Cycle 1
Health 2025-05-08 · Fire 2025-05-08
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Chula Vista, CA
South Bay Post Acute Care
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
553 F Street, Chula Vista, CA
(619) 426-8611
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2011-07-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.96
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,125
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.61
Composite VBP score used to determine payment impact.
Payment multiplier
1.0148
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.11
Baseline 19.01% · Performance 17.67% · Measure score 8.11 · Achievement 8.11 · Improvement 6.25
Healthcare-associated infections
7.09
Baseline 5.74% · Performance 5.71% · Measure score 7.09 · Achievement 7.09 · Improvement 0
Total nurse turnover
5.79
Baseline 57.14% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 4.81
Adjusted total nurse staffing
2.84
Baseline 3.75 hours · Performance 3.89 hours · Measure score 2.84 · Achievement 2.84 · Improvement 0.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.06% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 240 · Observed rate 15% · Lower 95% interval 9.69% |
| Discharge to community | 64.16% |
50.57%
13.6 pts better
|
Better than the National Rate · Eligible stays 221 · Observed rate 58.37% · Lower 95% interval 59.64% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.16% |
95.27%
1.1 pts worse
|
Numerator 145 · Denominator 154 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 154 |
| Discharge self-care score | 69.91% |
53.69%
16.2 pts better
|
Numerator 79 · Denominator 113 |
| Discharge mobility score | 68.14% |
50.94%
17.2 pts better
|
Numerator 77 · Denominator 113 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 154 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.72% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 3.39% · Lower 95% interval 3.52% |
| Staff COVID-19 vaccination coverage | 5.88% |
8.2%
2.3 pts worse
|
Numerator 8 · Denominator 136 |
| Staff flu vaccination coverage | 67.04% |
42%
25 pts better
|
Numerator 120 · Denominator 179 |
| Discharge function score | 74.34% |
56.45%
17.9 pts better
|
Numerator 84 · Denominator 113 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 99% |
96.28%
2.7 pts better
|
Numerator 99 · Denominator 100 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 72 |
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.3% |
98.2%
4.9 pts worse
|
95.5%
2.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
1.6%
0.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 1.8% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 56.5% |
6.8%
49.7 pts worse
|
11.4%
45.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.1% · Q2 54.2% · Q3 70.6% · Q4 54.0% · 4Q avg 56.5% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
4.1%
2.6 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 3.9% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.7% |
13.7%
2 pts better
|
19.6%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 13.7% · Q3 11.3% · Q4 13.5% · 4Q avg 11.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
14.2%
10.8 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q3 8.0% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.5% |
11.0%
1.5 pts better
|
16.3%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
10.7%
About the same
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 14.6% · Q3 20.8% · Q4 4.3% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.0%
0.2 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 3.8% · 4Q avg 1.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
10.9%
19.3 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.7% · Q2 39.3% · Q3 20.8% · Q4 21.2% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.7%
1.5 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.2% · Q3 7.9% · Q4 8.8% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.0%
5.7 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.7% · Q3 99.4% · Q4 99.7% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
11.2%
5 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 17.7% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 1.4% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
93.2%
5.6 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
23.2%
1 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 22.9% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-21 · Fire 2022-11-21
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-11-29 · Fire 2018-11-29
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-05-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-05-08
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-28
D · Potential for more than minimal harm
2022-11-21
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-05
E · Potential for more than minimal harm
2018-11-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-03-07
D · Potential for more than minimal harm
2018-11-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-03-07
D · Potential for more than minimal harm
2018-11-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-03-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-05-13
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 2025-05-15
D · Potential for more than minimal harm
2024-01-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-08
E · Potential for more than minimal harm
2022-11-21
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 2022-12-14
E · Potential for more than minimal harm
2022-11-21
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-21
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 2022-12-14
D · Potential for more than minimal harm
2022-11-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-21
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 2022-12-14
D · Potential for more than minimal harm
2022-11-21
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-21
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-21
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 2022-12-14
D · Potential for more than minimal harm
2022-11-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-21
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-21
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 2022-12-14
D · Potential for more than minimal harm
2022-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-14
D · Potential for more than minimal harm
2018-11-29
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 2019-01-04
D · Potential for more than minimal harm
2018-11-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-01-04
D · Potential for more than minimal harm
2018-11-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-01-04
D · Potential for more than minimal harm
2018-11-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-01-04
D · Potential for more than minimal harm
2018-11-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-01-04
D · Potential for more than minimal harm
2018-11-29
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-01-04
D · Potential for more than minimal harm
2018-11-29
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-01-04
D · Potential for more than minimal harm
2018-11-29
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 2019-01-04
D · Potential for more than minimal harm
2018-11-29
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2019-01-04
D · Potential for more than minimal harm
2018-11-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-04
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
Burnam, Soon
Corporate Officer · Individual
Fitch, Craig
Corporate Officer · Individual
Flake, Matthew
Corporate Officer · Individual
Jimenez, John
Operational/Managerial Control · Individual
Jimenez, John
W-2 Managing Employee · Individual
Willits, Adam
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
National City Post Acute
National City, CA
4-star overall rating with 3-star inspections with $15,652 in total fines with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Hillcrest Manor Sanitarium
National City, CA
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Reo Vista Healthcare Center
San Diego, CA
4-star overall rating with 3-star inspections with $11,391 in total fines with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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