Your report for Santa Fe Post-Acute
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- CaliforniaLowest tier among peers1,154 rated homes · average 3.2★
- San Diego CountyLowest tier among peers81 rated homes · average 3.9★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs CA avg
- StaffingCan add or remove a star1★−2.1 vs CA avg
- Quality measuresCan add or remove a star4★−0.1 vs CA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersCA avg3.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 24% of peersCA avg4.1★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff—hrsNo dataCA avg4.51Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only—hrsNo dataCA avg0.65Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better—No dataCA avg38%RN turnover—
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$85,943Above only 10% of peersCA avg$26,970Fines · denials1 · 1
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthFeb 2019 – Sep 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Sep 24, 2025Cycle 1worst K · immediate jeopardy
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationK · patternCorrected Nov 19, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Nov 19, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Nov 19, 2025
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Nov 19, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Nov 19, 2025
- F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 19, 2025
Sep 4, 2025Cycle 1worst D · no actual harm
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Oct 15, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 15, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Oct 15, 2025
May 19, 2025Cycle 1worst D · no actual harm
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Jun 19, 2025
May 2, 2025Cycle 1worst E · no actual harm
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jun 2, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jun 2, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Jun 2, 2025
- F567Honor the resident's right to manage his or her financial affairs.Resident RightsD · isolatedCorrected Jun 2, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jun 2, 2025
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jun 2, 2025
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Jun 2, 2025
Feb 6, 2025Cycle 1worst D · no actual harm
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Mar 6, 2025
May 31, 2024Cycle 2worst D · no actual harm
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jul 1, 2024
Sep 21, 2023Cycle 3worst K · immediate jeopardy
- F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Quality of Life and CareK · patternCorrected Nov 6, 2023
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Nov 6, 2023
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareG · isolatedCorrected Nov 27, 2023
- F838Conduct 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.AdministrationG · isolatedCorrected Nov 6, 2023
Sep 7, 2023Cycle 3worst D · no actual harm
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Sep 8, 2023
Jul 14, 2023Cycle 3worst D · no actual harm
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsD · isolatedCorrected Aug 9, 2023
Jul 7, 2023Cycle 3worst D · no actual harm
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jul 21, 2023
Jun 27, 2023Cycle 3worst D · no actual harm$85,943, payment denial
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Aug 9, 2023
Apr 17, 2023Cycle 3worst D · no actual harm
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected May 9, 2023
Feb 16, 2023Cycle 3worst D · no actual harm
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Mar 6, 2023
Feb 13, 2023Cycle 3worst D · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Mar 3, 2023
Jul 14, 2022Cycle 2worst E · no actual harm
- F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryD · isolatedCorrected Aug 12, 2022
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Aug 12, 2022
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Aug 12, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 12, 2022
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareE · patternCorrected Aug 12, 2022
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Aug 12, 2022
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Aug 12, 2022
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Aug 12, 2022
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Aug 12, 2022
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Aug 12, 2022
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Nutrition and DietaryD · isolatedCorrected Aug 12, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Aug 12, 2022
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryD · isolatedCorrected Aug 12, 2022
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Aug 12, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Aug 12, 2022
- F914Provide bedrooms that don't allow residents to see each other when privacy is needed.EnvironmentalD · isolatedCorrected Aug 12, 2022
Feb 7, 2019Cycle 3worst F · no actual harm
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Apr 4, 2019
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 4, 2019
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Apr 4, 2019
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Apr 4, 2019
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Apr 4, 2019
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Feb 7, 2019
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Apr 4, 2019
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Feb 7, 2019
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryE · patternCorrected Apr 4, 2019
- F838Conduct 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.AdministrationE · patternCorrected Apr 4, 2019
- F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Feb 7, 2019
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalD · isolatedCorrected Apr 4, 2019
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined—hrs
- Registered nursesRN hours only—hrs
- Licensed practical nursesLPN hours—hrs
- Nurse aidesCNA hours—hrs
- Weekend nursingAll staff on Saturdays and Sundays—hrs
- California average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better—CA avg 38%
- RN turnoverRegistered nurses only—Not ranked by CMS
- Administrators who leftIn the past year—
- Occupancy187 certified beds · ~178 residents a day95%Above 83% of peersCA avg 88%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $85,943In fines
- 1Fine
- 1Payment denial
- $26,970CA avg in fines
Actions on record
- Jun 27, 2023Civil money penalty$85,943
- Jun 27, 2023Denial of payment for new admissionsfrom Sep 27, 2023
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Bayshire Senior Communities12 facilities in the chain3.1★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Bayshire LLC
- Scott Kirby
- Karanbir Brar
- Scott Kirby
- David Tanner
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 555723 · 247 E. BOBIER DRIVE, VISTA, CA, 92084.
- Percentiles compare this facility with every rated nursing home in California and San Diego County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









