Cycle 1
Health 2025-06-19 · Fire 2025-06-19
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
San Diego, CA
Mission Hills Post Acute Care
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3680 Reynard Way, San Diego, CA
(619) 297-4484
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1973-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.30
Registered nurse staffing
LPN hours / resident day
1.37
Licensed practical nurse staffing
Aide hours / resident day
2.40
Nurse aide staffing
Weekend hours
3.45
Weekend nurse staffing
RN turnover
56%
Annual RN turnover
Total nurse turnover
59%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
1.6%
0.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 13.1% |
6.8%
6.3 pts worse
|
11.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.5% |
4.1%
1.6 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.1% |
13.7%
4.6 pts better
|
19.6%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
14.2%
4.9 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.7% |
11.0%
10.7 pts worse
|
16.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
10.7%
2.8 pts better
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
10.9%
9.3 pts worse
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
4.7%
4 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
94.0%
5.9 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
11.2%
4.2 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.3% |
93.2%
6.1 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.1% |
23.2%
8.1 pts better
|
23.9%
8.8 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-01-27 · Fire 2022-01-27
23 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-10-10 · Fire 2019-10-10
11 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-01
D · Potential for more than minimal harm
2022-01-27
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-02-10
D · Potential for more than minimal harm
2022-01-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-10
D · Potential for more than minimal harm
2022-01-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-02-10
D · Potential for more than minimal harm
2022-01-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-02-10
D · Potential for more than minimal harm
2022-01-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-02-10
E · Potential for more than minimal harm
2019-10-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-19
D · Potential for more than minimal harm
2019-10-10
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2019-11-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-19
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-06-19
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-06-19
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-06-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-19
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-03-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-01-28
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-28
E · Potential for more than minimal harm
2024-10-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-10-08
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-07-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-04-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-03-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-03-14
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-03-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-21
G · Actual harm
2022-01-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-02-24
F · Potential for more than minimal harm
2022-01-27
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2022-02-24
F · Potential for more than minimal harm
2022-01-27
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2022-02-24
F · Potential for more than minimal harm
2022-01-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-02-24
E · Potential for more than minimal harm
2022-01-27
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-02-24
E · Potential for more than minimal harm
2022-01-27
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2022-02-24
E · Potential for more than minimal harm
2022-01-27
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F578 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-02-24
E · Potential for more than minimal harm
2019-10-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-10-10
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-10-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-10-10
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-10-10
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-10-10
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-10-10
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-10-10
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-10-10
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-10-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-10
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare South LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Afshar, Pouya
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Oh, Katherine
Corporate Director · Individual
Rapp, Damien
Operational/Managerial Control · Individual
Sato, Ami
Corporate Director · Individual
Twomagnets LLC
Operational/Managerial Control · Organization
Willits, Adam
Corporate Director · Individual
Nearby options
Other facilities in reach
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Hillcrest Heights Healthcare Center
San Diego, CA
3-star overall rating with 3-star inspections with $6,351 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Balboa Nursing & Rehabilitation Center
San Diego, CA
4-star overall rating with 3-star inspections with 17 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
St. Pauls Health Care Center
San Diego, CA
2-star overall rating with 2-star inspections with 26 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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