26 health deficiencies
Top issue: Pharmacy Service (8 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
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
235 Nutmeg Street, San Diego, CA
(619) 239-8687
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
59
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-09-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.74
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.59
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
1.52
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
6,170
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9879
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.85
Baseline 21.74% · Performance 20.16% · Measure score 2.85 · Achievement 2.74 · Improvement 2.85
Healthcare-associated infections
4.33
Baseline 5.43% · Performance 6.54% · Measure score 4.33 · Achievement 4.33 · Improvement 0
Total nurse turnover
0.76
Baseline 51.92% · Performance 60.56% · Measure score 0.76 · Achievement 0.76 · Improvement 0
Adjusted total nurse staffing
5.57
Baseline 4.53 hours · Performance 4.66 hours · Measure score 5.57 · Achievement 5.57 · Improvement 0.58
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.58% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 7.41% · Lower 95% interval 6.65% |
| Discharge to community | 50.97% |
50.57%
0.4 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 50.77% · Lower 95% interval 41% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.5% |
95.27%
2.2 pts better
|
Numerator 39 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 2 · Denominator 40 · Adjusted rate 6.42% |
| Healthcare-associated infections requiring hospitalization | 6.54% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 2.44% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | 23.16% |
8.2%
15 pts better
|
Numerator 22 · Denominator 95 |
| Staff flu vaccination coverage | 73.27% |
42%
31.3 pts better
|
Numerator 74 · Denominator 101 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 22 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 60% |
25.2%
34.8 pts better
|
Numerator 12 · Denominator 20 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.3
0.2 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.3 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.6
0.8 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.6 · Expected 1.1 · Used in QM five-star |
| 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 | 97.7% |
98.2%
0.5 pts worse
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
1.6%
0.4 pts worse
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 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 who lose too much weight | 1.0% |
4.1%
3.1 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.9% |
13.7%
12.8 pts better
|
19.6%
18.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.3% |
14.2%
5.1 pts worse
|
16.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 25.0% · 4Q avg 19.3% · 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 | 5.5% |
11.0%
5.5 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.4% |
10.7%
3.3 pts better
|
14.9%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 4.5% · Q3 9.1% · Q4 3.4% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.0%
0.2 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.2%
0.9 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.8% |
10.9%
0.9 pts worse
|
19.8%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 11.9% · Q3 12.4% · Q4 14.6% · 4Q avg 11.8% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.7%
1.4 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 1.9% · Q4 7.9% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
94.0%
4.1 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 96.7% · Q3 98.1% · Q4 100.0% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 31.1% |
11.2%
19.9 pts worse
|
12.0%
19.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.1% · Observed 27.3% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 1.8% · Q4 5.7% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
93.2%
1.6 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.9% |
23.2%
7.7 pts worse
|
23.9%
7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.9% · Observed 21.2% · Expected 16.3% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (8 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (7 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-18
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-05-16
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-05-16
Fire Safety
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
Corrected 2023-05-16
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-05-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-16
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-16
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-16
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2023-05-16
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-05-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-16
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-06-11
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2019-06-11
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-06-11
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-06-11
Fire Safety
Use approved construction type or materials.
Corrected 2019-06-11
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 2019-06-11
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-06-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-06-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-11
Inspection history
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 2025-12-19
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-04
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 2025-10-04
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-07-26
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-26
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-26
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-26
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-07-26
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-26
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 2025-07-26
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-26
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-26
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-07-26
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-26
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2025-07-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-26
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 2025-07-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-26
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-26
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-07-26
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-03
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 2025-07-03
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-03
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2025-07-03
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-05
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2023-05-05
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 2023-05-05
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-05-05
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-05
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-05
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-05-05
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 2023-05-05
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-05-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-05
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-05
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-05-05
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-23
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2019-05-17
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-05-17
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 2019-05-17
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-05-17
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-05-17
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 2019-05-17
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2019-05-17
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-05-17
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-17
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-05-17
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
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
San Diego, CA
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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
Jump out