San Diego Post-Acute Center

In the surveyor’s words

From the most serious findings on record at San Diego Post-Acute Center, in the surveyor’s own words.

• Immediate jeopardy, patternF760May 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure six out of seven residents (187, 126, 2, 181, 73, 43) were free of any potential or actual significant medication errors when: Licensed Nurse (LN) 1 prepared eight morning medications for Resident 76 including clozapine (used for schizophrenia, a distorted perception of reality), topiramate (used to treat seizures, abnormal and disruptive electrical activity in the brain), and levetiracetam (used to treat seizures) and gave the medications to LN 2 to administer. LN 2 then administered Resident 76's medications to Resident 187. […]

• Immediate jeopardy, isolatedF726Jun 4, 2026

  Based on interview and record review, the facility failed to ensure three of 16 Registered Nurses (RNs 1, 11, 16) were trained and competent to administer an intravenous (IV-the administration of fluids, medications, or nutrients directly into the bloodstream through a needle or tube inserted into a vein) medication administration using a Medicine Ball infusion system (balloon-like reservoir filled with medication that relies on its own elastic walls to generate steady, continuous pressure, slowly pushing fluid into a patient's vein) to residents receiving an IV treatment. […]

• Immediate jeopardy, isolatedF726May 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure two of four licensed nurses (LN 1 and LN 2) reviewed for medication administration training and competency were trained and deemed competent to administer medications through a facility approved and documented validation evaluation. Licensed Nurse (LN) 1 prepared eight morning medications for Resident 6 including clozapine (used for schizophrenia, a distorted perception of reality), topiramate (used to treat seizures, abnormal and disruptive electrical activity in the brain), and levetiracetam (used to treat seizures) and gave the medications to LN 2 to administer. LN 2 then administered Resident 76's medications to Resident 187. […]

• Actual harm, isolatedF600Jun 16, 2026

  Based on observation, interview and record review, the facility failed to ensure one of one resident (Resident 1) was free from sexual abuse when:Maintenance Personnel (MP) kissed Resident 1's forehead without consentMP made contact with Resident 1's upper extremities without consentMP pulled Resident 1's pants without consentMP sat on Resident 1's bed without consentAs a result, MP had continued access to Resident 1These failures to identify and report allegations of abuse did not protect Resident 1 Cross reference F600 F607 F609 F610Findings:On 5/11/2026 at 8 A.M. an unannounced onsite was conducted to investigate one facility reported incident of alleged abuse. On 5/19/2026 additional facility reported incident of alleged abuse for the same parties involved (MP to Resident 1). […]

• Actual harm, isolatedF600Jan 23, 2026

  Based on observation, interview, and record review, the facility failed to ensure four of four residents (Resident 3, 4, 5, and 6) were free from physical abuse when:1. Resident 5's behavioral triggers (stimuli that may cause a specific action or response) were not identified, assessed, and care planned.2. Resident 6's wandering behavior into other residents' rooms was not identified, assessed, and care planned.As a result:1. Resident 5, when triggered, pushed Resident 4 down on 11/14/25, punched Resident 3 in the mouth on 12/25/25, and yelled at and grabbed Resident 6's arm on 12/30/25. Resident 3 sustained a laceration to the inner upper lip, experienced pain, and was distressed.2. Resident 6 entered Resident 5's room on 12/30/25 and put on his clothes. […]