Cycle 1
Health 2025-01-30 · Fire 2025-01-30
15 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
El Cajon, CA
Granite Hills Healthcare & Wellness Centre, LLC
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1340 E Madison Ave, El Cajon, CA
(619) 447-1020
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
99
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-02-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.34
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.63
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
93%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,497
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9872
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.20
Baseline 19.36% · Performance 19.02% · Measure score 5.20 · Achievement 5.20 · Improvement 0.96
Healthcare-associated infections
4.88
Baseline 8.91% · Performance 6.80% · Measure score 4.88 · Achievement 3.46 · Improvement 4.88
Total nurse turnover
0.52
Baseline 45.24% · Performance 61.54% · Measure score 0.52 · Achievement 0.52 · Improvement 0
Adjusted total nurse staffing
2.46
Baseline 3.49 hours · Performance 3.78 hours · Measure score 2.46 · Achievement 2.46 · Improvement 0.77
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 148 · Observed rate 9.46% · Lower 95% interval 7.96% |
| Discharge to community | 55.45% |
50.57%
4.9 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 46.46% · Lower 95% interval 47.13% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.94% |
95.27%
2.3 pts worse
|
Numerator 79 · Denominator 85 |
| Falls with major injury | 3.53% |
0.77%
2.8 pts worse
|
Numerator 3 · Denominator 85 |
| Discharge self-care score | 61.82% |
53.69%
8.1 pts better
|
Numerator 34 · Denominator 55 |
| Discharge mobility score | 74.55% |
50.94%
23.6 pts better
|
Numerator 41 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 85 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.8% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 6.67% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 64.43% |
42%
22.4 pts better
|
Numerator 96 · Denominator 149 |
| Discharge function score | 67.27% |
56.45%
10.8 pts better
|
Numerator 37 · Denominator 55 |
| Transfer of health information to provider | 91.67% |
95.95%
4.3 pts worse
|
Numerator 22 · Denominator 24 |
| Transfer of health information to patient | 89.66% |
96.28%
6.6 pts worse
|
Numerator 26 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 34.29% |
25.2%
9.1 pts better
|
Numerator 12 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
2.3
1.1 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.6 · 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 100.0% · Q4 98.7% · 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 | 2.2% |
1.6%
0.6 pts worse
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.5% · Q3 2.5% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.2% |
6.8%
12.4 pts worse
|
11.4%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.0% · Q2 15.4% · Q3 13.0% · Q4 9.1% · 4Q avg 19.2% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
4.1%
3.4 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
13.7%
2.3 pts worse
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 16.7% · Q3 16.0% · Q4 13.9% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.6% |
14.2%
13.4 pts worse
|
16.7%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 30.6% · Q3 27.3% · Q4 25.6% · 4Q avg 27.6% · 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 | 5.9% |
11.0%
5.1 pts better
|
16.3%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 5.9% · Q3 3.0% · Q4 5.7% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.2% |
10.7%
0.5 pts worse
|
14.9%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 15.3% · Q3 10.8% · Q4 8.3% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
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% · 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 1.3% · Q2 0.0% · Q3 2.8% · 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 | 16.6% |
10.9%
5.7 pts worse
|
19.8%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 25.5% · Q3 10.9% · Q4 18.5% · 4Q avg 16.6% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.7%
0.1 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.5% · Q3 6.2% · Q4 7.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
94.0%
2.8 pts worse
|
81.7%
9.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 90.2% · Q3 88.0% · Q4 91.3% · 4Q avg 91.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
11.2%
0.8 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 10.3% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.5%
1.1 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 5.8% · Q4 2.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.3% |
93.2%
10.9 pts worse
|
79.7%
2.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
23.2%
2.9 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 25.0% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-17 · Fire 2021-06-17
23 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2019-08-08 · Fire 2019-08-08
21 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-30
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-02-20
F · Potential for more than minimal harm
2025-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-20
F · Potential for more than minimal harm
2025-01-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-20
E · Potential for more than minimal harm
2025-01-30
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 2025-02-20
D · Potential for more than minimal harm
2025-01-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-01-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-01-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-01-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-20
C · Minimal harm
2025-01-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-20
C · Minimal harm
2025-01-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-20
C · Minimal harm
2025-01-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-02-20
D · Potential for more than minimal harm
2021-06-17
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-06-17
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-06-17
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-06-17
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-06-17
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-06-17
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-06-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-06-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-07-30
D · Potential for more than minimal harm
2019-08-08
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2019-10-03
D · Potential for more than minimal harm
2019-08-08
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2019-10-03
D · Potential for more than minimal harm
2019-08-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-10-03
D · Potential for more than minimal harm
2019-08-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-10-03
D · Potential for more than minimal harm
2019-08-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-10-03
D · Potential for more than minimal harm
2019-08-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-10-03
D · Potential for more than minimal harm
2019-08-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-14
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 2025-08-22
D · Potential for more than minimal harm
2025-03-21
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 2025-04-08
F · Potential for more than minimal harm
2025-01-30
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 2025-02-21
E · Potential for more than minimal harm
2025-01-30
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 2025-02-21
E · Potential for more than minimal harm
2025-01-30
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 2025-02-21
E · Potential for more than minimal harm
2025-01-30
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
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 2025-02-21
D · Potential for more than minimal harm
2025-01-30
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-30
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 2025-02-21
D · Potential for more than minimal harm
2025-01-30
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 2025-02-21
D · Potential for more than minimal harm
2025-01-30
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 2025-02-21
D · Potential for more than minimal harm
2024-12-27
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 2025-01-22
D · Potential for more than minimal harm
2024-10-29
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 2024-11-08
D · Potential for more than minimal harm
2024-09-24
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-05
E · Potential for more than minimal harm
2024-08-02
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-07-18
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 2024-08-01
G · Actual harm
2024-05-17
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 2024-05-31
D · Potential for more than minimal harm
2024-05-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-02-14
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 2024-03-15
D · Potential for more than minimal harm
2023-10-20
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 2023-11-06
D · Potential for more than minimal harm
2023-09-13
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 2023-09-29
D · Potential for more than minimal harm
2023-09-13
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-10
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 2023-08-31
D · Potential for more than minimal harm
2023-06-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-04-18
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 2023-05-19
D · Potential for more than minimal harm
2023-04-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-18
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 2023-05-19
F · Potential for more than minimal harm
2021-06-17
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2021-08-09
F · Potential for more than minimal harm
2021-06-17
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 2021-08-09
F · Potential for more than minimal harm
2021-06-17
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 2021-08-09
E · Potential for more than minimal harm
2021-06-17
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 2021-08-09
E · Potential for more than minimal harm
2021-06-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-06-17
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 2021-08-09
D · Potential for more than minimal harm
2021-06-17
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 2021-08-09
D · Potential for more than minimal harm
2021-06-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-06-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-06-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-06-17
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 2021-08-09
D · Potential for more than minimal harm
2021-06-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-06-17
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-06-17
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2021-08-09
D · Potential for more than minimal harm
2019-08-08
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 2019-09-08
D · Potential for more than minimal harm
2019-08-08
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 2019-09-08
D · Potential for more than minimal harm
2019-08-08
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2019-09-08
D · Potential for more than minimal harm
2019-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-09-08
D · Potential for more than minimal harm
2019-08-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-09-08
D · Potential for more than minimal harm
2019-08-08
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 2019-09-08
D · Potential for more than minimal harm
2019-08-08
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 2019-09-08
D · Potential for more than minimal harm
2019-08-08
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 2019-09-08
D · Potential for more than minimal harm
2019-08-08
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 2019-09-08
D · Potential for more than minimal harm
2019-08-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-09-08
D · Potential for more than minimal harm
2019-08-08
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 2019-09-08
D · Potential for more than minimal harm
2019-08-08
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 2019-09-08
Penalties and ownership
What sits behind the stars
Ownership
Brius LLC
5% Or Greater Direct Ownership Interest · Organization
Benson, Jimi
Operational/Managerial Control · Individual
Corporate Interface Services LLC
Operational/Managerial Control · Organization
Rechnitz, Shlomo
Operational/Managerial Control · Individual
Rockport Administrative Services, LLC
Operational/Managerial Control · Organization
Savelkoul, Michelle
Operational/Managerial Control · Individual
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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
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Country Hills Post Acute
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1-star overall rating with 1-star inspections with 30 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
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3-star overall rating with 2-star inspections with abuse icon flag with $33,732 in total fines with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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