Cycle 1
Health 2025-02-13 · Fire 2025-02-13
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
La Mesa, CA
Community Care Center
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
8665 La Mesa Blvd., La Mesa, CA
(619) 465-0702
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
119
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Links Healthcare Group
Operator or chain grouping
Approved since
1968-02-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
31 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.75
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.55
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.39
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.17
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.13
CMS adjusted total nurse staffing hours
Case-mix index
1.99
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,759
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9918
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.87
Baseline 19.76% · Performance 19.18% · Measure score 4.87 · Achievement 4.87 · Improvement 1.64
Healthcare-associated infections
6.38
Baseline 6.95% · Performance 5.93% · Measure score 6.38 · Achievement 6.38 · Improvement 4.73
Total nurse turnover
4.23
Baseline 50.34% · Performance 46.38% · Measure score 4.23 · Achievement 4.23 · Improvement 1.06
Adjusted total nurse staffing
0
Baseline 3.65 hours · Performance 3.15 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.12% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 182 · Observed rate 15.38% · Lower 95% interval 9.25% |
| Discharge to community | 54.39% |
50.57%
3.8 pts better
|
No Different than the National Rate · Eligible stays 166 · Observed rate 43.37% · Lower 95% interval 46.16% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 196 · Denominator 196 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 196 |
| Discharge self-care score | 50.6% |
53.69%
3.1 pts worse
|
Numerator 42 · Denominator 83 |
| Discharge mobility score | 33.73% |
50.94%
17.2 pts worse
|
Numerator 28 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 1.53% |
2.29%
0.8 pts better
|
Numerator 3 · Denominator 196 · Adjusted rate 1.45% |
| Healthcare-associated infections requiring hospitalization | 5.93% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 136 · Observed rate 5.88% · Lower 95% interval 3.95% |
| Staff COVID-19 vaccination coverage | 11.84% |
8.2%
3.6 pts better
|
Numerator 27 · Denominator 228 |
| Staff flu vaccination coverage | 49.06% |
42%
7.1 pts better
|
Numerator 131 · Denominator 267 |
| Discharge function score | 45.78% |
56.45%
10.7 pts worse
|
Numerator 38 · Denominator 83 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 81 · Denominator 81 |
| Transfer of health information to patient | 94.83% |
96.28%
1.5 pts worse
|
Numerator 55 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 28 · Denominator 98 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 3.4 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.0 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
98.2%
0.6 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
1.6%
0.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.4% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.7% |
6.8%
0.9 pts worse
|
11.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 8.6% · Q3 12.3% · Q4 6.6% · 4Q avg 7.7% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
4.1%
1.2 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.4% · Q3 7.9% · Q4 4.5% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
13.7%
0.2 pts worse
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 14.1% · Q3 12.1% · Q4 13.7% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.6% |
14.2%
3.6 pts better
|
16.7%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 4.0% · Q3 6.1% · Q4 13.6% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.3% |
11.0%
4.3 pts worse
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
10.7%
0.7 pts worse
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 15.6% · Q3 5.0% · Q4 10.4% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.0%
0.5 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.9% · Q3 1.4% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.2%
0.2 pts worse
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 1.4% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.0% |
10.9%
4.9 pts better
|
19.8%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 12.5% · Q3 4.3% · Q4 6.4% · 4Q avg 6.0% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.7%
0.7 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 2.8% · Q3 2.8% · Q4 2.7% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
11.2%
4.7 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 6.7% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.6% · Q3 1.2% · Q4 2.2% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
93.2%
3.2 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
23.2%
About the same
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 24.8% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2021-10-21 · Fire 2021-10-21
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-03
F · Potential for more than minimal harm
2025-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-02-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-02-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-02-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-02-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-02-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-19
F · Potential for more than minimal harm
2024-02-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-27
D · Potential for more than minimal harm
2021-10-21
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-21
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-21
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-08
C · Minimal harm
2021-10-21
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2021-11-08
C · Minimal harm
2021-10-21
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2021-11-08
C · Minimal harm
2021-10-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-11-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-02-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-13
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-04
F758 · Pharmacy Service Deficiencies
Health
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 2025-03-04
D · Potential for more than minimal harm
2025-02-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-04
D · Potential for more than minimal harm
2024-12-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-08-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-02-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-29
F693 · Quality of Life and Care Deficiencies
Health
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 2024-03-22
D · Potential for more than minimal harm
2024-02-29
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-29
F758 · Pharmacy Service Deficiencies
Health
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 2024-03-22
D · Potential for more than minimal harm
2023-12-08
F849 · Administration Deficiencies
Health
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 2023-12-19
D · Potential for more than minimal harm
2023-04-25
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-05-11
E · Potential for more than minimal harm
2021-10-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-11-20
E · Potential for more than minimal harm
2021-10-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-11-20
E · Potential for more than minimal harm
2021-10-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-21
F584 · Resident Rights Deficiencies
Health
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 2021-11-20
D · Potential for more than minimal harm
2021-10-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-11-20
Penalties and ownership
What sits behind the stars
Ownership
Links Healthcare Group LLC
5% Or Greater Direct Ownership Interest · Organization
Tilford, Toby
5% Or Greater Indirect Ownership Interest · Individual
Rodriguez, Curtis
5% Or Greater Indirect Ownership Interest · Individual
Bernholz, Victoria
Operational/Managerial Control · Individual
Carter, Melissa
Operational/Managerial Control · Individual
Deguzman, Myrna
Operational/Managerial Control · Individual
Frojelin, Antonette
Operational/Managerial Control · Individual
Links Healthcare Group LLC
Operational/Managerial Control · Organization
Links Support Services, LLC
Operational/Managerial Control · Organization
Michlin, Bernard
Operational/Managerial Control · Individual
Ramirez, Sharon
Operational/Managerial Control · Individual
Rivera, Regine
Operational/Managerial Control · Individual
Rodriguez, Curtis
Operational/Managerial Control · Individual
Rodriguez, Curtis
Corporate Officer · Individual
Tilford, Toby
Operational/Managerial Control · Individual
White, Curtis
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Grossmont Hospital D/P SNF
La Mesa, CA
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Grossmont Post Acute Care
La Mesa, CA
5-star overall rating with 4-star inspections with $11,466 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Parkway Hills Nursing & Rehabilitation
La Mesa, CA
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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