 stated she needed staff to identify the food items and the location of the food on her plate. Resident 86 then stated that she would have to wait to eat and then call to remind the staff that she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, 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 randomly selected residents (Resident 91 and 61). This failure had the potential to place Resident 91 and Resident 61 at risk for inaccurate pain medication administration and/or diversion (illegal distribution or abuse of prescription drugs) of controlled medications (medications that the use and possession of are controlled by the federal government). Findings:1. A review of Resident 91's admission record indicated the resident was admitted to the facility on [DATE] for the diagnosis including post-surgery care for joint replacement surgery and osteoarthritis (a condition where the cartilage in the joints wears down over time and causes pain). A review of Resident 91's physician order dated 7/21/25 indicated: Oxycodone HCL oral tablet (a type of controlled medication) 5 MG (milligrams). Give one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices related to hand hygiene (washing hands with soap and water or using alcohol-based hand sanitizer) during wound care for one resident (Resident 51). As a result of this deficient practice, Resident 51 was at an increased risk of infection. Findings: A review of Resident 51's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke, loss of blood flow to a part of the brain) and hemiplegia (paralysis or severe weakness on one side of the body).A review of Resident 51's physician order for wound treatment dated 7/29/25, indicated Resident 51 had an unstageable pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the coccyx (tailbone) area. On 8/6/25 at 10:24 A.M., an observation of wound treatment for Resident 51 was conducted with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice for one resident (1) reviewed for wound care and treatment. This deficient practice placed Resident 1 at risk for harm related to poor wound healing and infection. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of type two diabetes mellitus (health condition in which the body is unable to regulate blood sugar levels; can lead to complications of poor circulation and multi-system problems with the eyes, heart, kidneys, and limbs [arms, legs]), per Resident 1's admission Record. A record review of Resident 1's Minimum Data Set (MDS- nursing assessment tool that is used to develop a plan of care) dated 6/21/24 , indicated a Brief Interview for Mental Status (BIM- developed by reviewing the resident's status during the prior seven day period) score of 15 points out of 15 possible points which indicated Resident 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain an effective infection control program when the facility did not: 1. Report coronavirus (COVID-19: A highly contagious respiratory disease caused by the SARS-CoV-2 virus) outbreaks to the local/state public health officials in a timely manner. 2. Review the facility infection control policies and procedures on an annual basis during a COVID-19 outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) at the facility. These failures had the potential to increase the risk of healthcare-associated infections for staff, residents, and visitors in the facility. Findings: 1. A joint interview and record review of the facility's infection control log was conducted on 6/27/24 at 12 P.M., with the infection preventionist (IP) nurse. The IP stated that two nursing staff (licensed nurse [LN] 1 and 2) had COVID-19 symptoms that started on 6/16/24. The IP nurse stated that COVID-19 testing was conducted when LN 1 tested positive on 6/18/24 and LN 2 tested…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-17 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one medication (med) was administered per physician ' s order for one resident (2). Resident 2 ' s Insulin Lispro (med to control high blood sugar) was administered via injection, and not via insulin pump (medical device that supplies a continuous flow of insulin subcutaneously [beneath the skin]), as ordered. As a result, Resident 2 ' s blood sugar level dropped below a normal range. This failure had the potential to affect Resident 2 ' s health, comfort, and well-being. FINDINGS: Resident 2 was admitted to the facility on [DATE] with diagnoses which included diabetes type 1 (DM 1 – high blood sugar; body produces very little insulin – hormone that lowers the level of sugar in the blood), end stage renal disease (permanent kidney failure) and cirrhosis of the liver (severe scarring of the liver). A review of Resident 2 ' s medical records were conducted. The Order Summary Report, dated 4/1/2024, indicated Resident 2 had an order for Insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-08 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement person-centered care plans related to the monitoring and inspection of bed alarms (auditorial alarms that alerts caregivers when patients leave or attempt to leave their beds), for three of three residents (Resident 1, 2, and 3), reviewed for accidental falls. As a result, there was the potential for Resident 1, 2, and 3 ' s bed alarms to not be monitored for functionality and staff were unaware of the bed alarms were in use. Findings: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral autosomal dominant arteriopathy (an inherited disease that causes strokes and other neurological impairments), per the facility ' s admission Record. On 3/1/24 Resident 1 ' s clinical record was reviewed. According to the facility ' s admission Minimum Data Set (MDS-a clinical assessment tool), dated 2/14/24, Resident 1 was alert, but aphasic (inability to form words), and required staff assistance for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess post Fall Risk Evaluations to ensure a higher score was in place after an actual fall, in order to prevent future falls from occurring for one of three residents, (Resident 2) reviewed for Accidents related to falls. As a result, post Fall Risk Evaluation scores decreased after each fall, putting Resident 2 at risk for additional falls. Findings: Resident 2 was admitted to the facility on [DATE], with diagnoses which included wedge compression fracture of second lumbar vertebra (lower spine) and history of falling, per the facility ' s admission Record. On 3/1/24, Resident 2 ' s clinical record was reviewed. According to the facility ' s admission MDS, dated [DATE], a cognitive score of 10 was listed, which indicated moderately impaired cognition. The functional status indicated staff assistance was required to transfer (moving from lying, to standing and to sitting), eating and toilet use. The resident had a history of falls, prior…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review the facility failed to ensure 2 of 13 sampled resident's (24 and 107) Physician Orders for Life Sustaining Treatment (POLST) document was acknowledged and signed by the resident's physician. As a result, the residents' end of life wishes may not have been followed. Findings: 1. Resident 24 was admitted to the facility on [DATE], with diagnosis that included spinal stenosis, per the facility's Face Sheet. Resident 24 was cognitively intact according to the history and physical dated 7/24/23. On 8/24/23 Resident 24's Electronic Medical Record (EMR) was reviewed. The POLST in the EMR chart was signed by Resident 24 and dated 7/23/23. A copy of the POLST was requested on 8/23/23 and was received 8/24/23. The POLST was not signed by Resident 24's physician until 8/23/23. 2. Resident 107 was admitted to the facility on [DATE], with diagnosis that included a stroke, per the facility's Face Sheet. On 8/24/23, Resident 107's Electronic Medical Record (EMR) was reviewed. The POLST was not found in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 9 citations
- Potential for harm · D2023-08-25 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 1 of 13 sampled residents (36) was properly assessed for a psychiatric diagnosis when he was prescribed, and administered antipsychotic and anti-seizure medications. As a result, Resident 36 received medications for a condition he did not have. Findings: Resident 36 was admitted to the facility on [DATE], with diagnosis that included encephalopathy (disease of the brain), and dementia (decline in cognition, memory loss) per the facility's Face Sheet. On 8/25/23 Resident 36's Electronic Medical Record (EMR) was reviewed. Resident 36 had a physician's order dated 7/6/23, for Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) 100 mg, give 300mg every night for behavioral and physical symptoms. Resident 36 also had an order dated 7/10/23, for Depakote sprinkles (used to treat seizure disorders, mental/mood conditions (such as manic phase of bipolar disorder), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a care plan for 1 of 13 sampled residents (125). This failure had the potential risk of not providing appropriate and individualized care for Resident 125. Findings: Resident 125 was admitted to the facility on [DATE] with diagnoses that included Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms, and retention of urine (the bladder does not empty completely) according to the facility's admission Record. An observation of Resident 125 was conducted on 8/23/23 at 9:15 A.M. Resident 125 was reclining in bed and had an indwelling urinary catheter draining amber-colored urine. A review of Resident 125's medical record was conducted on 8/23/23 at 9:30 A.M. A physician's order, dated 8/17/23, indicated, Indwelling urinary catheter: change urinary drainage bag as needed; Indwelling urinary catheter: secure with catheter strap; Indwelling urinary catheter: cleanse site with soap and water. In addition, no care plan for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the Medication Regime Review (MRR) identified 1 of 13 sampled residents (36) who was on multiple psychoactive medications without a psychiatric diagnosis. As a result, Resident 36 received inappropriate medications. Findings: Resident 36 was admitted to the facility on [DATE], with diagnosis that included encephalopathy, and dementia per the facility's Face Sheet. On 8/25/23 Resident 36's Electronic Medical Record (EMR) was reviewed. Resident 36 had a physician's order dated 7/6/23, for Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) 100 mg, give 300mg every night for behavioral and physical symptoms. Resident 36 also had an order dated 7/10/23, for Depakote sprinkles (used to treat seizure disorders, mental/mood conditions (such as manic phase of bipolar disorder), and to prevent migraine headaches) oral cap delayed release, 125 mg 1 capsule every day for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 1 of 13 sampled residents (53) had not been put on Trazodone for a non-FDA approved indication, which resulted in this medication becoming an unnecessary drug for Resident 53, as this medication had been prescribed without an adequate (FDA approved) indication. This deficient practice resulted in this resident receiving Trazodone for a clinical indication, which had not been FDA approved, which could have caused this resident harm. Findings: Resident 53 was admitted to the facility on [DATE], with diagnosis that included encephalopathy, per the facility's Face Sheet. On 8/25/23 Resident 53's Electronic Medical Record (EMR) was reviewed. Resident 53 had a physician's order dated 7/18/23, for Trazodone (DESYREL) [a medication used to treat depression] 50 mg 1 tablet by mouth at bedtime for insomnia. This medication had been prescribed to treat Resident 53's inability to sleep, not depressive disorder for which this medication has been FDA approved.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that medications were administered safely for 1 of 13 sampled residents (155). This failure had the potential to cause a medication error for Resident 155. Findings: Resident 155 was admitted to the facility on [DATE], with diagnoses that included a fracture of the left femur (thigh bone) and a history of falling, according to the facility's admission Record. An observation was conducted of Resident 155 on 8/22/23 at 11:35 A.M. Resident 155 was relaxing in bed and a medicine cup with 3 medications was set on the overbed table. A concurrent observation and interview was conducted with licensed nurse (LN) 11 on 8/22/23 at 11:36 A.M. LN 11 stated the medicine cup on the overbed table contained two doses of Colace (stool softener) and one dose of Senna (laxative). LN 11 stated, It is not acceptable to leave unattended meds (medications) at the resident's bedside. A review of Resident 155's medical record was conducted on 8/23/23 at 11…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility did not maintain the temperature range of a resident's room between 71° F and 81° F for 1 sampled resident (161). As a result, a resident was exposed to cold temperatures. Findings: Resident 161 was admitted to the dacility on 1/29/19 with diagnoses that included fracture of sacrum (a bone at the base of the spine) per the facility's admission Record. On 2/12/19 at 10:57 A.M., an observation and interview was conducted of Resident 161. Resident 161 stated, the facility was too cold. Resident 161 further stated, she had to stay in bed because it was too cold to sit up in a chair. The thermostat in Resident 161's room read 68° F. On 2/13/19 at 7:55 A.M., an observation and interview was conducted with the PS. The PS stated, Resident 161's heater was turned off. The PS used an infrared thermometer to check the temperature of Resident 161's room. The result read 68.2° F. On 2/13/19 at 7:59 A.M., an interview was conducted with Resident 161. Resident 161 stated, she did not know her heater was off, she did not want her heater to be turned…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-14 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents' reported concerns were acted upon promptly for three of the three consecutive resident council minutes reviewed. This failure had the potential for residents needs to not met, affecting their dignity and quality of life. Findings: On 2/13/19 at 9:57 A.M., an interview was conducted with the ACTS. The ACTS stated there was no Resident Council in the facility. The ACTS stated residents were mostly concerned about having difficulty getting help from the CNAs. On 2/13/19 at 10:08 A.M., the facility form, titled, ABSENTEE PARTICIPANTS FOR RESIDENT COUNCIL was reviewed with the ACTS and contained the following information: Resident Council Department Feedback, Department: Nursing, dated 11/28/18 Resident's Feedback, Sometimes it takes a while to get help from the CNA's. 5 resident names were listed. Departmental Response: Inservice CNA and LN, Skill check with CNA. Resident Council Department Feedback, Department: Nursing, dated 12/23/18 Resident's Feedback, Sometimes it's hard to get help from CNA's NOC…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-02-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not follow a physician's order on medication dosing for 1 sampled resident (163). As a result, Resident 163 exceeded the ordered maximum amount of acetaminophen (pain medication) per day. Findings: Resident 163 was admitted to the facility on [DATE] with diagnoses to include fracture of femur (thigh bone) per the facility's admission record. On 2/12/19 a review was conducted of Resident 163's physician's orders. Resident 163 had the following orders: Do not exceed 3,000mg of Acetaminophen from all sources within a period of 24 hours. Percocet 5-325mg (pain medication), half of a tablet 1 hour before rehab (162.5mg of acetaminophen). Acetaminophen 650mg, 1 tablet 4 times per day for pain management. Acetaminophen 650mg, 1 tablet every 4 hours as needed for pain. On 2/12/19 at 1:44 P.M., an interview was conducted with Resident 163. Resident 163 stated, the staff had not given her enough medicine for her leg pain. On 2/13/19 at 8:20 A.M., an interview was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-14 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to verify the accuracy of the meal trays prior to serving to the residents for one of four meal observations. This failure had the potential for residents to receive incorrect diet and food consistency. Findings: On 2/12/19 at 12:27 P.M., a lunch meal observation was conducted on the second floor unit. A CNA opened the meal cart and immediately took one food tray and delivered the food tray in room [ROOM NUMBER]B. After delivering the food tray, the same CNA took another tray from the cart and proceeded directly to room [ROOM NUMBER]A. The CNA did not check either tray prior to delivering them to the resident's room. On 2/12/19 at 1:11 P.M., an interview was conducted with CNA 7. CNA 7 stated the trays did not need to be checked by an LN because they were already checked by the nutritionist down in the kitchen. On 2/12/19 at 1:15 P.M., an interview was conducted with LN 6. LN 6 stated trays should be checked by the LNs first before serving…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.2 | +1.8 vs chain |
| Health inspection | 5 of 5 | 2.8 | +2.2 vs chain |
| Staffing | 3 of 5 | 2.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| AFSHAR, POUYA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2022 |
| BURNAM, SOON | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 10/01/2011 |
| STEVENSON, MATTHEW | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/15/2016 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | since 10/01/2011 |
| PORT, BARRY | Individual | CORPORATE OFFICER | since 10/01/2011 |
| WILLITS, ADAM | Individual | CORPORATE OFFICER | since 02/01/2017 |
| TWOMAGNETS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2011 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | since 10/01/2011 |
| NOBEL HEALTH PROPERTIES LLC | Organization | ADP OF THE SNF | since 10/01/2011 |
| THE ENSIGN GROUP INC | Organization | ADP OF THE SNF | since 10/01/2011 |
CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the California Medicaid page for homes that do.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555739. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.