Cycle 1
Health 2025-09-26 · Fire 2025-09-26
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Vista, CA
Vista Knoll Specialized Care Facility
5-star overall rating with 4-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
2000 Westwood Road, Vista, CA
(760) 630-2273
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
119
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1990-05-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.77
Registered nurse staffing
LPN hours / resident day
0.97
Licensed practical nurse staffing
Aide hours / resident day
2.54
Nurse aide staffing
Weekend hours
3.69
Weekend nurse staffing
RN turnover
31%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.6
1 pts better
|
1.8
1.2 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 | 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 | 1.6% |
1.6%
About the same
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
6.8%
4.8 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.5% |
13.7%
9.8 pts worse
|
19.6%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
14.2%
1.3 pts better
|
16.7%
3.8 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 | 4.2% |
11.0%
6.8 pts better
|
16.3%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
10.7%
4.1 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.1% |
10.9%
2.2 pts worse
|
19.8%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.7%
2.6 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
94.0%
4.5 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
11.2%
2.1 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
93.2%
2.9 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
23.2%
4.7 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-26 · Fire 2022-08-26
12 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-03-04 · Fire 2019-03-04
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-09
E · Potential for more than minimal harm
2025-09-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-09-26
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 2025-11-19
D · Potential for more than minimal harm
2025-09-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-09-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-09-26
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-09-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-09-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-09-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-11-19
D · Potential for more than minimal harm
2022-08-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-26
K343 · Smoke Deficiencies
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 2022-09-19
D · Potential for more than minimal harm
2022-08-26
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-19
E · Potential for more than minimal harm
2019-03-04
K771 · Miscellaneous Deficiencies
Fire Safety
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
Corrected 2019-05-16
D · Potential for more than minimal harm
2019-03-04
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-05-16
D · Potential for more than minimal harm
2019-03-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-05-16
D · Potential for more than minimal harm
2019-03-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-05-16
D · Potential for more than minimal harm
2019-03-04
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 2019-05-16
D · Potential for more than minimal harm
2019-03-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-05-16
D · Potential for more than minimal harm
2019-03-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-05-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-09-26
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 2025-12-20
D · Potential for more than minimal harm
2025-09-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-09-26
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 2025-12-20
D · Potential for more than minimal harm
2025-09-26
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 2025-12-20
D · Potential for more than minimal harm
2025-09-26
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-09-26
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-09-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-09-26
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-12-20
D · Potential for more than minimal harm
2024-09-04
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 2024-10-01
D · Potential for more than minimal harm
2024-04-15
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-05-01
D · Potential for more than minimal harm
2023-05-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-25
E · Potential for more than minimal harm
2022-08-26
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 2022-09-26
E · Potential for more than minimal harm
2022-08-26
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 2022-09-26
E · Potential for more than minimal harm
2022-08-26
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 2022-09-26
D · Potential for more than minimal harm
2022-08-26
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 2022-09-26
D · Potential for more than minimal harm
2022-08-26
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 2022-09-26
D · Potential for more than minimal harm
2022-08-26
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 2022-09-26
D · Potential for more than minimal harm
2022-08-26
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 2022-09-26
D · Potential for more than minimal harm
2022-08-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-09-26
D · Potential for more than minimal harm
2022-08-26
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 2022-09-26
D · Potential for more than minimal harm
2022-08-26
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 2022-09-26
E · Potential for more than minimal harm
2019-03-04
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2019-03-28
E · Potential for more than minimal harm
2019-03-04
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 2019-03-28
E · Potential for more than minimal harm
2019-03-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-28
D · Potential for more than minimal harm
2019-03-04
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 2019-03-28
D · Potential for more than minimal harm
2019-03-04
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 2019-03-28
D · Potential for more than minimal harm
2019-03-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-03-28
D · Potential for more than minimal harm
2019-03-04
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 2019-03-28
D · Potential for more than minimal harm
2019-03-04
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 2019-03-28
D · Potential for more than minimal harm
2019-03-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-03-28
D · Potential for more than minimal harm
2019-03-04
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2019-03-28
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
Gardner, Clayton
Operational/Managerial Control · Individual
Gardner, Clayton
W-2 Managing Employee · Individual
Willits, Adam
Corporate Director · Individual
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