Vista Knoll Specialized Care Facility

Name: Vista Knoll Specialized Care Facility
Address: 2000 WESTWOOD ROAD, Vista, CA, 92083, US
Telephone: 7606302273

2000 Westwood Road, Vista, CA 92083 · San Diego County · 119 certified beds · avg 153 residents/day · certified since May 30, 1990

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.14

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Jun 11, 2026 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

All citations in the current public record (35)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 11, 2026	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 11, 2026	D · Potential for harm, one-off	The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. · from a complaint
Jun 8, 2026	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jun 8, 2026	D · Potential for harm, one-off	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Sep 26, 2025	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Sep 26, 2025	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Sep 26, 2025	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Sep 26, 2025	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Sep 26, 2025	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Sep 26, 2025	D · Potential for harm, one-off	The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Sep 26, 2025	D · Potential for harm, one-off	The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
Sep 26, 2025	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Sep 26, 2025	D · Potential for harm, one-off	The facility did not dispose of garbage and refuse properly.
Sep 4, 2024	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Apr 15, 2024	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint
Aug 26, 2022	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Aug 26, 2022	E · Potential for harm, repeated	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Aug 26, 2022	E · Potential for harm, repeated	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Aug 26, 2022	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Aug 26, 2022	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Aug 26, 2022	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Aug 26, 2022	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Aug 26, 2022	D · Potential for harm, one-off	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Aug 26, 2022	D · Potential for harm, one-off	The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Aug 26, 2022	D · Potential for harm, one-off	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 4, 2019	E · Potential for harm, repeated	The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Mar 4, 2019	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 4, 2019	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 4, 2019	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Mar 4, 2019	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Mar 4, 2019	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Mar 4, 2019	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Mar 4, 2019	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Mar 4, 2019	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Mar 4, 2019	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 9).

Year	Citations	Serious (G–L)	Worst severity that year
2019	10	0	E
2022	10	0	E
2024	2	0	D
2025	9	0	D
2026	4	1	G ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.14	4.31	3.95	top 49% in California; top 34% in the U.S.
Registered Nurse hours	0.73	0.61	0.69	top 22% in California; top 34% in the U.S.
Weekend total nurse staffing	3.60	3.90	3.50	bottom 39% in California; top 37% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.44	0.51	0.48	top 39% in California; top 41% in the U.S.
Total nursing staff turnover (%)	39.8	36.7	45.8	bottom 39% in California; top 36% in the U.S.
RN turnover (%)	47.6	38.1	42.9	bottom 30% in California; bottom 40% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.79, RN 0.66, weekend 3.30. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Flagstone Healthcare South LLC	Organization	Direct Ownership Interest	NOT APPLICABLE	01/30/2006
The Ensign Group INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	10/01/2003
Baroudi, Sam	Individual	Managing Control - Governing Body	NOT APPLICABLE	04/12/2016
Baroudi, Sam	Individual	Operational/Managerial Control	NOT APPLICABLE	04/12/2016
Baroudi, Sam	Individual	ADP of the SNF	NOT APPLICABLE	06/22/2025
Burnam, Soon	Individual	Managing Control - Governing Body	NOT APPLICABLE	01/02/2014
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	01/30/2006
Elite Work Finders INC	Organization	Operational/Managerial Control	NOT APPLICABLE	10/01/2003
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	10/01/2003
Gardner, Clayton	Individual	Managing Control - Governing Body	NOT APPLICABLE	10/01/2009
Gardner, Clayton	Individual	Operational/Managerial Control	NOT APPLICABLE	10/01/2009
Gardner, Clayton	Individual	ADP of the SNF	NOT APPLICABLE	06/22/2025
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Ohi Asset (ca), LLC	Organization	ADP of the SNF	NOT APPLICABLE	10/01/2003
Port, Barry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	06/22/2025
Willits, Adam	Individual	Corporate Director	NOT APPLICABLE	01/30/2019

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you make sure resident assessments are completed and submitted to the state on time?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"Can you show me the call buttons in the bathrooms and bathing areas, and tell me your average response time when one is pressed?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Pacific Villas Post Acute	0.7 mi	Oceanside, CA		—/5
La Paloma Healthcare Center	0.7 mi	Oceanside, CA	★★★★★	5/5
Vista View Post Acute	1.3 mi	Vista, CA	★★★★☆	3/5
Bayshire Carlsbad	2.6 mi	Carlsbad, CA	★★★★☆	4/5
Santa Fe Post-Acute	3.1 mi	Vista, CA	★★☆☆☆	2/5
Carlsbad by the Sea	4.6 mi	Carlsbad, CA	★★★★★	5/5
Village Square Healthcare Center	6.2 mi	San Marcos, CA	★★★★☆	4/5
Glenbrook	8.3 mi	Carlsbad, CA	★★★★★	4/5
The Dorothy & Joseph Goldberg Healthcare Center	9.7 mi	Encinitas, CA	★★★★★	4/5
Aviara Healthcare Center	10.5 mi	Encinitas, CA	★★★★☆	3/5
Encinitas Post-Acute	10.8 mi	Encinitas, CA	★★★★☆	4/5
Meadowbrook Village Christian Retirement Community	11.3 mi	Escondido, CA	★★★★★	4/5

Compare this facility with the 3 closest →

All facilities in Vista →

Facility data as of CMS processing date 2026-08-01. CCN 555425.

The Care File

Visit checklist — Vista Knoll Specialized Care Facility

2000 Westwood Road, Vista, CA 92083 · 7606302273

Health inspection rating 4/5 · CMS overall 5/5· Fines (3y): $0

Most serious findings on record:

▲ Jun 11, 2026 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you make sure resident assessments are completed and submitted to the state on time?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "Can you show me the call buttons in the bathrooms and bathing areas, and tell me your average response time when one is pressed?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 555425 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)