Cycle 1
Health 2025-08-06 · Fire 2025-08-06
4 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
San Diego, CA
The Springs At Pacific Regent
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3884 Nobel Drive, San Diego, CA
(858) 625-8700
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1999-06-28
CMS approved date
Coverage
Medicare
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
0.73
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
2.00
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.27
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.72
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.33
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.48
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.83
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
441
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.81
Composite VBP score used to determine payment impact.
Payment multiplier
1.0223
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 20.77% · Performance 17.00% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
10
Baseline 5.80% · Performance 4.57% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
5.23
Baseline 67.86% · Performance 43.21% · Measure score 5.23 · Achievement 5.01 · Improvement 5.23
Adjusted total nurse staffing
2.69
Baseline 3.50 hours · Performance 3.84 hours · Measure score 2.69 · Achievement 2.69 · Improvement 0.99
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.27% |
10.72%
1.5 pts better
|
Better than the National Rate · Eligible stays 811 · Observed rate 7.64% · Lower 95% interval 7.57% |
| Discharge to community | 72.8% |
50.57%
22.2 pts better
|
Better than the National Rate · Eligible stays 802 · Observed rate 69.08% · Lower 95% interval 69.59% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.34% |
95.27%
2.1 pts better
|
Numerator 549 · Denominator 564 |
| Falls with major injury | 0.18% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 564 |
| Discharge self-care score | 71.17% |
53.69%
17.5 pts better
|
Numerator 237 · Denominator 333 |
| Discharge mobility score | 59.76% |
50.94%
8.8 pts better
|
Numerator 199 · Denominator 333 |
| Pressure ulcers or injuries, new or worsened | 1.42% |
2.29%
0.9 pts better
|
Numerator 8 · Denominator 564 · Adjusted rate 1.47% |
| Healthcare-associated infections requiring hospitalization | 4.57% |
7.12%
2.5 pts better
|
Better than the National Rate · Eligible stays 472 · Observed rate 2.97% · Lower 95% interval 3.2% |
| Staff COVID-19 vaccination coverage | 1.41% |
8.2%
6.8 pts worse
|
Numerator 2 · Denominator 142 |
| Staff flu vaccination coverage | 35.2% |
42%
6.8 pts worse
|
Numerator 63 · Denominator 179 |
| Discharge function score | 71.47% |
56.45%
15 pts better
|
Numerator 238 · Denominator 333 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 122 · Denominator 122 |
| Transfer of health information to patient | 99.29% |
96.28%
3 pts better
|
Numerator 417 · Denominator 420 |
| Resident COVID-19 vaccinations up to date | 17.73% |
25.2%
7.5 pts worse
|
Numerator 50 · Denominator 282 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 100.0% · Q4 99.8% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
11.2%
3.4 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.2% · Expected 10.3% · 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 1.0% · Q2 0.3% · Q3 0.3% · Q4 0.3% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.0% |
93.2%
2.8 pts better
|
79.7%
16.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
23.2%
0.3 pts better
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 19.2% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-25 · Fire 2023-08-25
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-02-14 · Fire 2019-02-14
8 health deficiencies
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-06
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-08-13
D · Potential for more than minimal harm
2023-08-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-01
D · Potential for more than minimal harm
2019-02-14
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 2019-05-08
D · Potential for more than minimal harm
2019-02-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-05-08
D · Potential for more than minimal harm
2019-02-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-05-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-06
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 2025-08-29
D · Potential for more than minimal harm
2025-08-06
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 2025-08-29
D · Potential for more than minimal harm
2025-08-06
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 2025-08-29
D · Potential for more than minimal harm
2025-08-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-29
D · Potential for more than minimal harm
2024-09-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-05-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-03-08
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 2024-04-01
D · Potential for more than minimal harm
2024-03-08
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 2024-04-01
D · Potential for more than minimal harm
2023-08-25
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 2023-09-01
D · Potential for more than minimal harm
2023-08-25
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-25
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 2023-09-01
D · Potential for more than minimal harm
2023-08-25
F756 · Pharmacy Service Deficiencies
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 2023-09-01
D · Potential for more than minimal harm
2023-08-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-25
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 2023-09-01
D · Potential for more than minimal harm
2023-06-02
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-06-02
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 2023-06-21
D · Potential for more than minimal harm
2023-05-22
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 2023-06-13
D · Potential for more than minimal harm
2023-03-29
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-04-18
D · Potential for more than minimal harm
2019-02-14
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 2019-03-19
D · Potential for more than minimal harm
2019-02-14
F585 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2019-03-19
D · Potential for more than minimal harm
2019-02-14
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 2019-03-19
D · Potential for more than minimal harm
2019-02-14
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 2019-03-19
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
Port, Barry
Corporate Officer · Individual
Stevenson, Matthew
Operational/Managerial Control · Individual
Twomagnets LLC
Operational/Managerial Control · Organization
Willits, Adam
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Vi At La Jolla Village
San Diego, CA
5-star overall rating with 5-star inspections with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
La Jolla Nursing And Rehabilitation Center
La Jolla, CA
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
The Cove At La Jolla
La Jolla, CA
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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