Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arroyo Vista Nursing Center during CMS and state inspections, most recent first.
A resident with a history of fractures and intact cognition was denied re-entry to the facility after returning from an authorized out on pass, as staff—following NP instructions—considered the resident AMA and directed him to the ER. The resident, who was not informed of any curfew, was left outside until police intervened and required staff to allow him back in.
A resident with intact cognition and independence in ADLs was denied re-entry to the facility after returning late from an OOP leave, without prior notification of such a rule. No IDT meeting was conducted or documented after the incident, and the resident was not included in person-centered care planning, despite facility policy requiring such involvement after significant events.
A resident with a physician's order for Out on Pass privileges was denied re-entry to the facility after midnight due to uncommunicated rules, resulting in the resident being locked out for several hours. The care plan was not updated to reflect this incident, and staff were unclear about the applicable rules and interventions, contrary to facility policy requiring IDT review and revision.
The facility failed to maintain sanitary conditions in the kitchen, with multiple food items improperly dated and an ice machine with mold due to an overdue filter change. These issues were identified during a kitchen tour and interviews with staff, revealing inconsistencies in following food labeling procedures and maintenance schedules.
The facility failed to maintain infection control standards by improperly storing a resident's CPAP mask and not implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices. The CPAP mask was left uncovered near a urinal, and EBP signage and supplies were missing. Additionally, visitors were not educated on hand hygiene, increasing infection risks.
The facility failed to offer and provide education on the pneumococcal vaccine to four residents over 65, as revealed by a review of their records. Interviews with the IP and DON confirmed the expectation to offer the vaccine, but documentation was lacking, indicating non-compliance with the facility's immunization policy.
The facility failed to document the offering of COVID-19 vaccines to four residents, as required by policy. Despite previous vaccinations, there was no record of offers, receipts, or declinations since their admission. The IP and DON highlighted the importance of documentation and regular vaccine offers, aligning with the facility's policy to minimize COVID-19 risks.
The facility failed to implement care plans for two residents, one with end-stage renal disease requiring dialysis and another with substance use disorder and nicotine dependence. The absence of a dialysis care plan led to improper post-dialysis care for a resident, while another resident's care plan contained irrelevant interventions for their substance use disorder. The facility's policy on comprehensive person-centered care planning was not followed, resulting in unmet care needs and poor communication among caregivers.
A resident with severe pain was not administered the correct dosage of Oxycodone as per physician's orders, receiving 5 mg instead of the prescribed 10 mg for severe pain. This occurred on multiple occasions, as confirmed by a nurse and the DON, indicating a failure to follow the facility's pain management policy.
A resident with end-stage renal disease did not receive timely post-dialysis care as required by physician's orders. The dialysis dressing was not removed within the specified four to six hours after treatment, but rather the following morning. This oversight was confirmed by interviews with the resident and nursing staff, including the nurse responsible, who admitted to forgetting the task and inaccurately documenting its completion. The facility's policy emphasized timely assessment and documentation, which was not adhered to, posing a potential risk to the resident's dialysis access site.
A resident with a history of substance use disorder and nicotine dependency did not receive necessary behavioral health services at the facility. Despite being admitted with a history of substance use and cigarette use, the facility's documentation failed to reflect this, resulting in no nicotine replacement therapy or support for substance use disorder being offered. Interviews with staff confirmed the lack of interventions, contrary to the facility's policy on providing necessary behavioral health care.
A resident with a knee replacement surgery did not receive pain medication as ordered. The Lidocaine patch was not removed as scheduled, remaining on the resident's knee 12 hours longer than recommended. The responsible nurse admitted to forgetting to remove the patch, which could affect the medication's efficacy. Facility policies on medication administration were not followed, leading to this deficiency.
The facility's medication error rate was 7.14%, exceeding the acceptable threshold. Errors included a nurse incorrectly mixing a potassium supplement and administering fewer tablets than prescribed. The DON emphasized the importance of following package instructions and physician's orders to ensure medication efficacy.
Resident Denied Re-Entry After Authorized Out on Pass
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by denying re-entry to a resident who returned from an authorized out on pass (OOP). The resident, who had a history of multiple fractures and was cognitively intact and independent in activities of daily living, was accustomed to leaving the facility on day passes. On the incident date, the resident returned after midnight and was not allowed back into the facility, as staff were instructed by the nurse practitioner (NP) to consider the resident as having left against medical advice (AMA) and to direct him to the emergency room. The resident was not previously informed that returning after midnight would result in being locked out, and the facility's records included a physician's order permitting OOP without a specified curfew. Nursing notes document that the resident arrived at the facility, was informed of the NP's order, and was left outside the facility door. Police were called and, after determining there was no medical reason to send the resident to the emergency room and that he had established residency, instructed staff to allow the resident back inside. The resident was eventually let back into his room after several hours outside. The facility's policy on resident rights and responsibilities was reviewed, but there was no evidence that the resident had been made aware of any curfew or restriction related to OOP returns.
Resident Excluded from Person-Centered Care Planning After OOP Incident
Penalty
Summary
The facility failed to ensure that a resident was included in the development and implementation of his person-centered plan of care following an incident related to his return from an Out on Pass (OOP) leave. The resident, who had a history of multiple fractures and was cognitively intact and independent in activities of daily living, was denied re-entry to the facility after returning late from a day pass due to unforeseen circumstances. The resident reported not being informed of any rule that would prevent him from re-entering the facility after midnight, and he was only allowed back inside after contacting the police several hours later. A review of the resident's medical record showed a physician's order permitting OOP and no evidence of cognitive impairment. However, there was no documentation of an Interdisciplinary Team (IDT) meeting or care conference following the incident, despite facility policy and staff statements indicating that such meetings should occur quarterly and after significant events or changes in condition. The last documented IDT for the resident was several months prior to the incident, and there was no record of the resident refusing participation in an IDT. Interviews with facility staff, including the Social Service Director, Assistant Director of Nursing, and a licensed nurse, confirmed that no IDT was conducted after the incident. Staff acknowledged that IDTs are essential for collaborative care planning and updating care plans to reflect changes or address issues. The absence of an IDT meant that the resident was not involved in reviewing or updating his care plan after the incident, contrary to facility policy and resident rights.
Failure to Revise Care Plan for Out on Pass Privileges
Penalty
Summary
The facility failed to revise the care plan for a resident who had a physician's order to leave the facility on an Out on Pass (OOP). The resident, who had multiple fractures of the pelvis and right ribs and used a manual wheelchair, was not informed of any time restrictions or rules regarding re-entry to the facility after leaving on a day pass. On one occasion, the resident was denied entry back into the facility after midnight due to facility rules that had not been communicated to him, resulting in him being locked out for three hours until police were called. There was no documentation of an Interdisciplinary Team (IDT) meeting or care plan revision following this incident. Review of the resident's care plan showed it had last been updated months prior to the incident and did not reflect the current situation or address the specific circumstances of the resident's OOP privileges. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the care plan was not updated after the incident, and staff were unclear about the rules and interventions to be applied. The facility's policy required the care plan to be reviewed and revised by the IDT, but this was not done in response to the incident.
Deficiencies in Food Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, specifically regarding food storage methods and ice machine maintenance. During an initial kitchen tour, it was observed that multiple food items were not dated correctly. An open box of corn starch and rice cereal were not transferred to sealed containers and labeled with a use-by date. An open bottle of imitation vanilla flavoring was also not labeled with a use-by date. Additionally, boxes of fountain juices and bags of toasted oats cereal were labeled with numbers and dates without clear indication of their meaning. Interviews with the Certified Dietary Manager and the Registered Dietitian revealed that food items should be marked with received, opened, and use-by dates, which was not consistently done. The ice machine was found to have black residue, identified as mold, inside the ice bin, and the water filter was 45 days past its due date for replacement. The Maintenance Director admitted to finding black residue during monthly cleanings and acknowledged the filter was overdue for a change. The Contracted Technician confirmed that the filter's antimicrobial properties could have prevented mold if it had been changed on time. A review of the contractor's service work order did not include a filter change, and the facility's policy indicated that ice should be handled in a sanitary manner. These deficiencies had the potential to lead to food contamination and foodborne illnesses for the residents.
Infection Control Deficiencies in CPAP Storage and EBP Implementation
Penalty
Summary
The facility failed to implement proper infection control procedures in several instances. A resident's CPAP machine mask and tubing were not stored in a sanitary manner, as the mask was observed dangling uncovered near an empty urinal. The resident confirmed that the CPAP machine was not cleaned at the facility, and the staff, including a licensed nurse and the Director of Nursing (DON), acknowledged that the mask should be stored in a plastic bag and cleaned after each use to prevent respiratory infections. The facility's policy indicated that equipment should be cleaned after use, but this was not adhered to. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices, as there was no signage or isolation supplies outside their rooms. The Infection Preventionist and the DON confirmed that EBP should be in place according to CDC guidelines. Furthermore, visitors were not educated on the need for hand hygiene when entering a resident's room under EBP, as observed when two visitors entered without performing hand hygiene. Staff members admitted to not educating visitors, which was against the facility's policy that required all staff to ensure compliance with infection control measures.
Failure to Offer Pneumococcal Vaccine and Education
Penalty
Summary
The facility failed to offer and provide education regarding the benefits and potential side effects of the pneumococcal vaccine to four residents reviewed for immunizations. These residents, identified as Residents 18, 71, 105, and 201, were all over the age of 65, a demographic particularly susceptible to pneumococcal infections. The review of their admission and immunization records showed no indication that they were offered or received the pneumococcal vaccine, nor was there documentation of any education provided about the vaccine. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the facility's expectation was to offer the pneumococcal vaccine to eligible residents to protect them from pneumonia and its complications. The facility's policy on immunizations emphasized the importance of vaccinations for the health and well-being of long-term care residents, particularly those aged 65 and older, who are at higher risk for pneumococcal infections. However, the lack of documentation and action in offering the vaccine to the identified residents indicates a failure to adhere to this policy.
Failure to Document COVID-19 Vaccine Offers to Residents
Penalty
Summary
The facility failed to ensure that four out of ten sampled residents were offered the COVID-19 vaccine, as required by their policy. Resident 39, who was admitted to the facility, had received the COVID-19 vaccination in 2021, but there was no documentation indicating that they were offered, received, or declined the vaccine since admission. Similarly, Resident 201 had no documentation of being offered, receiving, or declining the COVID-19 vaccine since their admission. Resident 30 had received a COVID-19 booster shot in 2022, but again, there was no documentation of any offer, receipt, or declination of the vaccine since admission. Resident 9 had received a booster shot in 2021, but there was no documentation of an updated vaccine offer since their admission. During interviews, the Infection Preventionist (IP) stated that the facility offers updated COVID-19 vaccinations to residents every three to four months and that each resident's vaccination status, including refusals or declinations, should be documented in their electronic chart under Immunizations. The IP also mentioned that any education provided to residents regarding the COVID-19 vaccine should be documented. The Director of Nursing (DON) emphasized the importance of offering the COVID-19 vaccine to residents, noting that even if it does not prevent COVID-19, it can prevent severe effects of the disease, especially since residents are older and more susceptible. The facility's policy mandates offering and administering COVID-19 immunizations to eligible residents and documenting whether the resident received or did not receive the vaccine in the electronic health record.
Failure to Implement Care Plans for Dialysis and Substance Use Disorder
Penalty
Summary
The facility failed to implement care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 16, who was admitted with end-stage renal disease and dependent on dialysis, did not have a care plan for dialysis. Observations and interviews revealed that the dialysis dressing was not removed within the recommended timeframe, and the site was not assessed for bleeding or infection as required. The lack of a care plan meant that the necessary guidelines for post-dialysis care were not communicated to the staff, resulting in a lapse in care. Resident 151, admitted with a substance use disorder and nicotine dependence, also lacked an appropriate care plan. The existing care plan contained interventions unrelated to the resident's diagnosis, such as avoiding rearranging furniture, and lacked specific interventions for managing substance use disorder and nicotine dependence. The Director of Nursing acknowledged that the care plan for psychosocial well-being could have been more specific, indicating a failure to provide tailored care instructions for the resident's needs. The facility's policy on comprehensive person-centered care planning emphasizes the importance of developing care plans that include measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs. However, the absence of specific care plans for both residents highlights a failure to adhere to this policy, resulting in unmet care needs and a lack of communication among caregivers.
Failure to Administer Correct Pain Medication Dosage
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 200, who was admitted with diagnoses including cancer and acute appendicitis. The resident had physician's orders for Oxycodone HCl to be administered based on their pain level, with 5 mg for moderate pain and 10 mg for severe pain. However, the medication administration record showed that the resident received only 5 mg of Oxycodone on multiple occasions despite reporting severe pain levels ranging from 7 to 8 out of 10. Interviews with Licensed Nurse 1 revealed that the nurse administered the incorrect dosage of Oxycodone, acknowledging that the physician's order was not followed. The Director of Nursing confirmed that the resident was undermedicated for their pain level, which was contrary to the facility's policy on pain recognition and management. This failure had the potential to prevent the resident from receiving adequate pain relief.
Failure to Timely Remove Dialysis Dressing
Penalty
Summary
The facility failed to provide appropriate post-dialysis care for a resident with end-stage renal disease who required dialysis treatment. The resident, who had intact cognition, was scheduled for dialysis on Mondays, Wednesdays, and Fridays. The physician's orders specified that the dialysis dressing should be removed four to six hours after the treatment to assess the site for bleeding or signs of infection. However, on one occasion, the dressing was not removed until the following morning, which was contrary to the physician's orders and facility policy. This oversight was confirmed through interviews with the resident and several licensed nurses, including the nurse responsible for the oversight, who admitted to forgetting to remove the dressing and inaccurately documenting its removal in the Medication Administration Record (MAR). The Director of Nursing (DON) and other nursing staff acknowledged the importance of following the physician's orders to ensure the safety of residents. The facility's policy on dialysis care emphasized the need for timely assessment and documentation of the dialysis access site. Despite these guidelines, the failure to remove the dressing in a timely manner and assess the site as required posed a potential risk to the resident's dialysis access site. The incident highlighted a lapse in adherence to established protocols, which could have led to complications such as infection or damage to the dialysis access site.
Failure to Provide Behavioral Health Services for Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a substance use disorder and nicotine dependency. Resident 151 was admitted with a history of psychoactive substance use and cigarette use, and was previously receiving a nicotine patch. However, the facility's medical documentation, including the history and physical written by the attending MD, did not reflect this history. Consequently, the resident did not receive any nicotine replacement therapy or support for substance use disorder, such as resources for Narcotics Anonymous, as confirmed by the Social Services Director (SSD). Interviews with the resident and facility staff revealed that no interventions were provided to address the resident's nicotine use or substance use disorder. The Director of Nursing (DON) acknowledged that the facility should have reviewed the hospital paperwork and conducted an admission smoking assessment to address the resident's needs. The facility's policy on Behavioral Health Services mandates providing necessary care to maintain residents' well-being, which was not adhered to in this case.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that a medication was administered as ordered by the physician for one resident, identified as Resident 106. Resident 106, who was admitted with a diagnosis including knee replacement surgery, was observed with two white pain patches on her left knee. These patches were intended for pain management following her surgery. The resident reported that the patches were from the previous day and had not been replaced as scheduled. According to the physician's order, the Lidocaine External Patch 4% was to be applied once a day at 9 A.M. and removed at 9 P.M., in line with the manufacturer's instructions to use the patch for up to 12 hours within a 24-hour period. During an interview and observation, it was revealed that the patch was not removed as scheduled, remaining on the resident's knee approximately 12 hours longer than recommended. Licensed Nurse 12 confirmed that the patch should have been removed 12 hours after application due to potential cardiac effects. The Director of Nursing stated that the patches were to be applied and removed per the physician's orders and manufacturer's recommendations, emphasizing the importance of documenting the date and time of application. Licensed Nurse 11, who was responsible for removing the patch, admitted to forgetting to do so, which could affect the medication's efficacy. The facility's policy on medication administration and the six rights of medication administration were not adhered to, leading to this deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed rate of 7.14%. During the medication administration process, two errors were identified among 28 opportunities. One error involved a Licensed Nurse (LN) incorrectly mixing Effer-K, a potassium supplement, with five ounces of water instead of the instructed 2-3 ounces. This error was identified during an observation and interview with LN 13, who acknowledged the mistake and remade the medication. LN 13 emphasized the importance of following the manufacturer's instructions, as different brands might have varying requirements. Another error occurred when LN 13 administered medication to a resident, providing 11 capsules and tablets instead of the prescribed 12, as per the physician's order. This discrepancy was discovered during a record review and interview with LN 13, who recognized the importance of adhering to physician's orders to ensure residents receive necessary medications for their medical conditions. The Director of Nursing (DON) confirmed the facility's standard to follow package instructions and physician's orders, highlighting the potential impact on medication efficacy if not followed correctly.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Diego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| University Care Center | 1.4 mi | — | 0 | 0 |
| Jacob Healthcare Center | 1.5 mi | — | 17 | 0 |
| Brighton Place San Diego | 1.7 mi | — | 1 | 0 |
| Golden Hill Post Acute | 1.8 mi | — | 6 | 0 |
| St. Pauls Health Care Center | 3.5 mi | — | 4 | 0 |
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