Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grossmont Hospital D/p Snf during CMS and state inspections, most recent first.
The facility failed to store and serve food in accordance with professional standards, with spoiled food found among non-spoiled items, improper labeling and covering of food, and failure to initiate the cool-down process for cooked chicken. Additionally, dietary aides did not wear beard guards and used contaminated gloves to handle ready-to-eat food.
The facility failed to implement an Antibiotic Stewardship Program to monitor antibiotic use. The infection prevention nurse (IPN) was unable to provide a proper tracking list and incorrectly stated that no residents were on antibiotics. Further review revealed that a resident had been on antibiotics, which IPN had failed to track. The director of nursing (DON) and director of regulatory affairs (DRA) confirmed that reports for infection control surveillance could be generated in the new computer system, but the facility's policy did not provide guidance for the skilled nursing facility (SNF).
A facility failed to reassess a resident's pain after administering pain medications, leading to inadequate pain management. The resident, with diagnoses including gout and cancer, received pain medications multiple times without proper documentation of pain reassessment, contrary to the facility's policy. Interviews with staff confirmed the oversight, partly attributed to a new EMR system.
The facility failed to ensure that two residents were appropriately offered the pneumococcal vaccine and provided with education regarding its benefits and potential side effects. The Infection Prevention Nurse (IPN) did not have a process to readily identify residents' vaccination statuses, leading to missed opportunities and inefficiencies in tracking and offering vaccinations.
The facility failed to ensure that two residents were offered or re-offered the COVID-19 vaccination and did not document that education regarding the vaccine had been provided. The infection prevention nurse (IPN) did not have a process to readily identify residents' vaccination status, leading to a deficiency in offering and educating residents about the COVID-19 vaccine, especially during a COVID-19 outbreak in the facility.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and served in accordance with professional standards for food safety. Spoiled food was found stored among non-spoiled food inside the walk-in refrigerators, and food items were stored without being covered, labeled, or dated. Specifically, salads were uncovered and unlabeled, basil was moldy and slimy, and other produce items were rotten and not labeled. Additionally, cooked chicken was left uncovered in the walk-in refrigerator, and the cool-down process was not initiated for the chicken, which is a mandatory procedure to ensure food safety. The patient services manager and cook acknowledged these issues during the observation. Three dietary aides were observed not wearing beard guards while in the kitchen and during food service, which is against the facility's policy. One dietary aide used contaminated gloves to touch ready-to-eat food, further risking food contamination. The general manager confirmed that beard guards should have been worn and that the dietary aide should have used tongs instead of gloved hands to handle bread rolls. The facility's policies on infection prevention and food safety management were not followed, as evidenced by the lack of proper labeling, covering, and dating of food items, as well as the failure to implement the cool-down process for cooked food. Staff training logs indicated that the involved staff had received training on these procedures but did not adhere to them during the survey. The general manager acknowledged these deficiencies and the need for proper food safety practices to prevent contamination and ensure resident safety.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program to monitor antibiotic use, which was identified during an interview and record review. The infection prevention nurse (IPN 1) was unable to provide a proper tracking list for antibiotic use and incorrectly stated that no residents were on antibiotics. However, the Matrix for Providers indicated that a resident had received antibiotics for a urinary tract infection (UTI). Upon further review, it was revealed that the resident had been on antibiotics from 5/13/24 through 5/18/24, which IPN 1 had failed to track and monitor. IPN 1 admitted to not monitoring or tracking antibiotic use since the implementation of a new computer charting system and did not attend daily stand-up meetings where such issues would be discussed. The director of nursing (DON) and director of regulatory affairs (DRA) confirmed that reports for infection control surveillance and antibiotic monitoring could be generated in the new computer system and that IPN 1 had access to these reports. The facility's policy on Antimicrobial Stewardship Program (ASP) was also found to be inadequate as it addressed antibiotic stewardship at the acute care level but did not provide guidance for the skilled nursing facility (SNF).
Failure to Reassess Pain After Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was reassessed after pain medications were administered. Resident 74, who was admitted with diagnoses including gout and cancer, requested a pain pill during an initial survey screening. The resident had physician orders for different pain medications based on the severity of pain. On multiple occasions, the resident received pain medications without proper documentation of pain reassessment. For instance, on 5/18/24, pain medication was given at 1:58 A.M. for a pain level of 6 out of 10, but there was no documented evidence of reassessment. Similarly, at 10:31 A.M., pain medication was administered without documenting the pain level, and the reassessment at 11 A.M. was done only 30 minutes after administration, contrary to the facility's policy of 45 minutes. Additionally, at 5:10 P.M., there was no documented evidence of pain assessment before and after medication administration. Later, at 7:49 P.M., the resident complained of a pain level of 5 out of 10 but was not medicated until an hour later, by which time the pain had increased to 6 out of 10. Interviews with LN 10 and the DON confirmed that the resident should have been reassessed an hour after medication administration and that the reassessment should have been documented in the pain assessment tab. The DON acknowledged that the new EMR system might not have triggered the reassessment, leading to the oversight. The facility's policy on pain management, last revised on 5/2/24, specifies that pain reassessment should be performed within 45-60 minutes for oral medications to evaluate the effectiveness and safety of pain management interventions. The failure to adhere to this policy resulted in inadequate pain management for Resident 74.
Failure to Appropriately Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents were appropriately offered the pneumococcal vaccine and provided with education regarding its benefits and potential side effects. Specifically, Resident 124 was offered the vaccine while actively infected with COVID-19, which was deemed inappropriate by both the Infection Prevention Nurse (IPN) and the Director of Nursing (DON). Additionally, there was no documentation that Resident 5 received education about the vaccine before refusing it, and the resident was not re-offered the vaccine in subsequent years as required by the facility's policy. The IPN admitted to not having a process to readily identify residents' vaccination statuses and was not compiling or tracking this information. This lack of tracking led to missed opportunities to ensure all residents were offered the pneumococcal vaccine and provided with the necessary education. The joint interview and record review with the IPN and DON revealed that it took over two hours to determine the vaccination status of just five residents, highlighting the inefficiency and gaps in the current system.
Failure to Offer/Re-Offer COVID-19 Vaccination and Document Education
Penalty
Summary
The facility failed to ensure that two residents were offered or re-offered the COVID-19 vaccination and did not document that education regarding the vaccine had been provided. Resident 122's clinical record showed that the resident received a COVID-19 vaccine on 1/13/22, but there was no documentation that the latest version of the vaccine had been offered. Resident 11's clinical record indicated that the resident refused the vaccine on 1/26/24, but there was no documentation that education about the vaccine had been provided to the resident to make an informed refusal. The infection prevention nurse (IPN) admitted that she did not have a process to readily identify residents' vaccination status and was not compiling or tracking the information to ensure all residents were offered the COVID-19 vaccine and that education had been provided. This lack of tracking and documentation led to the deficiency in offering and educating residents about the COVID-19 vaccine, especially during a COVID-19 outbreak in the facility that started on 5/15/24. During the survey, it was revealed that the IPN had to review each resident's clinical record individually to determine their vaccination status, which took a considerable amount of time. The director of nursing (DON) had to assist the IPN in locating the vaccination information. Both IPN 1 and IPN 2 acknowledged that the COVID-19 vaccination status of all residents should have been reviewed and the vaccine re-offered to eligible residents when the outbreak began. The facility's policy indicated that all residents should be screened and offered the COVID-19 vaccine if eligible, and that education regarding the benefits and potential side effects should be documented in the resident's medical record. However, this policy was not followed, leading to the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near La Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grossmont Post Acute Care | 0.2 mi | — | 2 | 0 |
| Community Care Center | 0.6 mi | — | 0 | 0 |
| Country Manor La Mesa Healthcare Center | 1.2 mi | — | 0 | 0 |
| Arbor Hills Nursing Center | 1.2 mi | — | 8 | 0 |
| Parkway Hills Nursing & Rehabilitation | 1.2 mi | — | 34 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.