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 Sharp Chula Vista Med Ctr Snf during CMS and state inspections, most recent first.
The facility failed to accommodate residents' preferences for bus outings, which were discontinued during the COVID-19 pandemic. Despite receiving a grant for outings, the facility was unable to secure suitable transportation for residents in wheelchairs. Residents expressed a strong desire for group outings to maintain their independence and experience the outside world, but the facility did not fulfill these needs.
The facility failed to monitor and document target behaviors and side effects for psychotropic medications for four residents, leading to potential unnecessary medication use and adverse effects. A resident was not monitored for behaviors and side effects related to antidepressants and anti-anxiety medication, while two other residents lacked proper monitoring for antidepressant medications. Another resident's antidepressant use lacked appropriate target behavior monitoring, with discrepancies between care plans and physician orders.
The facility's kitchen was found to have multiple deficiencies, including dented and expired food items, improper labeling and storage, unsanitary conditions, and inadequate personal hygiene practices. These issues were acknowledged by the facility's management and pose a risk of foodborne illnesses to residents.
A resident with arteriosclerotic cardiovascular disease transitioned from skilled to custodial care without receiving an Advanced Beneficiary Notice (ABN), despite having remaining Medicare days. The facility issued a Notice of Medicare Non-Coverage (NOMNOC) instead, failing to inform the resident of private pay options or appeal rights. Interviews revealed staff were unaware of the ABN requirement, and the facility's policy was not followed.
A resident with a history of stroke was readmitted to an LTC facility with a new stroke diagnosis, resulting in a decline in ADLs and dependence on tube feeding. Despite these changes, the facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days, as required. Staff interviews confirmed the oversight, noting that the resident's condition had significantly declined and was not expected to return to baseline within two weeks.
The facility failed to implement care plans for three residents regarding RNA ROM exercises. A resident with a traumatic brain injury received fewer passive ROM exercises than prescribed, leading to contractures. Another resident with weakness and confusion did not receive the required active and passive ROM exercises, risking contractures and decline. A third resident with stroke-related hemiparesis received fewer ROM exercises than ordered, risking further decline. Staff interviews and observations confirmed these deficiencies.
A facility failed to provide ordered ROM exercises for three residents, leading to potential worsening of contractures. One resident with a traumatic brain injury received fewer passive ROM exercises than ordered due to staffing issues. Another resident with weakness and confusion did not receive any ROM exercises despite orders. A third resident with stroke-related hemiparesis received fewer exercises than prescribed. The facility's policy emphasized adherence to the written plan for maintaining residents' independence.
The facility failed to properly store and label insulin aspart, with bottles not labeled with open dates, leading to potential interchanging and compromised medication integrity. The DON confirmed that without proper labeling, LNs could not ensure the correct use of insulin, which has a 28-day expiration upon opening.
The facility did not address transportation concerns for outdoor activities raised by the resident council in their QAPI program. Although the DON acknowledged the issue and its potential impact on residents' quality of life, it was not documented or formalized in the QAPI plan. Efforts to restore transportation options post-pandemic were ongoing, but the issue remained unaddressed in the QAPI activities.
The facility failed to implement proper infection prevention and control practices for two residents. A CNA entered a resident's room on contact precautions without PPE, and an LN did not wear a gown or change gloves during high-contact care for a resident on enhanced barrier precautions. These actions violated the facility's infection control policies, posing a risk of infection spread.
The facility failed to implement an effective antibiotic stewardship program, as the Infection Preventionist and pharmacy staff did not adequately track and monitor antibiotic use. A resident was coded for antibiotic use on the MDS but not on the MAR, indicating a gap in oversight. Interviews revealed inconsistencies in tracking processes, and there was no documented evidence of a comprehensive tracking list, contrary to the facility's policy.
A resident reported to their Responsible Party that a CNA had pulled their arm and spoken hurtfully. The Social Worker informed management, but the DON and Clinical Lead were unaware of the abuse allegation. The Clinical Lead investigated other concerns but did not address the abuse allegation, thinking it was an old incident, contrary to the facility's policy requiring immediate investigation.
A resident with a potential malignancy diagnosis was not protected from unauthorized visitors despite an APS case indicating financial exploitation concerns. The facility failed to create a care plan or communicate restrictions to staff, allowing restricted individuals to visit the resident multiple times.
Failure to Provide Resident Outings
Penalty
Summary
The facility failed to accommodate the activity preferences of its residents, specifically regarding bus outings, which were previously available before the COVID-19 pandemic. During a confidential group meeting, six residents expressed dissatisfaction with the discontinuation of these outings, which included trips to stores, parks, and other recreational locations. The facility's bus and driver were no longer available, and efforts to find alternative transportation had been unsuccessful due to cost and capacity issues. The residents emphasized their desire for group outings to experience the outside world and maintain their independence. The facility's records from February to September 2024 indicated ongoing attempts to secure transportation, but no progress was made. Interviews with staff members revealed that the facility had received a grant for bus outings, but they were still unable to find suitable transportation for residents in wheelchairs. The Director of Nursing acknowledged the residents' rights to outings and the facility's failure to accommodate these needs. The facility's policy on activities emphasized the importance of community outings and accommodating residents' preferences, which was not fulfilled in this case.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to appropriately monitor and document the target behaviors and side effects for psychotropic medications for four residents, leading to potential unnecessary medication use and adverse effects. Resident 274 was not monitored for behaviors and side effects related to two antidepressants and one anti-anxiety medication. Interviews revealed that the monitoring was subjective and lacked objective measures, and side effects were not documented in the medication administration record (MAR). The facility's policy required monitoring for suspected adverse drug reactions, which was not adhered to in this case. Residents 35 and 58 also lacked proper monitoring for behaviors and side effects associated with their antidepressant medications. For Resident 35, there was no measurement of sleep hours to evaluate the effectiveness of Trazodone, and the MAR showed zeros for a month of use. Similarly, Resident 58's record did not include a way to measure the behavior for Trazodone, and the MAR also showed zeros for a month's use. The facility's policy emphasized the importance of monitoring for adverse drug reactions, which was not followed. Resident 51's use of antidepressant medication lacked appropriate target behavior monitoring. The care plan and physician's orders did not align, leading to confusion about the target behavior for monitoring. Interviews indicated that there was no clear method to measure depressive behavior, such as continuous crying or refusal of care. The facility's policy required documentation of the necessity for medication and monitoring of its effects, which was not adequately implemented for Resident 51.
Multiple Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in its kitchen, leading to multiple deficiencies. Observations revealed dented cans of thyme and hoisin sauce, which were acknowledged by the Food Service Manager (FSM) and Food Operations Manager (FOM) as potentially hazardous due to the risk of botulism. Additionally, expired food items such as wonton chips, split peas, corn starch, barley, beans, dried red chili peppers, mango mousse, parmesan cheese, and shredded zucchini were found, which the FSM and FOM agreed should be discarded to ensure food safety. Further deficiencies were noted in the labeling and storage of food items. Unlabeled and improperly sealed food items, including pasta, graham crumbs, chili peppers, bread, hash browns, and various vegetables, were observed. The FSM and FOM acknowledged the importance of labeling to ensure freshness and prevent contamination. The facility's policy on food storage was not adhered to, as evidenced by cracked and loose container lids, dust, and spilled food on container lids, which could lead to contamination. Additional unsanitary conditions included the presence of moldy strawberries, wilted produce, dirty rugs, trash in storage areas, and improper storage of ready-to-eat food above raw meat. Kitchen utensils were found with crusted food debris, and personal items such as employee drinks and belongings were improperly stored in food preparation areas. A Nutrition Assistant was observed preparing food without a hair covering, increasing the risk of contamination. These findings indicate a failure to comply with professional standards and the facility's own policies, potentially exposing residents to foodborne illnesses.
Failure to Provide Advanced Beneficiary Notice for Custodial Care Transition
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to a resident, identified as Resident 282, who transitioned from skilled services to custodial care. Resident 282 was admitted with a history of arteriosclerotic cardiovascular disease and had remaining Medicare days when skilled services were discontinued. The facility's Assistant Director (AD 1) acknowledged that a Notice of Medicare Non-Coverage (NOMNOC) was issued instead of an ABN, despite the resident not exhausting Medicare skilled days. This oversight resulted in Resident 282 not being informed of the option to continue services under private pay or the associated costs, nor having the opportunity to appeal the decision. Interviews with facility staff, including AD 1, AD 2, and the Director of Nursing (DON), revealed a lack of awareness and proper procedure regarding the issuance of the ABN. AD 2 confirmed that the ABN provided was unsigned and that the business office had not issued an ABN document before September 2024. The DON expressed that it was crucial for the resident and their responsible party to be notified about the transition to custodial care and the implications of non-coverage. The facility's policy required an ABN to be completed and signed when services were believed to be non-covered, which was not adhered to in this case.
Failure to Complete SCSA for Resident with Significant Change
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days for a resident who experienced a significant change in condition. The resident, who had a history of stroke, was readmitted to the facility with a new stroke diagnosis and exhibited a decline in activities of daily living (ADLs), becoming dependent on tube feeding and unable to participate in the Brief Interview for Mental Status (BIMS). Despite these changes, the facility did not conduct the required SCSA, which is necessary to update the resident's plan of care based on their current health status. Interviews with facility staff, including MDS Coordinators and the Director of Nursing (DON), confirmed that the resident's condition had significantly declined in multiple areas, including mental status, nutrition, and ADLs. The staff acknowledged that an SCSA should have been completed as the resident was not expected to return to their prior levels of function within two weeks. The failure to conduct the SCSA was attributed to the completion of another comprehensive admission MDS instead, which did not adequately reflect the resident's current health status and needs.
Failure to Implement ROM Exercises as per Care Plans
Penalty
Summary
The facility failed to implement care plans for three residents concerning Restorative Nursing Assistant (RNA) range of motion (ROM) exercises. Resident 1, who had a traumatic brain injury and was in a vegetative state, was supposed to receive passive ROM exercises daily to prevent further contractures. However, the RNA weekly summary indicated that Resident 1 only received these exercises five times a week instead of the prescribed seven times. Observations showed that Resident 1's hands were contracted, and interviews with staff confirmed the lack of adherence to the care plan. Resident 45, who was admitted with weakness and confusion, required assistance with activities of daily living and was supposed to receive both active and passive ROM exercises five times a week. However, interviews with staff revealed that these exercises were not being provided as per the care plan. The care plan aimed to prevent contractures and decline in ROM, but it was not implemented, as confirmed by the staff and the Director of Nursing (DON). Resident 51, who had a stroke with right-sided hemiparesis, was dependent on staff for most activities and was supposed to receive daily ROM exercises. The RNA weekly summary showed that Resident 51 received these exercises only five times a week instead of daily. Interviews with staff and the DON confirmed that the care plan was not followed, which was necessary to prevent contractures and decline in performing activities of daily living. The facility's policies did not clearly indicate the implementation of care plans, contributing to the deficiency.
Failure to Provide Ordered ROM Exercises
Penalty
Summary
The facility failed to consistently provide Restorative Nursing Assistant (RNA) services for range of motion (ROM) exercises as per physician's orders for three residents with limited ROM. Resident 1, who had a traumatic brain injury and was in a vegetative state, was supposed to receive passive ROM exercises seven times a week to prevent worsening of contractures. However, due to insufficient RNA staffing, Resident 1 only received these exercises five times a week, which was not in compliance with the physician's orders. Resident 45, who was admitted with weakness and confusion, was ordered to receive both active and passive ROM exercises five times a week. Despite this, there were no records of ROM exercises being provided to Resident 45 since the order was given. This oversight was confirmed by the staff, who acknowledged that Resident 45 was not enrolled in the RNA program and did not receive the necessary exercises to prevent the development of contractures. Resident 51, who had a stroke with right-sided hemiparesis, was ordered to receive daily ROM exercises. However, the facility only provided these exercises five times a week, contrary to the physician's orders. The staff confirmed the discrepancy, acknowledging that the exercises were not provided as frequently as required. The facility's policy on the Restorative Nursing Program emphasized the importance of following the written plan to help residents achieve and maintain the highest possible levels of independence, which was not adhered to in these cases.
Improper Storage and Labeling of Insulin Aspart
Penalty
Summary
The facility failed to properly store and label house supply/stock medications, specifically insulin aspart, with open dates. During an observation and interview, it was found that two boxes of insulin aspart were stored in a medication refrigerator, each containing one bottle. One box was labeled with an open date, but the bottle inside was not labeled. The other box was labeled with an expiration date, but again, the bottle inside was not labeled with an open date. This lack of labeling could lead to the interchanging of bottles, compromising the integrity of the medication. The Director of Nursing (DON) confirmed that insulin has a 28-day expiration upon opening and acknowledged that without proper labeling, Licensed Nurses (LNs) would not be able to determine which bottle corresponded to the correct box with the open date. This oversight could result in the use of ineffective medication. The facility's policy on drug storage and security requires all medications to be accurately labeled with expiration dates and stored in a manner that reduces the likelihood of error.
Failure to Address Resident Council Concerns in QAPI
Penalty
Summary
The facility failed to identify and address concerns raised in the residents council minutes regarding transportation for outdoor activities within their Quality Assurance and Performance Improvement (QAPI) program. During an interview with the QAPI program members, it was revealed that the team utilized various sources of information, including family and resident feedback, to track performance and make necessary changes to policies and procedures. However, the Director of Nursing (DON) admitted that while concerns from the resident council were discussed, they were not documented or formalized into the QAPI plan. The DON further explained that transportation for activities had been halted during the pandemic, and efforts were being made to restore these options. Despite recognizing that the lack of transportation could affect residents' quality of life, the facility did not formally address the issue in their QAPI activities. A review of the facility's QAPI policy indicated that the program should encompass all segments of care and services impacting clinical care, quality of life, and resident choice, yet the transportation issue was not included.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two residents, leading to deficiencies in care. For Resident 52, who was on contact precautions due to a history of methicillin-resistant Staphylococcus aureus (MRSA), a CNA entered the resident's room without performing hand hygiene or wearing the required personal protective equipment (PPE), such as a gown and gloves. The CNA admitted to not knowing why the resident was on contact precautions and acknowledged the importance of following these precautions to prevent the spread of infection. Additionally, the Infection Prevention nurse did not have a complete list of residents on infection control precautions, which contributed to the oversight. For Resident 1, who was in a vegetative state and on enhanced barrier precautions (EBP) due to the use of a gastrostomy tube, a licensed nurse (LN) failed to wear a gown and did not change gloves between procedures while administering tube feeding. The LN incorrectly believed that wearing a gown was discretionary and admitted to not changing gloves after touching a potentially contaminated curtain. The Director of Nursing (DON) confirmed that the expectation was for staff to wear a gown and gloves during high-contact activities with residents on EBP to prevent infection spread. The facility's policies on standard and transmission-based precautions, as well as enhanced barrier precautions, were not followed by the staff, leading to potential risks of infection spread among residents, staff, and visitors. The lack of adherence to these protocols highlights a significant deficiency in the facility's infection control practices.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as per its own policy and procedure. During an interview and record review, the Infection Preventionist (IP) acknowledged that while the pharmacy assisted with logging and tracking antibiotics, there was no comprehensive tracking system in place. The IP was responsible for tracking urinary tract infections (UTIs), but there was no documented evidence of a line tracking list for antibiotics. This lack of documentation and oversight was further highlighted by the fact that a resident was coded for antibiotic use on the Minimum Data Set (MDS) but was not listed on the medication administration record (MAR), indicating a gap in tracking and monitoring antibiotic use. Interviews with pharmacy staff revealed further inconsistencies in the antibiotic tracking process. Pharm 1 stated that he did not track the antibiotic line list and suggested that another pharmacist might be responsible. Pharm 2 mentioned the use of antibiotic escalation but emphasized the need for a collaborative process to ensure all information is available and accessible to the healthcare team. The facility's long-term care policy on antimicrobial stewardship indicated the need for a designated committee to monitor antimicrobial use, but this was not effectively implemented, leading to a deficiency in the facility's antibiotic stewardship program.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse for one of the sampled residents, leading to an increased risk of abuse for the resident. The resident was admitted to the facility and later reported to their Responsible Party (RP) that a Certified Nursing Assistant (CNA) had pulled their arm and spoken to them in a hurtful manner. The RP communicated these concerns to the facility's Social Worker (SW), who then informed the facility's management. However, the Director of Nursing (DON) and the Clinical Lead (CL) were not aware of the abuse allegation. The CL conducted an investigation into the RP's concerns but did not investigate the abuse allegation, mistakenly believing it was related to an old incident. This oversight was contrary to the facility's policy, which mandates immediate investigation of any abuse charges.
Failure to Implement Care Plan for Resident Safety
Penalty
Summary
The facility failed to develop a care plan to ensure the safety of a resident who was at risk due to financial exploitation concerns. The resident was admitted with a diagnosis that included an ill-defined liver mass concerning for malignancy. An Adult Protective Services (APS) case was opened after a family member expressed concerns about the resident's financial transactions with neighbors. Despite the APS report and a psychiatrist's determination that the resident lacked the capacity for financial decision-making, the facility did not create a care plan to restrict certain visitors, leading to unauthorized visits by individuals suspected of exploiting the resident. Interviews with facility staff, including the Director of Nursing (DON), Licensed Nurses (LN), and Certified Nurse Assistants (CNA), revealed a lack of awareness and communication regarding the restricted visitors. The visitor logs showed that the restricted individuals visited the resident multiple times after the APS report was filed. The facility's policy required care plans to be reviewed and revised as needed, but no such plan was created for the resident, and there was no documentation of restricted visitors in the resident's records.
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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 Chula Vista
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Veterans Home Of California - Chula Vista | 0.7 mi | — | 9 | 0 |
| South Bay Post Acute Care | 4.3 mi | — | 1 | 0 |
| Reo Vista Healthcare Center | 4.4 mi | — | 6 | 0 |
| Ridgeview Skilled Nursing Facility | 4.7 mi | — | 3 | 0 |
| National City Post Acute | 5.6 mi | — | 25 | 0 |
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