Cycle 1
Health 2025-03-14 · Fire 2025-03-14
30 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
El Cajon, CA
Country Hills Post Acute
1-star overall rating with 1-star inspections with 30 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1580 Broadway, El Cajon, CA
(619) 441-8745
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
305
Certified beds
Average residents
292
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1990-07-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.29
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.66
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,944
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 16.25% · Performance 21.56% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.79% · Performance 9.68% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.08
Baseline 52.12% · Performance 34.73% · Measure score 7.08 · Achievement 7.08 · Improvement 5.88
Adjusted total nurse staffing
3
Baseline 4.24 hours · Performance 3.93 hours · Measure score 3 · Achievement 3 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.17% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 350 · Observed rate 7.71% · Lower 95% interval 6.5% |
| Discharge to community | 43.29% |
50.57%
7.3 pts worse
|
Worse than the National Rate · Eligible stays 223 · Observed rate 34.53% · Lower 95% interval 35.52% |
| Medicare spending per beneficiary | 1.56 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 99.23% |
95.27%
4 pts better
|
Numerator 258 · Denominator 260 |
| Falls with major injury | 0.38% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 260 |
| Discharge self-care score | 50.93% |
53.69%
2.8 pts worse
|
Numerator 82 · Denominator 161 |
| Discharge mobility score | 36.65% |
50.94%
14.3 pts worse
|
Numerator 59 · Denominator 161 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 4 · Denominator 260 · Adjusted rate 1.64% |
| Healthcare-associated infections requiring hospitalization | 9.68% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 220 · Observed rate 11.36% · Lower 95% interval 6.99% |
| Staff COVID-19 vaccination coverage | 9.75% |
8.2%
1.6 pts better
|
Numerator 43 · Denominator 441 |
| Staff flu vaccination coverage | 30.06% |
42%
11.9 pts worse
|
Numerator 141 · Denominator 469 |
| Discharge function score | 62.11% |
56.45%
5.7 pts better
|
Numerator 100 · Denominator 161 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 92 · Denominator 92 |
| Transfer of health information to patient | 92.16% |
96.28%
4.1 pts worse
|
Numerator 47 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 26.97% |
25.2%
1.8 pts better
|
Numerator 41 · Denominator 152 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.3
0.3 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.6 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.6
0.6 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
98.5%
1.2 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
1.6%
0.8 pts worse
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.6% · Q3 2.7% · Q4 2.7% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.1% |
6.8%
7.3 pts worse
|
11.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 15.2% · Q3 11.9% · Q4 12.7% · 4Q avg 14.1% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
4.1%
2.3 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 8.5% · Q3 7.1% · Q4 2.9% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
13.7%
9.4 pts worse
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 22.8% · Q3 22.4% · Q4 23.7% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.3% |
14.2%
6.1 pts worse
|
16.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 19.8% · Q3 20.6% · Q4 14.6% · 4Q avg 20.3% · 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 | 4.9% |
11.0%
6.1 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 6.6% · Q3 5.2% · Q4 5.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
10.7%
2.5 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 7.4% · Q3 7.0% · Q4 8.1% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.7% · Q4 0.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.2%
1 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.8% |
10.9%
7.1 pts better
|
19.8%
16 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.8% · Q3 3.4% · Q4 3.4% · 4Q avg 3.8% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
4.7%
1.6 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.9% · Q3 6.9% · Q4 7.7% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.4% |
94.0%
3.6 pts worse
|
81.7%
8.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 82.4% · Q4 78.1% · 4Q avg 90.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
11.2%
0.5 pts worse
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 12.1% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.5%
1.3 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.4% · Q3 2.2% · Q4 1.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
23.2%
2 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 23.7% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-29 · Fire 2024-03-29
20 health deficiencies
Top issue: Environmental (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-04-21 · Fire 2022-04-21
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-09
F · Potential for more than minimal harm
2025-03-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-09
E · Potential for more than minimal harm
2025-03-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-14
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-09
F · Potential for more than minimal harm
2024-05-16
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-03-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-01
E · Potential for more than minimal harm
2022-04-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-05-24
E · Potential for more than minimal harm
2022-04-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-05-24
D · Potential for more than minimal harm
2022-04-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-05-24
D · Potential for more than minimal harm
2022-04-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-24
D · Potential for more than minimal harm
2022-04-21
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2022-05-24
D · Potential for more than minimal harm
2022-04-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-05-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-27
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-07-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-29
F761 · Pharmacy Service Deficiencies
Health
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 2025-09-05
D · Potential for more than minimal harm
2025-07-29
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 2025-09-05
E · Potential for more than minimal harm
2025-06-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-04-07
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-06
F · Potential for more than minimal harm
2025-03-14
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 2025-04-13
E · Potential for more than minimal harm
2025-03-14
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 2025-04-13
E · Potential for more than minimal harm
2025-03-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-13
E · Potential for more than minimal harm
2025-03-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-13
E · Potential for more than minimal harm
2025-03-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-13
E · Potential for more than minimal harm
2025-03-14
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-04-13
E · Potential for more than minimal harm
2025-03-14
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-04-13
E · Potential for more than minimal harm
2025-03-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-03-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-03-14
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 2025-04-13
D · Potential for more than minimal harm
2025-03-14
F625 · Resident Rights Deficiencies
Health
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 2025-04-13
D · Potential for more than minimal harm
2025-03-14
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-03-14
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 2025-04-13
D · Potential for more than minimal harm
2025-03-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-03-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-03-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-03-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-03-14
F761 · Pharmacy Service Deficiencies
Health
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 2025-04-13
D · Potential for more than minimal harm
2025-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-03-14
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-03-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-04-13
D · Potential for more than minimal harm
2025-02-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-21
F · Potential for more than minimal harm
2024-03-29
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 2024-04-29
F · Potential for more than minimal harm
2024-03-29
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 2024-04-29
E · Potential for more than minimal harm
2024-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-03-29
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
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 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
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 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F803 · Nutrition and Dietary Deficiencies
Health
Ensure 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.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-01-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-12
D · Potential for more than minimal harm
2024-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-12
D · Potential for more than minimal harm
2023-10-19
F622 · Resident Rights Deficiencies
Health
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 2023-11-29
D · Potential for more than minimal harm
2023-06-08
F622 · Resident Rights Deficiencies
Health
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 2023-07-08
D · Potential for more than minimal harm
2023-04-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-03-09
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 2023-04-24
E · Potential for more than minimal harm
2022-04-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-06-06
E · Potential for more than minimal harm
2022-04-21
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 2022-06-06
E · Potential for more than minimal harm
2022-04-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-06
D · Potential for more than minimal harm
2022-04-21
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-06-06
D · Potential for more than minimal harm
2022-04-21
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 2022-06-06
D · Potential for more than minimal harm
2022-04-21
F690 · Quality of Life and Care Deficiencies
Health
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 2022-06-06
D · Potential for more than minimal harm
2022-04-21
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 2022-06-06
D · Potential for more than minimal harm
2022-04-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-06-06
D · Potential for more than minimal harm
2022-04-21
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 2022-06-06
D · Potential for more than minimal harm
2022-04-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-06-06
D · Potential for more than minimal harm
2022-04-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-06-06
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Graf, Zachary
W-2 Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Michlin, Bernard
Contracted Managing Employee · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Cottonwood Canyon Healthcare Center
El Cajon, CA
3-star overall rating with 2-star inspections with $11,408 in total fines with 19 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Granite Hills Healthcare & Wellness Centre, LLC
El Cajon, CA
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
The Royal Home
El Cajon, CA
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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