Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 National City Post Acute during CMS and state inspections, most recent first.
The facility failed to provide and document required bed-hold notifications and ombudsman transfer notices for two residents who experienced unplanned hospital transfers due to respiratory issues, including shortness of breath and hypoxia. One resident with DM and moderate cognitive deficits was sent to the hospital after a decline in respiratory status, but the 24-hour bed-hold notification was not signed and there was no documented ombudsman notification. Another resident with CHF and severe cognitive deficits was transferred to the hospital for hypoxia, yet the record lacked evidence of bed-hold notification and ombudsman transfer notice. Staff interviews confirmed that, despite established roles for nursing, Social Services, and Medical Records in providing bed-hold information and faxing transfer notices, these notifications were not completed or documented as required.
A resident with a history of Paroxysmal Atrial Fibrillation experienced an unwitnessed fall that was documented in clinical notes but not coded on the quarterly MDS assessment. The MDSN and DON confirmed the fall should have been coded according to RAI guidelines, resulting in inaccurate reporting of the resident's fall history and health status.
A resident with a history of cervical disc disorder was found to have head lice and received appropriate treatment, but staff did not initiate contact precautions or monitor the resident’s former or new roommates for lice during a room change. Both LNs and the DON confirmed that required infection control procedures, including roommate assessment and isolation, were not followed according to CDC guidelines and facility policy.
A resident with glaucoma did not receive prescribed Latanoprost eye drops on multiple occasions because LNs failed to administer the medication and did not notify the DON or ADM about the pharmacy delivery delay, resulting in missed doses and lack of documentation.
Multiple residents and staff reported significant delays in call light response and personal care due to insufficient CNA staffing, particularly when CNAs were assigned to 1:1 monitoring. Family members and private caregivers sometimes had to provide care themselves. Staff interviews and resident council minutes confirmed ongoing issues with unmet care needs, especially during periods of short staffing and lack of a dedicated shower aide. Facility leadership was not fully aware of the extent of these problems.
Surveyors found that two residents' room had insects present and a sliding door screen in disrepair, with one resident using an insect trap due to concern about insects entering. The maintenance supervisor confirmed the insect presence and noted the sliding door was open, which could allow insects inside. These conditions did not meet the facility's policy for a safe, clean, and homelike environment.
A resident with limited mobility and recent surgical wounds developed a stage 2 pressure injury on the coccyx that was not identified until it was already open, and did not consistently receive prescribed wound care treatments. Multiple CNAs and LNs confirmed the resident required assistance with repositioning and that wound care duties were performed by medication nurses without formal wound management training, leading to missed treatments and worsening of the resident's condition.
A resident who preferred a vegan diet and specifically requested tofu did not receive it during her stay, as the CDM failed to obtain the item despite being aware of the request. The facility's policy requires accommodation of resident dietary preferences, but the resident was only provided with some vegan food and not the requested tofu.
A resident with chronic pain conditions did not receive prescribed pain medication for several days because the prescription expired and was not renewed in time. Staff interviews and record reviews confirmed that the resident, who was cognitively intact, repeatedly requested pain relief but was told the medication was unavailable. The process for reordering and renewing the prescription was not followed, and the issue was compounded by the timing over a weekend, resulting in unmanaged pain.
A resident was discharged with opioid medication that was not part of the Nurse Practitioner's plan, due to a failure by the Licensed Nurse to verify the discharge plan. The resident, admitted with a lumbar fracture, was supposed to receive pain management with Gabapentin and acetaminophen. However, the resident was given 12 tablets of hydrocodone/acetaminophen upon discharge, contrary to the NP's instructions. The facility's policy did not require verification of opioid medications with the provider, leading to this oversight.
A resident with End Stage Renal Disease sustained a fracture to the left humerus during a transfer from bed to wheelchair due to the failure of facility staff to use a gait belt, as required by the resident's care plan and facility policy. The incident led to severe pain and the need for hospitalization to place a new dialysis access site. Interviews revealed that the CNAs involved did not adhere to the proper transfer protocol, compromising the resident's safety.
A facility failed to implement appropriate isolation precautions for a resident diagnosed with Covid-19. Upon returning from the hospital, the resident was placed in a room with two roommates without wearing a face mask, and the room was not set up for contact droplet isolation. The Manager of Staff Development and the Director of Infection Prevention acknowledged the oversight, which was contrary to the facility's policy requiring N95 respirators, gloves, gowns, and eye protection. This delay in implementing precautions placed others at risk of exposure.
Failure to Provide Bed-Hold and Ombudsman Transfer Notifications for Unplanned Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required notifications related to emergent hospital transfers and bed-hold rights for two residents. For Resident 1, who had diabetes mellitus and moderate cognitive deficits with a BIMS score of 12/15, nursing staff identified a change in condition when the resident complained of shortness of breath late at night. A licensed nurse obtained orders for a STAT chest X-ray and a breathing treatment, but the resident’s condition continued to decline, and the resident requested transfer to the hospital. Emergency medical services transported the resident to the hospital in the early morning hours. Review of the medical record showed that the 24-hour bed-hold notification section was not signed, and there was no documentation that a Notice of Transfer was sent to the California Long-Term Care Ombudsman Program. Interviews with staff clarified the facility’s internal process and confirmed the lack of required notifications for Resident 1. The Medical Records Director stated that the former Social Services Director was responsible for discharge and transfer notifications, including ombudsman notification, and that Medical Records was responsible for completing and faxing the Notice of Transfer to the ombudsman for unexpected hospital transfers. The Medical Records Director acknowledged that this process was not completed for Resident 1. The Social Services Director stated that Social Services handled advance discharge notifications and obtained fax confirmations, while Medical Records was responsible for ombudsman notification for unplanned hospital transfers, and that nursing staff were responsible for notifying residents and/or responsible parties of the 24-hour bed-hold policy. For Resident 2, who had congestive heart failure and severe cognitive deficits and was rarely or never understood, a licensed nurse reported that the resident experienced hypoxia and that the physician and the resident’s conservator were notified. The resident was assessed by a nurse practitioner, labs were ordered, and the resident was later transferred to the hospital due to hypoxia. Record review for this resident showed there was no documentation of a bed-hold notification or a Notice of Transfer to the ombudsman in the requested records. Although the Medical Records Director stated that the ombudsman was notified of Resident 2’s transfers, the record lacked evidence of such notification. The facility’s transfer or discharge policy indicated that appropriate notice was to be provided to the resident and/or legal representative, but the survey findings showed that required notifications and confirmations related to bed-hold rights and ombudsman notification were not documented for these unplanned hospital transfers.
Failure to Accurately Code Resident Fall on MDS Assessment
Penalty
Summary
The facility failed to accurately code a fall incident on the Minimum Data Set (MDS) for one resident. The resident, who had a history of Paroxysmal Atrial Fibrillation, experienced an unwitnessed fall in her room, as documented in both the Intradisciplinary (IDT) note and a progress note. The fall was not coded on the resident's quarterly MDS assessment, which instead indicated that no fall had occurred since admission or the prior assessment. This omission was confirmed during interviews with the MDS Nurse (MDSN) and the Director of Nursing (DON), both of whom acknowledged that the fall should have been coded according to the Resident Assessment Instrument (RAI) guidelines. The inaccurate coding resulted in the resident's fall not being reflected in the federal database, which is used for care planning and monitoring of fall risks. The resident's care plan had previously identified a risk for falls, but the failure to code the incident on the MDS meant that the assessment did not accurately represent the resident's health status or fall history at the time of the deficiency.
Failure to Implement Infection Control Measures for Lice Infestation
Penalty
Summary
The facility failed to follow proper infection control procedures for a resident who was identified with pediculosis (lice). Upon admission, the resident complained of an itchy scalp and was found to have head lice, for which treatment with permethrin 1% shampoo was ordered and administered. Despite this, the facility did not initiate contact precautions or isolation measures as required by CDC guidelines, and there was no documentation that the resident’s former or new roommates were assessed, screened, or monitored for lice during or after the room change. Both licensed nurses involved confirmed that contact precautions were not implemented and that there was no evidence of monitoring or assessment of the roommates for lice. The Director of Nursing acknowledged that the facility did not follow its own policy or CDC recommendations, which require contact precautions for at least 24 hours after initiation of effective therapy for lice. The DON also confirmed that no monitoring of roommates occurred during the resident’s room transfer and that a sign for precautions was not placed on the door. The facility’s policy indicated that the interdisciplinary team should implement measures to eliminate infestation and prevent spread, but these steps were not documented or carried out in this instance.
Failure to Administer Prescribed Ophthalmic Medication Due to Pharmacy Delay and Lack of Notification
Penalty
Summary
Licensed Nurses (LNs) failed to consistently administer prescribed eye drop medication to a resident diagnosed with glaucoma, as ordered by the physician. The resident was readmitted with a diagnosis that included glaucoma, and the physician's order specified the use of Latanoprost ophthalmic solution for both eyes. A review of the medication administration record (MAR) revealed that the resident did not receive the prescribed eye drops on several dates, and there was no documentation of administration for those days. During a joint review and interview, it was confirmed that the missed doses were due to a delay in the delivery of the medication from the pharmacy. The nurses' notes indicated the medication was not available, but the LNs did not notify the Director of Nursing (DON) or the Administrator (ADM) to expedite the delivery. The facility's policy provided did not address the requirement to follow physician's orders, contributing to the failure to ensure the resident received treatment and care in accordance with professional standards of practice.
Insufficient Staffing Leads to Delayed Resident Care and Unmet Needs
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the daily care needs of residents, resulting in significant delays in responding to call lights and providing personal care. Multiple residents and their family members reported waiting 30 minutes to an hour for assistance with incontinence care and other needs. Certified Nursing Assistants (CNAs) were frequently unavailable due to being assigned to one-on-one (1:1) monitoring of other residents, leaving their assigned residents unattended for extended periods. In some cases, family members or private caregivers had to step in to provide care due to staff unavailability. Observations and interviews revealed that CNAs were responsible for both their assigned residents and those of colleagues who were on 1:1 monitoring, at times resulting in a single CNA being responsible for up to 19-20 residents. CNAs reported being unable to complete their duties, including providing showers, due to the additional burden of 1:1 monitoring and the lack of a dedicated shower aide. Licensed Nurses (LNs) did not assist with call lights or transfers, further exacerbating the delays in care. Resident council meeting minutes from recent months documented ongoing complaints from multiple residents about excessive wait times for assistance and staff not responding to their needs. The Director of Staff Development (DSD) confirmed that there were days when staffing levels were below the minimum required to provide adequate care, particularly on weekends with call-ins. The DSD and CNAs acknowledged that the current staffing practices, including the rotation of CNAs for 1:1 monitoring and the absence of a dedicated shower aide, resulted in neglect of other residents' needs. Facility leadership was unaware of the extent of the issue and the impact on resident care, despite documented complaints and staff concerns.
Insects Observed and Damaged Screen Door Compromise Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, safe, and comfortable homelike environment for residents when insects were found in a resident room and the screen of the sliding door was in disrepair. During an unannounced visit, two residents reported the presence of insects, with one resident stating she had placed an insect trap due to fear of insects entering the room. The maintenance supervisor confirmed the presence of a large black insect in the trap and noted that the sliding door was open, which could allow insects to enter. The resident was unsure if the screen door was broken, and the maintenance supervisor indicated that residents sometimes open the sliding door. The facility's policy requires providing a safe, clean, and homelike environment, but these conditions were not met in this instance.
Failure to Timely Identify and Treat Pressure Injuries and Surgical Wounds
Penalty
Summary
The facility failed to timely identify and treat the development of pressure injuries for a resident who was at moderate risk due to limited mobility and required assistance with repositioning. Upon admission, the resident had no pressure wounds on the coccyx, and skin assessments confirmed the absence of such wounds in the following weeks. However, the resident later developed an open wound on the buttocks, which was not identified or reported until it had progressed to a stage 2 pressure injury. Multiple certified nursing assistants confirmed that the resident could not reposition independently and did not refuse assistance, and one CNA reported noticing redness but could not recall to whom it was reported. The facility also failed to consistently provide prescribed treatments for the resident's existing surgical wounds on the right foot and knee. Treatment administration records showed several missed treatments for the resident's surgical sites, including post-amputation and wound vacuum therapies. Interviews with licensed nurses revealed that, due to the absence of a dedicated treatment nurse, medication nurses—who lacked formal wound management training—were responsible for wound care. These nurses reported being overwhelmed with multiple duties, making it unlikely that all treatments were administered as ordered. As a result of these lapses, the resident's surgical wounds did not heal properly, became infected, and ultimately led to further amputations. The director of nursing confirmed that the expectation was for CNAs to report skin changes promptly and for licensed nurses to ensure timely assessment and treatment, which did not occur in this case. The facility's policy emphasized the importance of structured risk assessment and individualized care planning, but these procedures were not effectively implemented for this resident.
Failure to Provide Requested Vegan Food Option
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's stated dietary preferences. The resident, who was admitted following surgery, informed the Certified Dietary Manager (CDM) of her preference for a vegan diet and specifically requested tofu. Despite this request, the CDM acknowledged that tofu was not available in the facility and, although some vegan food was purchased, tofu was not obtained for the resident during her stay. The CDM admitted fault for not fulfilling the resident's preference for tofu. During a review of the resident's clinical and dietary records, facility leadership, including the Administrator, confirmed that the facility is responsible for meeting residents' dietary needs and preferences, including ordering specific requested items such as tofu. The facility's own policy states that menus should be developed to meet resident choices, including religious, cultural, and ethnic needs, while ensuring nutritional adequacy. The failure to provide the requested tofu resulted in the resident not receiving her preferred diet.
Failure to Provide Timely Pain Medication Due to Lapsed Prescription
Penalty
Summary
The facility failed to ensure that a resident with chronic pain conditions, including a chronic left foot ulcer and gout, had access to prescribed pain medication. The resident, who was cognitively intact and able to make decisions, reported running out of pain medication and experiencing pain for several days, which affected his sleep. The care plan instructed staff to medicate the resident as ordered and to advise him to request pain medication before pain became severe. However, staff interviews and record reviews confirmed that the prescription for the resident's pain medication had expired and was not renewed in a timely manner, resulting in the resident not receiving pain relief as needed. Licensed nurses and a CNA confirmed that the resident regularly requested pain medication and that there was no pain medication available for several days. The process for medication reordering was not followed, as no renewal or authorization form was sent to the attending physician before the prescription expired. Staff also indicated that the lack of medication was exacerbated by the timing of the prescription running out over a weekend, making it more difficult to obtain a physician's signature for renewal. The Director of Nursing acknowledged the expectation that pain medications should be available to prevent resident suffering.
Failure to Verify Opioid Discharge Plan
Penalty
Summary
The deficiency involved a failure by Licensed Nurse (LN) 1 to verify a provider's discharge plan regarding opioid medication for Resident 1 upon discharge. Resident 1, who had been admitted with a lumbar fracture, was discharged to a board and care facility. The Nurse Practitioner (NP) had documented a discharge plan that included pain management with Gabapentin and acetaminophen, but not opioids. However, LN 1's discharge summary notes indicated that Resident 1 was discharged with 12 tablets of hydrocodone/acetaminophen, which was not part of the NP's plan. Interviews with LN 2 and LN 3 revealed that the Case Manager was responsible for initiating the discharge process, and LN 1 was responsible for Resident 1's discharge, including medication instructions. LN 2 stated that LNs should verify with the attending physician whether opioid medication should continue upon discharge. The Director of Nursing (DON) confirmed that LNs are expected to verify the discharge plan and reconcile medications, especially opioids, for safety. The facility's policy on discharge did not include verification of opioid medications with the provider, contributing to the oversight.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility staff failed to safely transfer a resident, who was reviewed for pain, from the bed to a wheelchair using a gait belt, resulting in a fracture to the resident's left humerus. The resident, who was admitted with diagnoses including End Stage Renal Disease and dependence on renal dialysis, required total assistance for transfers as per their care plan. On the day of the incident, two CNAs assisted in transferring the resident without using a gait belt, contrary to the facility's policy and the resident's care plan. During the transfer, the resident began to slip, and one of the CNAs grabbed the resident's hand, resulting in a popping sound and subsequent injury. The incident led to the resident experiencing severe pain and the cancellation of their dialysis session, necessitating hospitalization for the placement of a new dialysis access site. Interviews with the CNAs involved revealed a lack of adherence to the proper transfer protocol, as they did not use a gait belt and instead lifted the resident by her arms. The facility's policies clearly stated the requirement for using a gait belt for residents needing assistance with transfers, which was not followed in this case. The Director of Nursing acknowledged the failure to use a gait belt, which compromised the safety of the transfer.
Failure to Implement Covid-19 Isolation Precautions
Penalty
Summary
The facility failed to implement appropriate isolation precautions for a resident diagnosed with Covid-19, which was identified during an annual recertification survey. Upon returning from the hospital, the resident was placed in a room with two other roommates without wearing a face mask, and the room was not set up for contact droplet isolation as required for Covid-19 cases. Instead, one of the roommates was on Enhanced Barrier Precautions (EBP), which did not provide adequate protection against Covid-19, as it did not require a specialized face mask or eye protection. The Manager of Staff Development and the Director of Infection Prevention both acknowledged that the resident should have been placed on contact droplet isolation immediately upon return from the hospital. The facility's policy on Covid-19 management and isolation precautions clearly indicated the need for N95 respirators, gloves, gowns, and eye protection, along with appropriate signage to notify personnel and visitors of the necessary precautions. The delay in implementing these measures placed other residents, staff, and visitors at risk of exposure to Covid-19.
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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 National City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Manor Sanitarium | 0.3 mi | — | 1 | 0 |
| Castle Manor Nursing & Rehabilitation Center | 1.6 mi | — | 0 | 0 |
| Friendship Manor Nursing & Rehab Center | 1.8 mi | — | 0 | 0 |
| South Bay Post Acute Care | 1.8 mi | — | 1 | 0 |
| Paradise Valley Health Care | 1.8 mi | — | 2 | 0 |
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