Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Veterans Home Of California - Chula Vista during CMS and state inspections, most recent first.
A resident with nicotine dependence and a PRN order for nicotine lozenges was found in bed with a medication cup containing a white tablet left unattended on the bedside drawer, with no staff present. The resident reported it was a nicotine wafer left by the nurse and ingested it, hoping it was the nicotine lozenge. The RN reported having given two lozenges but only saw the resident take one and believed direct observation was unnecessary for PRN doses. Review showed no evaluation or MD order for the resident to self-administer medications, despite facility policy requiring medications to be promptly administered as part of the complete act of administration.
A resident was readmitted with an order for IV Zosyn to treat an abdominal infection, but the facility did not have the medication available and could not obtain it from their contracted after-hours pharmacy. This resulted in delayed treatment and the resident being transferred to another facility for care.
Staff, including CNAs and an LVN, did not wear surgical masks as required in a unit with active Covid-19 cases, despite the facility's mitigation plan mandating source control masking during outbreaks. Interviews confirmed staff were aware of the policy, but masks were not consistently worn, increasing the risk of viral transmission.
The facility failed to maintain food safety and sanitation in the kitchen, with unlabeled and undated food items, expired meat substitute, and broken tiles creating unsanitary conditions. These deficiencies could expose residents to contaminated food and unsanitary practices.
The facility failed to notify the ombudsman of the transfer of three residents to the hospital, as required. One resident with diabetes and skin damage, another with a recent amputation, and a third with osteomyelitis were transferred without notification. The ADON was unaware of the requirement, and the facility's policy did not address notifying the ombudsman.
A facility failed to provide a written bed hold policy notification to a resident and/or his representative upon transfer to a hospital. Despite the facility's policy requiring such notification, there was no evidence of it in the resident's medical records. Interviews with RNs confirmed the oversight, potentially leaving the resident uninformed about their rights to return.
A resident experienced significant weight loss, and the facility failed to update the nutrition care plan to reflect necessary interventions. Despite the resident's moderate impairment and awareness of weight loss, the care plan was not revised to include dietary needs and preferences. The facility's policies on care plan updates were not followed, leading to a deficiency in providing appropriate nutrition interventions.
A resident experienced significant unintentional weight loss due to the facility's failure to implement a comprehensive approach for monitoring nutrition interventions. The RD did not update the care plan to address the resident's ongoing weight loss, and there was a lack of communication between dietary and nursing teams, hindering effective intervention.
The facility failed to ensure safe pharmaceutical services, with expired medications found in medication rooms and carts, and inadequate controlled drug records for a resident. Expired Procrit, Mantoux, insulin, and nitroglycerin were available for use, violating facility policy. Additionally, mismatched prescription numbers for a resident's narcotic medication indicated poor record-keeping, risking drug diversion or misuse.
A LTC facility experienced a medication error rate of 7.14% due to errors involving two residents. One resident received glipizide without the required 30-minute pre-meal interval, and another resident was given fexofenadine with fruit juice, contrary to guidelines. Additionally, a medication was omitted for the second resident. The errors occurred due to non-adherence to the facility's medication administration policies and guidelines.
The facility failed to ensure proper labeling and storage of medications. An outdated insulin vial was found in the Unit 700 Medication Room, and a bulk bottle of atovaquone oral suspension was improperly stored in the Unit 300 Medication Room. The pharmacist acknowledged these issues, which were contrary to the facility's policy and manufacturer's instructions.
A resident with dysphagia was not scheduled for a dental appointment despite a physician's order and facility policy requiring an initial dental screening upon admission. The resident had not seen a dentist since October 2023 and reported discomfort with ill-fitting dentures. The charge nurse failed to notify the office assistant to arrange the appointment, and there was no documentation of a request for dental evaluation.
The facility failed to serve food at acceptable temperatures, with observations showing meals below the required 130°F. Residents reported meals, especially breakfast, were often cold. The Director of Dietetics acknowledged the issue, and the facility's policy emphasized serving food at required temperatures.
The facility failed to follow Enhanced Barrier Precautions for two residents, leading to potential infection control issues. Staff did not wear required PPE during high-contact activities for residents with gastrostomy tubes. Additionally, improper storage of a single-use syringe and an unsealed saline spray in the medication room posed contamination risks. These actions were contrary to the facility's infection prevention policies.
A facility failed to implement a comprehensive care plan for a resident with mental health diagnoses, as their aggressive behaviors were not documented or communicated to the IDT. The resident's behavior towards staff was not monitored as required, leading to a lack of awareness among the care team until a meeting months later.
A resident with cognitive impairments eloped from an LTC facility, resulting in a fall and injury. The facility failed to assess the resident's supervision needs and did not conduct an Elopement Risk Assessment despite previous incidents. Staff did not adhere to monitoring protocols, leading to the resident being unsupervised for nine hours.
The facility failed to report suspected financial abuse within 24 hours for a resident with severe cognitive impairment. Despite multiple indications of delinquent payments by the resident's DPOA, the facility delayed reporting to APS and CDPH, resulting in a year-long delay in oversight and investigation.
Unattended Nicotine Lozenge Left at Bedside Without Self-Administration Authorization
Penalty
Summary
Nursing staff failed to ensure medications were properly administered and not left unattended at the bedside for a resident with an order for nicotine lozenges. The resident had a diagnosis of nicotine dependence and a physician’s order for nicotine 2 mg lozenges to be given as needed. During observation, the resident was found lying in bed with a clear plastic medication cup containing a single white circular tablet on the bedside drawer, with no nursing staff present. The resident stated the tablet was a nicotine wafer that the nurse had left there and then ingested the tablet, stating he hoped it was the nicotine lozenge. Further review showed that the MAR documented administration of one 2 mg nicotine lozenge earlier that morning, while the RN reported having given two lozenges and only witnessing the resident take one. The RN stated that because the lozenges were ordered as needed, she did not believe she had to see the resident take them. The supervising RN confirmed that medications should not be left unattended at the bedside and that the resident had not been evaluated for self-administration of medications. Another RN confirmed there was no physician order for the resident to self-administer medications. The facility’s medication administration policy required that medications be promptly given to the proper resident as part of the complete act of administration.
Failure to Provide Ordered IV Antibiotic Upon Readmission
Penalty
Summary
The facility failed to provide necessary treatment for a resident who was readmitted with an order for intravenous (IV) Zosyn, an antibiotic required for an abdominal infection following acute appendicitis with abscess. The hospital had communicated the need for IV Zosyn prior to the resident's transfer, and the facility staff, including the RN Case Manager and Director of Nursing, were aware of the requirement. However, upon the resident's arrival, the facility did not have IV Zosyn available, and the in-house pharmacy was closed. Attempts to obtain the medication from the contracted after-hours IV pharmacy were unsuccessful, as the pharmacy was not open during the weekend hours. The facility's process for reviewing new admissions or readmissions included determining whether the facility could meet the resident's care needs. Despite this, the staff did not verify the availability of IV Zosyn before accepting the resident for readmission. The emergency medication kit did not contain IV Zosyn, and the pharmacy manager was not informed in advance about the need for this medication. The facility's after-hours pharmacy contract indicated that emergency or expedited orders could be delivered on weekends and holidays upon mutual agreement, but this process was not successfully executed in this case. As a result of the facility's inability to provide the ordered IV antibiotic, the resident experienced a delay in receiving necessary medication and was subsequently transferred to another facility that could provide the required treatment. The failure to ensure medication availability prior to readmission directly led to the deficiency identified in the report.
Failure to Enforce Masking Protocols During Covid-19 Outbreak
Penalty
Summary
Staff on Unit 300 failed to adhere to the facility's infection prevention and control program by not wearing surgical masks as required in an area where residents with active Covid-19 infections resided. During an observation, two CNAs were seen with their surgical masks around their necks, not covering their nose and mouth, while passing nourishments to residents. Additionally, an LVN was observed at the nurse's station without a mask. Interviews with the involved staff confirmed their awareness of the masking requirement, and the Infection Preventionist stated that surgical masks were required on the units, with N-95 masks needed for direct care of Covid-19 positive residents. The facility's mitigation plan, reviewed during the investigation, specified that source control masking is required during a VRI outbreak or surge in cases, which was the current situation with multiple residents and staff testing positive for Covid-19. Despite this, staff, including visiting hospice nurses, were not consistently following the masking procedures as outlined in the mitigation plan. The DON and Standard Compliance Coordinator acknowledged the expectation for all staff and visitors to adhere to the masking requirements during the outbreak.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain food safety and sanitation measures in the kitchen, as observed during a survey. A plastic bin containing a white powdered substance, identified as a thickening agent for pureed foods, was found unlabeled and undated under a food preparation counter. Additionally, a bag of opened frozen peanut butter cookies and three sandwiches in the refrigerator were also found without labels or dates. These items were not in compliance with the 2022 Federal Food and Drug Administration Food Code, which requires proper labeling and dating of food items to ensure safety and prevent foodborne illnesses. Further observations revealed a bag of meat substitute in the walk-in freezer that was past its expiration date, which should have been discarded according to the facility's policy and the FDA Food Code. Additionally, five broken tiles were found at the base of the wall next to the dish drying racks, creating unsanitary conditions. The facility's policy requires that kitchen areas be kept clean and in good repair, which was not adhered to in this instance. These deficiencies had the potential to expose residents to contaminated food and unsanitary practices, increasing the risk of foodborne illnesses.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the ombudsman of the transfer or discharge of three residents, which is a requirement to ensure residents' rights are protected. Resident 19, who had diabetes mellitus and sacral moisture-associated skin damage, was transferred to a hospital for further evaluation and treatment of buttocks wounds. There was no documented evidence that the ombudsman was notified of this transfer. Similarly, Resident 47, who was readmitted to the facility after a right above-knee amputation, was transferred to a hospital without the ombudsman being informed. Resident 99, diagnosed with osteomyelitis, was also transferred to a hospital for further evaluation and treatment without notifying the ombudsman. Interviews with the Assistant Director of Nursing (ADON) revealed that the facility did not have a practice of notifying the ombudsman when residents were transferred or discharged. The ADON was unaware of the requirement to notify the ombudsman, and the facility's policy and procedure on transfer/discharge did not address this requirement. This oversight in communication and policy led to the deficiency identified by the surveyors.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide a written bed hold policy notification to a resident and/or his representative upon the resident's transfer to an acute care hospital. This deficiency was identified during a review of the resident's medical records and interviews with facility staff. The resident was transferred to the hospital on August 27, 2024, and was readmitted to the facility on December 7, 2024, after a prolonged hospitalization. Despite the facility's policy requiring a bed hold notification to be provided and documented, there was no evidence of such notification in the resident's medical records. Interviews with Registered Nurses 5 and 6 confirmed that a bed hold notification was not completed for the resident at the time of transfer. The facility's policy, dated January 29, 2025, mandates that a licensed nurse must notify the resident or their representative about the bed hold policy and document this in the medical record. The failure to adhere to this policy potentially left the resident and/or his representative uninformed about the resident's rights to return to the facility following hospitalization.
Failure to Update Nutrition Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a person-centered care plan for weight loss was updated for a resident, identified as Resident 20, who experienced significant weight loss. Resident 20 was admitted with diagnoses including hypertension, rheumatoid arthritis, and chronic obstructive pulmonary disease. The resident had a BIMS score indicating moderate impairment and experienced a weight loss of over 7% from August 2024 to January 2025, without being on a physician-prescribed weight-loss regimen. Despite the resident's awareness of his weight loss and food preferences, the care plan was not updated to reflect necessary nutrition interventions. Observations and interviews revealed that Resident 20 consumed less than 55% of meals on average, and although there was an order for a Prostat supplement, it was not consistently administered. The Registered Nurse confirmed that the supplement was not given on a specific date, and the Registered Dietitian acknowledged that the care plan was not updated to include additional food items recommended. The care plan had not been revised to reflect the resident's ongoing weight loss and dietary needs, despite the dietitian's awareness and quarterly assessments. The facility's policies required care plans to be reviewed and updated quarterly or as necessary, but this was not adhered to in Resident 20's case. The Assistant Director of Nursing stated that dietary notes were separate from nursing notes, which may have contributed to the lack of communication and updates in the care plan. The failure to update the care plan as per the facility's policy and the resident's needs led to a deficiency in providing appropriate nutrition interventions for Resident 20.
Failure to Monitor Nutrition Interventions Leads to Significant Weight Loss
Penalty
Summary
The facility failed to implement a comprehensive systematic approach for monitoring nutrition interventions for a resident, leading to significant unintentional weight loss. The resident, who had a history of hypertension, rheumatoid arthritis, and chronic obstructive pulmonary disease, experienced a weight loss of 10.84% from July 2024 to January 2025. Despite the resident's weight loss being documented, the facility did not adequately update or follow through with the nutrition care plan to address the issue. The Registered Dietitian (RD) was responsible for updating the nutrition care plans and attending Nutritional At Risk (NAR) meetings. However, the RD did not consistently update the care plan to reflect the resident's ongoing weight loss and failed to implement recommended interventions such as a fortified diet. The RD acknowledged that the resident's nutrition assessment did not include additional foods recommended, and the care plan lacked a weight loss goal. Interviews with facility staff revealed a lack of communication and coordination between the dietary and nursing teams. The Assistant Director of Nursing (ADON) stated that dietary notes were separate from nursing notes, hindering the nursing staff's ability to carry out interventions. The facility's policies required the RD to monitor significant weight changes and update care plans, but these actions were not effectively executed, contributing to the resident's continued weight loss.
Expired Medications and Inadequate Drug Records Found in Facility
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for its residents, as evidenced by the presence of expired medications in the medication rooms and carts. During an inspection of the Unit 300 Medication Room, outdated Procrit, Mantoux vial, and insulin pen were found stored and available for resident use. The pharmacist acknowledged that these medications were expired and should have been removed from the medication refrigerator. The facility's policy clearly stated that drugs should not be kept in stock after their expiration date, yet these expired medications were still present. In another instance, an expired nitroglycerin vial was found in the Unit 700 Medication Cart. The Assistant Director of Nursing confirmed the expiration and acknowledged that the vial should have been removed according to the facility's policy. This oversight in managing medication expiration dates posed a risk of residents receiving outdated and potentially ineffective medications. Additionally, the facility failed to maintain organized and orderly controlled drug records for Resident 5. The prescription numbers on the resident's PRN hydrocodone/acetaminophen did not match the corresponding Controlled Drug Record, leading to discrepancies in narcotic accountability. The Director of Pharmacy and Supervising Registered Nurse acknowledged the mismatch and the delay in the use of the narcotic supply. This lack of proper record-keeping could result in drug diversion, abuse, or misuse, further compromising resident safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate due to three medication errors involving two residents. For one resident, the medication glipizide, which is used to manage blood sugar levels, was not administered 30 minutes before meals as required. The Licensed Vocational Nurse (LVN) prepared and administered the medication without adhering to the timing guidelines specified in both the facility's drug handbook and Lexi-comp, the facility's reference for drug information. The Director of Pharmacy confirmed that the medication should be given 30 minutes before the first main meal, but this protocol was not followed. Another resident experienced two medication errors. One medication was omitted, and the allergy medication fexofenadine was administered with fruit juice, contrary to the guidelines in Lexi-comp, which state that fexofenadine should not be given with fruit juices. The Registered Nurse (RN) responsible for administering the medications acknowledged the omission and the incorrect administration method. The facility's policy and procedure for medication pass and administration were not adhered to, as special considerations and timing were not properly noted or followed in the Medication Administration Record (MAR). The facility's policies, including those for medication pass and drug administration, emphasize the importance of administering medications as prescribed and noting special considerations in the MAR. However, these policies were not followed, leading to the medication errors. The Director of Pharmacy and nursing staff acknowledged the discrepancies between the facility's practices and the established guidelines, which contributed to the increased medication error rate.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were labeled and stored according to accepted standards and manufacturer's instructions. During an inspection of the Unit 700 Medication Room, an outdated insulin vial was found stored in the refrigerator, despite a pharmacy label indicating it should not be used after January 22, 2025. The pharmacist acknowledged the outdated insulin vial and stated it should not have been returned to the medication room refrigerator. The facility's policy, reviewed with the Director of Pharmacy, indicated that drugs should not be kept in stock after their expiration date, and no contaminated or deteriorated drugs should be available for use. In another instance, during an inspection of the Unit 300 Medication Room, a bulk bottle of atovaquone oral suspension for a resident was stored in the medication refrigerator at 38 degrees Fahrenheit, contrary to the manufacturer's instructions to store it at room temperature between 68 to 77 degrees Fahrenheit. The pharmacist acknowledged the discrepancy between the storage conditions and the manufacturer's labeling. The facility's policy, reviewed with the Director of Pharmacy, stated that nursing staff should review manufacturer's recommendations to ensure drugs are stored at appropriate temperatures.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to ensure a dental appointment was scheduled for a resident, identified as Resident 72, who was admitted with a diagnosis of dysphagia. During an observation and interview, it was noted that Resident 72 was without teeth or dentures and expressed discomfort with wearing dentures due to their fit. The resident had not been seen by a dentist since October 2023, despite a physician's order from November 2024 for a dental evaluation and treatment. The registered nurse confirmed that the charge nurse should have notified the office assistant to arrange a dental appointment and documented this in the resident's record, which was not done. The facility's policy required an initial dental screening examination upon admission, which was not adhered to in this case.
Failure to Serve Food at Acceptable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at an acceptable temperature, which could affect the meal and food intake of residents, potentially impairing their nutritional status. During a test tray observation, it was noted that the entree of carne with tortilla was served at 128 degrees Fahrenheit, and the milk was at 50.8 degrees Fahrenheit, both below the acceptable temperature as per the FDA Food Code, which requires food to be held at 130 degrees Fahrenheit or above. Additionally, the beans served as a side item were dried out, indicating a lack of proper food handling and temperature maintenance. Interviews with residents and observations further confirmed the issue, as nine residents reported that meals, particularly breakfast, were often served cold. One resident specifically mentioned that his food was often cool and expressed a preference for hotter meals. The Director of Dietetics acknowledged the low food temperatures and stated that food should be served at an acceptable temperature and palatability. The facility's policy on food preparation also emphasized the importance of serving food at required temperatures to conserve nutrients, flavor, and appearance.
Inadequate Infection Control Practices and Medication Storage Issues
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for two residents, leading to potential infection control issues. Resident 84, who was admitted with dysphagia and a gastrostomy tube, was observed receiving perineal hygiene care, medication administration, and tube feeding without the staff wearing the required personal protective equipment (PPE). Despite the presence of EBP signage, both a Certified Nursing Assistant and a Licensed Vocational Nurse did not wear gowns during these high-contact activities, which are essential to prevent the spread of multidrug-resistant organisms. Similarly, Resident 25, diagnosed with multiple sclerosis and dysphagia, was also subject to inadequate infection control practices. During medication administration via a gastrostomy tube, a Licensed Vocational Nurse failed to wear a gown, contrary to the EBP requirements indicated by the signage outside the resident's room. The Infection Control Nurse confirmed that gowns and gloves should have been worn to prevent the transmission of multidrug-resistant organisms. Additional deficiencies were noted in the medication room, where a single-use syringe labeled as sterile was improperly stored attached to a medication bottle, and an unsealed bottle of saline spray was found without its printed neckband. These practices posed a risk of contamination and were acknowledged by the facility's pharmacist and infection control nurse. The facility's policies on drug storage and infection prevention were not followed, contributing to the potential spread of infections and use of compromised medical supplies.
Failure to Document and Monitor Resident's Aggressive Behavior
Penalty
Summary
The facility failed to implement an accurate comprehensive person-centered care plan for a resident, who was admitted with diagnoses including Major Depressive Disorder, Panic Disorder, and Post-Traumatic Stress Disorder. The resident exhibited aggressive behaviors towards staff, which were not monitored or documented as required. The Director of Physical Therapy reported being verbally harassed by the resident over the past two years but did not document these behaviors in the medical record or notify the Interdisciplinary Team (IDT) until July 2024. This lack of documentation and communication resulted in the IDT being unaware of the resident's behavior issues until a meeting on July 22, 2024. The Social Services Director and Supervising Registered Nurse were also unaware of the resident's aggressive behavior until shortly before the IDT meeting. The facility's policy required behavior monitoring to be documented every shift, but this was not done. The Medical Doctor emphasized the importance of documentation for accurate assessment and treatment planning. The failure to document and communicate the resident's behaviors compromised the ability to address the resident's mental health needs effectively.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident, resulting in injury. The resident, who had a history of dementia and paranoid schizophrenia, left the facility unsupervised and was missing for approximately nine hours. During this time, the resident fell and sustained a two-centimeter forehead laceration that required five sutures. The facility staff did not assess the level of supervision required for the resident's safety, despite previous incidents indicating a risk of elopement. The resident had a documented history of attempting to leave the facility unsupervised, as evidenced by a previous fall at the facility's back gate. Despite this, the facility did not conduct an Elopement Risk Assessment or update the resident's care plan to address the risk of elopement. The facility's policy required staff to monitor residents' whereabouts every two hours, but this was not adhered to, as the resident's location was documented without direct visualization. Interviews with facility staff revealed a lack of adherence to established protocols for monitoring residents. The Certified Nurse Assistant (CNA) responsible for the resident's care did not visually confirm the resident's location, relying instead on routine assumptions. The Director of Nursing acknowledged the failure to conduct an Elopement Risk Assessment and the absence of policies to prevent elopements, citing the facility's status as an unlocked facility where residents have the right to leave.
Failure to Report Suspected Financial Abuse in a Timely Manner
Penalty
Summary
The facility failed to implement their policy and procedure for reporting suspected financial abuse within 24 hours for a resident with severe cognitive impairment. The resident's Durable Power of Attorney (DPOA) had not paid the monthly residential fees for an extended period, leading to a significant outstanding balance. Despite multiple indications and internal communications about the delinquent payments, the facility did not report the suspected financial abuse to Adult Protective Services (APS) or the California Department of Public Health (CDPH) in a timely manner. The Financial Case Worker (FCW) and other staff members were aware of the issue but did not take the necessary steps to report it immediately, resulting in a year-long delay in oversight and investigation. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, was financially dependent on the DPOA. The facility's internal records showed multiple attempts to contact the DPOA and discussions about the need to report the suspected abuse. However, the actual report to APS was not made until much later, despite clear signs of financial mismanagement. The Facility Administrator acknowledged the oversight and confirmed that the suspected abuse should have been reported immediately as per the facility's policy and state law.
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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) |
|---|---|---|---|---|
| Sharp Chula Vista Med Ctr Snf | 0.7 mi | — | 0 | 0 |
| South Bay Post Acute Care | 3.7 mi | — | 1 | 0 |
| Reo Vista Healthcare Center | 3.8 mi | — | 6 | 0 |
| Ridgeview Skilled Nursing Facility | 4.9 mi | — | 3 | 0 |
| National City Post Acute | 5 mi | — | 25 | 0 |
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