Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

B+
Grade
58
Score
CMS Ratings
10.3/22
Staffing Quality
13.4/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
6.0/10

Current Availability Estimate

Occupancy Rate91.7%
133
Total Beds
122
Occupied
11
Available

Basic Information

Address:

3202 DUKE STREET

SAN DIEGO, CA 92110

Number of Beds:

133

Estimated Occupancy:

92% (~11 available)

Chain:

PACIFIC HEALTHCARE HOLDINGS

Quality Ratings

Overall Rating:2/5 Stars
Health Inspection:2/5 Stars
Staffing Rating:3/5 Stars
Quality Measures:3/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

055322

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Below Average

This Facility

0.48

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Average

This Facility

4.13

hours

National Avg

3.89

hours

Breakdown:

RN: 0.48hLPN: 1.20hAide: 2.45h

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Total Deficiencies

178

Inspections

30

Oct 24, 2024 - Health Survey

36 deficiencies cited

Medium - PatternTag F0552

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected: Nov 21, 2024
Medium - PatternTag F0925

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected: Nov 21, 2024
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Nov 21, 2024
Medium - PatternTag F0847

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected: Nov 21, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Nov 21, 2024
Medium - PatternTag F0802

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected: Nov 21, 2024
Medium - PatternTag F0761

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected: Nov 21, 2024
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Nov 21, 2024
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Nov 21, 2024
Medium - PatternTag F0552

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected: Nov 21, 2024
Medium - PatternTag F0578

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected: Nov 21, 2024
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Nov 21, 2024
Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Nov 21, 2024
Medium - PatternTag F0625

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected: Nov 21, 2024
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Nov 21, 2024
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: Nov 21, 2024
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Nov 21, 2024
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Nov 21, 2024
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Nov 21, 2024
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Nov 21, 2024
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Nov 21, 2024
Medium - PatternTag F0761

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected: Nov 21, 2024
Medium - PatternTag F0802

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected: Nov 21, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Nov 21, 2024
Medium - PatternTag F0847

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected: Nov 21, 2024
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Nov 21, 2024
Medium - PatternTag F0925

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected: Nov 21, 2024
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Nov 21, 2024
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Nov 21, 2024
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Nov 21, 2024
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: Nov 21, 2024
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Nov 21, 2024
Medium - PatternTag F0625

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected: Nov 21, 2024
Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Nov 21, 2024
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Nov 21, 2024
Medium - PatternTag F0578

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected: Nov 21, 2024

Oct 10, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Oct 29, 2024From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Oct 29, 2024From Complaint

Sep 24, 2024 - Health Survey

12 deficiencies cited

Medium - PatternTag F0761

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected: Oct 3, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Oct 3, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Oct 3, 2024From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Oct 3, 2024From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Oct 3, 2024From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Oct 3, 2024From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Oct 3, 2024From Complaint
Medium - PatternTag F0761

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected: Oct 3, 2024From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Oct 3, 2024From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Oct 3, 2024From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Oct 3, 2024From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Oct 3, 2024From Complaint

Sep 4, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0583

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Corrected: Sep 26, 2024From Complaint
Medium - PatternTag F0583

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Corrected: Sep 26, 2024From Complaint

Aug 2, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Sep 5, 2024From Complaint
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Sep 5, 2024From Complaint

Jun 17, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Jul 15, 2024From Complaint
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Jul 15, 2024From Complaint

May 21, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0660

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Corrected: Jun 18, 2024From Complaint
Medium - PatternTag F0660

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Corrected: Jun 18, 2024From Complaint

Apr 18, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: May 15, 2024From Complaint
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: May 15, 2024From Complaint

Jan 25, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Feb 23, 2024From Complaint
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Feb 23, 2024From Complaint

Dec 21, 2023 - Health Survey

4 deficiencies cited

Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Jan 12, 2024From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Jan 12, 2024From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Jan 12, 2024From Complaint
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Jan 12, 2024From Complaint

Oct 26, 2023 - Health Survey

12 deficiencies cited

Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Dec 5, 2023
Medium - PatternTag F0558

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Corrected: Dec 5, 2023
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Dec 5, 2023
Medium - PatternTag F0644

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected: Dec 5, 2023
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: Dec 5, 2023
Medium - PatternTag F0849

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected: Dec 5, 2023
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Dec 5, 2023
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Dec 5, 2023
Medium - PatternTag F0849

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected: Dec 5, 2023
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: Dec 5, 2023
Medium - PatternTag F0644

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected: Dec 5, 2023
Medium - PatternTag F0558

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Corrected: Dec 5, 2023

Oct 2, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Oct 22, 2023From Complaint
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Oct 22, 2023From Complaint

Sep 24, 2023 - Health Survey

6 deficiencies cited

Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Oct 11, 2023From Complaint
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Oct 11, 2023From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Oct 11, 2023From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Oct 11, 2023From Complaint
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Oct 11, 2023From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Oct 11, 2023From Complaint

Sep 18, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0806

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected: Oct 9, 2023From Complaint
Medium - PatternTag F0806

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected: Oct 9, 2023From Complaint

Sep 14, 2023 - Health Survey

6 deficiencies cited

Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Oct 11, 2023From Complaint
Medium - PatternTag F0551

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

Corrected: Oct 11, 2023From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Oct 11, 2023From Complaint
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Oct 11, 2023From Complaint
Medium - PatternTag F0551

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

Corrected: Oct 11, 2023From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Oct 11, 2023From Complaint

Aug 4, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0602

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected: Aug 21, 2023From Complaint
Medium - PatternTag F0602

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected: Aug 21, 2023From Complaint

Aug 3, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected: Aug 31, 2023From Complaint
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected: Aug 31, 2023From Complaint

Aug 1, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Aug 31, 2023From Complaint
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Aug 31, 2023From Complaint

Jun 19, 2023 - Health Survey

6 deficiencies cited

Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Jul 19, 2023From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Jul 19, 2023From Complaint
Medium - PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected: Jul 19, 2023From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Jul 19, 2023From Complaint
Medium - PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected: Jul 19, 2023From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Jul 19, 2023From Complaint

Apr 21, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: May 16, 2023From Complaint
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: May 16, 2023From Complaint

Apr 12, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Apr 30, 2023From Complaint
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Apr 30, 2023From Complaint

Mar 22, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Mar 28, 2023From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Mar 28, 2023From Complaint

Feb 28, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0622

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected: Mar 30, 2023From Complaint
Medium - PatternTag F0622

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected: Mar 30, 2023From Complaint

Feb 7, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Mar 15, 2023From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Mar 15, 2023From Complaint

Jan 17, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jan 23, 2023From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jan 23, 2023From Complaint

Jan 3, 2023 - Health Survey

2 deficiencies cited

Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jan 30, 2023From Complaint
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jan 30, 2023From Complaint

Oct 19, 2022 - Health Survey

46 deficiencies cited

Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Nov 19, 2022
Medium - PatternTag F0694

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected: Nov 19, 2022
Medium - PatternTag F0693

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected: Nov 19, 2022
Medium - PatternTag F0691

Quality of Life and Care Deficiencies

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected: Nov 19, 2022
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Nov 19, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Nov 19, 2022
Medium - PatternTag F0908

Environmental Deficiencies

Keep all essential equipment working safely.

Corrected: Nov 19, 2022
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Nov 19, 2022
Medium - PatternTag F0625

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected: Nov 19, 2022
Medium - PatternTag F0622

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected: Nov 19, 2022
Medium - PatternTag F0605

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected: Nov 19, 2022
Medium - PatternTag F0604

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected: Nov 19, 2022
Medium - PatternTag F0554

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected: Nov 19, 2022
Medium - PatternTag F0552

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected: Nov 19, 2022
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Nov 19, 2022
Medium - PatternTag F0908

Environmental Deficiencies

Keep all essential equipment working safely.

Corrected: Nov 19, 2022
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Nov 19, 2022
Medium - PatternTag F0838

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected: Nov 19, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Nov 19, 2022
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Nov 19, 2022
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Nov 19, 2022
Medium - PatternTag F0742

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected: Nov 19, 2022
Medium - PatternTag F0740

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected: Nov 19, 2022
Medium - PatternTag F0732

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Corrected: Nov 19, 2022
Medium - PatternTag F0691

Quality of Life and Care Deficiencies

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected: Nov 19, 2022
Medium - PatternTag F0693

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected: Nov 19, 2022
Medium - PatternTag F0694

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected: Nov 19, 2022
Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Nov 19, 2022
Medium - PatternTag F0732

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Corrected: Nov 19, 2022
Medium - PatternTag F0740

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected: Nov 19, 2022
Medium - PatternTag F0742

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected: Nov 19, 2022
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Nov 19, 2022
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Nov 19, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Nov 19, 2022
Medium - PatternTag F0838

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected: Nov 19, 2022
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Nov 19, 2022
Medium - PatternTag F0552

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected: Nov 19, 2022
Medium - PatternTag F0554

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected: Nov 19, 2022
Medium - PatternTag F0604

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected: Nov 19, 2022
Medium - PatternTag F0605

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected: Nov 19, 2022
Medium - PatternTag F0622

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected: Nov 19, 2022
Medium - PatternTag F0625

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected: Nov 19, 2022
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Nov 19, 2022
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Nov 19, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Nov 19, 2022
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Nov 19, 2022

Sep 29, 2022 - Health Survey

6 deficiencies cited

Medium - PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected: Oct 29, 2022From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Oct 29, 2022From Complaint
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Oct 29, 2022From Complaint
Medium - PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected: Oct 29, 2022From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Oct 29, 2022From Complaint
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Oct 29, 2022From Complaint

Sep 16, 2022 - Health Survey

4 deficiencies cited

Medium - PatternTag F0573

Resident Rights Deficiencies

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Corrected: Sep 23, 2022From Complaint
Medium - PatternTag F0573

Resident Rights Deficiencies

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Corrected: Sep 23, 2022From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Sep 23, 2022From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Sep 23, 2022From Complaint

Sep 15, 2022 - Health Survey

2 deficiencies cited

Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Oct 31, 2022From Complaint
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Oct 31, 2022From Complaint

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

1 penalty in the past 3 years

Payment DenialMarch 2, 2026

Payment Denial: Started April 2, 2026

Duration: 5 days

Data processed: August 1, 2026

About Penalties: This data comes from CMS (Centers for Medicare & Medicaid Services) and shows fines and payment denials issued for health and safety violations. Penalties indicate serious deficiencies that required enforcement action.

Key Highlights

🛏
Beds Available
Approximately 11 beds potentially available
🏢
Part of Healthcare Chain
PACIFIC HEALTHCARE HOLDINGS

Frequently Asked Questions

What is the quality rating for THE PAVILION AT OCEAN POINT?

THE PAVILION AT OCEAN POINT has an overall CMS rating of 2 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

THE PAVILION AT OCEAN POINT has 133 certified beds. The facility averages 122 residents per day, with an occupancy rate of approximately 92%.

What type of ownership does this facility have?

This facility is for profit - limited liability company owned. It is part of the PACIFIC HEALTHCARE HOLDINGS network.

How can I contact THE PAVILION AT OCEAN POINT?

You can call THE PAVILION AT OCEAN POINT at (619)224-4141. The facility is located at 3202 DUKE STREET, SAN DIEGO, CA 92110.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

📚 Learn How to Evaluate Facilities

Understanding quality metrics helps you make better decisions. Check out these data-driven guides: