Cycle 1
Health 2024-09-13 · Fire 2024-09-13
12 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
El Cajon, CA
Victoria Post Acute Care
4-star overall rating with 3-star inspections with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
654 S. Anza, El Cajon, CA
(619) 440-5005
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
120
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2004-03-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing
LPN hours / resident day
1.22
Licensed practical nurse staffing
Aide hours / resident day
2.38
Nurse aide staffing
Weekend hours
3.81
Weekend nurse staffing
RN turnover
36%
Annual RN turnover
Total nurse turnover
57%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.3
0.4 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.6
1.4 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 |
| 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 | 98.8% |
98.2%
0.6 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
1.6%
1 pts worse
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 8.4% |
6.8%
1.6 pts worse
|
11.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.2% |
4.1%
2.9 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
13.7%
About the same
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 6.4% |
14.2%
7.8 pts better
|
16.7%
10.3 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 | 7.2% |
11.0%
3.8 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.7% |
10.7%
7 pts better
|
14.9%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.0%
0.3 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.5% |
10.9%
7.6 pts worse
|
19.8%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
4.7%
0.6 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
94.0%
5.5 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
11.2%
4.9 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
93.2%
3.5 pts worse
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.6% |
23.2%
3.4 pts worse
|
23.9%
2.7 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-28 · Fire 2022-09-28
19 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
14 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2019-12-12 · Fire 2019-12-12
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-09-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-09-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-24
C · Minimal harm
2024-09-13
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-24
C · Minimal harm
2024-09-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-24
C · Minimal harm
2024-09-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-24
F · Potential for more than minimal harm
2022-09-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-28
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-28
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-28
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-28
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 2022-10-17
D · Potential for more than minimal harm
2022-09-28
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-28
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-17
E · Potential for more than minimal harm
2019-12-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-02-10
D · Potential for more than minimal harm
2019-12-12
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2020-02-10
D · Potential for more than minimal harm
2019-12-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-02-10
D · Potential for more than minimal harm
2019-12-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-02-10
D · Potential for more than minimal harm
2019-12-12
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 2020-02-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-07-31
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-08-22
F · Potential for more than minimal harm
2024-09-13
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 2024-10-10
E · Potential for more than minimal harm
2024-09-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-13
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 2024-10-10
D · Potential for more than minimal harm
2024-09-13
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 2024-10-10
D · Potential for more than minimal harm
2024-09-13
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 2024-10-10
D · Potential for more than minimal harm
2024-09-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-13
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 2024-10-10
D · Potential for more than minimal harm
2024-09-13
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 2024-10-10
D · Potential for more than minimal harm
2024-09-13
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-08-30
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 2024-09-20
D · Potential for more than minimal harm
2024-07-24
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 2024-08-15
D · Potential for more than minimal harm
2024-07-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-04-17
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-19
D · Potential for more than minimal harm
2023-06-09
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 2023-07-12
G · Actual harm
2022-09-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-11-16
E · Potential for more than minimal harm
2022-09-28
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 2022-11-16
E · Potential for more than minimal harm
2022-09-28
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-09-28
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 2022-11-16
D · Potential for more than minimal harm
2022-09-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-09-28
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 2022-11-16
D · Potential for more than minimal harm
2022-09-28
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 2022-11-16
D · Potential for more than minimal harm
2022-09-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-09-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-09-28
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 2022-11-16
D · Potential for more than minimal harm
2022-09-28
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 2022-11-16
D · Potential for more than minimal harm
2022-09-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-09-28
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-09-28
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-11-16
D · Potential for more than minimal harm
2019-12-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-01-07
D · Potential for more than minimal harm
2019-12-12
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 2020-01-07
D · Potential for more than minimal harm
2019-12-12
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 2020-01-07
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
Dove, Edward
Operational/Managerial Control · Individual
Fam, Anthony
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Lincare Inc
Operational/Managerial Control · Organization
Oh, Katherine
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Willits, Adam
Corporate Director · Individual
Nearby options
Other facilities in reach
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Villa Las Palmas Healthcare Center
El Cajon, CA
3-star overall rating with 2-star inspections with abuse icon flag with $33,732 in total fines with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Magnolia Post Acute Care
El Cajon, CA
3-star overall rating with 2-star inspections with abuse icon flag with $180,730 in total fines with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Stillwater Post-Acute
El Cajon, CA
1-star overall rating with 2-star inspections with 21 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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