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 Post Acute Care during CMS and state inspections, most recent first.
A resident with COPD, heart failure, bronchitis, emphysema, and a solitary pulmonary nodule experienced shortness of breath and a physician gave a verbal order to an LPN for a chest x-ray. Due to miscommunication, the LPN did not enter the order or notify the mobile radiology service that day. The x-ray order was entered the next morning as STAT, but the exam was still not completed before the resident was later sent to the hospital for vomiting and shortness of breath, contrary to facility policy requiring timely radiology services when ordered.
A resident with COPD and chronic hypoxic respiratory failure was administered multiple CNS depressant medications, including mirtazapine, oxycodone, and alprazolam, without appropriate monitoring of vital signs or interdisciplinary team coordination. Despite pharmacy recommendations to monitor for CNS depression, there was no evidence of physician notification, care plan updates, or documented monitoring after medication administration. The resident experienced episodes of hypoxia and respiratory distress, and the facility lacked clear protocols for monitoring residents on multiple sedating medications.
A cognitively impaired resident was verbally and physically abused by a CNA, who called the resident derogatory names and smacked them on the head during a showering session. The incident, witnessed by a student CNA, led to the resident's agitation and was reported to the state health department. The facility's investigation confirmed the abuse, resulting in the termination of the involved CNAs.
A resident with Parkinsonism, psychosis, and dementia exhibited an angry outburst by hitting a CNA, but the incident was not documented or reported to the MD as required by the care plan. The MAR inaccurately showed zero outbursts, and the responsible LN was not informed. The facility's policy lacked guidance on care plan implementation, leading to unmanaged behavior.
A resident with severe cognitive impairment and a history of falls was transferred from bed to wheelchair without a gait belt, resulting in a chipped fracture to the right tibia. The CNA involved did not follow the facility's policy requiring the use of gait belts during transfers, as confirmed by interviews with the ADON and DON. The resident's family was informed of the incident, and medical records confirmed the injury.
Failure to Obtain Ordered STAT Chest X-Ray for Resident with Respiratory Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to obtain a chest x-ray as ordered for a resident with multiple serious pulmonary and cardiac diagnoses, including COPD, heart failure, bronchitis, emphysema, and a solitary pulmonary nodule. The resident was admitted with these conditions and later experienced a change in condition characterized by shortness of breath. On the morning of 1/24/26, a physician (MD 3) gave a verbal order to a licensed nurse (LN 2) for a chest x-ray. However, this order was not entered into the medical record on that date, and the mobile radiology service was not notified that day. As a result, there was no chest x-ray order documented on 1/24/26 in the facility’s order summary report. On 1/25/26, the chest x-ray order was finally entered into the system as a STAT order, which the Assistant Director of Nursing (ADON) stated should have been completed within six hours. Despite this, the mobile radiology service was not contacted until the morning of 1/25/26, and the chest x-ray was still not completed by the time the resident was transferred to an acute care hospital at 10:20 p.m. that evening for multiple episodes of vomiting with shortness of breath. The ADON confirmed that the chest x-ray should have been completed the same day it was originally ordered and that the facility’s policy requires obtaining radiology services when ordered. The failure to timely enter the order and notify the radiology provider resulted in the ordered chest x-ray not being performed prior to the resident’s transfer.
Failure to Monitor and Coordinate Care for Resident on Multiple CNS Depressants
Penalty
Summary
The facility failed to ensure necessary care monitoring and interdisciplinary team (IDT) coordination to prevent respiratory depression and excessive sedation in a resident who was administered multiple central nervous system (CNS) depressant medications, including mirtazapine, oxycodone, and alprazolam. The resident had a history of chronic obstructive pulmonary disease (COPD) and was admitted with chronic hypoxic respiratory failure, requiring home oxygen. Despite pharmacy recommendations to monitor for CNS depression due to the combination of these medications, there was no documented evidence that the physician was notified for clarification or that specific monitoring parameters were established. Review of the resident's medication administration records revealed that all three CNS depressant medications were administered on multiple occasions without documentation of vital signs, such as respiratory rate and oxygen saturation, within one hour after administration. The care plan was not updated to address the risk of CNS depression, and there was no written policy or procedure for monitoring residents on multiple sedating medications. Interviews with facility staff, including the ADON, LN, DON, and pharmacist, confirmed that the recommendations for monitoring were considered vague and were not clarified with the physician, nor were specific monitoring actions implemented. The resident experienced episodes of hypoxia, lethargy, and respiratory distress, including a significant decline in oxygen saturation and use of accessory muscles for breathing, which ultimately led to transfer to a higher level of care. There was no evidence of IDT documentation addressing the resident's change in condition, and the facility's policy requiring IDT collaboration and documentation in such cases was not followed. The lack of clear monitoring protocols and failure to update the care plan contributed to the deficiency identified in the report.
CNA Abuses Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from abuse by a certified nursing assistant (CNA). The incident involved CNA 2, who called the resident derogatory names and physically smacked the resident on the side of the head. This action was witnessed by a student certified nursing assistant (SCNA) during a showering session. The resident, who was dependent on staff for care, became agitated and attempted to hit back, indicating distress from the incident. The resident had a history of Parkinsonism, unspecified psychosis, and dementia with behavioral disturbances, and was noted to lack the capacity to understand and make decisions. The incident was reported to the California Department of Public Health, and an investigation was conducted. Interviews with staff and the SCNA confirmed the inappropriate behavior of CNA 2, who had previously been hit by the resident. Despite this, the facility's policy clearly defined such actions as abuse, regardless of the resident's mental state or the staff's intent. The facility's investigation substantiated the SCNA's report, leading to the termination of CNA 2 and CNA 3, who failed to report the incident. The director of staff development confirmed that both CNAs had received training on abuse prevention and dementia care, which included scenarios similar to the incident. The facility's policy emphasized the right of residents to be free from abuse, defining abuse as any willful infliction of injury or mental anguish, regardless of the resident's ability to comprehend or the staff's intent.
Failure to Implement Behavior Care Plan
Penalty
Summary
The facility failed to implement a resident's written care plans related to behavior management, resulting in an incident where the resident hit a staff member. The resident, who was admitted with diagnoses including Parkinsonism, unspecified psychosis, and dementia with behavioral disturbance, had a care plan in place to monitor and report any dangerous behavior to the medical doctor. However, this care plan was not followed when the resident exhibited an angry outburst by punching a certified nursing assistant (CNA) in the face during care. The incident was documented in an Employee Incident Report, but the resident's behavior was not recorded in the clinical record, nor was it reported to the medical doctor as required by the care plan. The Medication Administration Record (MAR) inaccurately indicated zero angry outbursts for the day of the incident, despite the occurrence of the physical altercation. Interviews with staff revealed that the licensed nurse responsible for the resident's care was not informed of the incident, leading to a failure to document the behavior and notify the medical doctor. The assistant director of nursing and other staff acknowledged that the care plans were not implemented and that the incident should have been documented and reported. The facility's policy on care planning did not provide guidance on care plan implementation, contributing to the oversight. This deficiency in care plan implementation had the potential to leave the resident's behavior unmanaged, as the necessary steps to address and document the behavior were not taken.
Failure to Use Gait Belt During Transfer Resulting in Resident Injury
Penalty
Summary
The facility failed to follow its own policy when a resident was transferred from bed to wheelchair without the use of a gait belt, resulting in a chipped fracture to the resident's right tibia. The resident, who had a history of repeated falls and severe cognitive impairment, required moderate assistance with transfers as assessed by the Physical Therapist. On the night of the incident, a CNA transferred the resident using a manual lift but did not use a gait belt, leading to the resident sliding from the wheelchair and sustaining an injury. Interviews with the CNA, ADON, and DON confirmed that the staff should always have gait belts in their possession and use them during transfers and ambulation, which was not adhered to in this case. The resident's medical records indicated severe cognitive impairment and a need for moderate assistance with transfers. The incident was witnessed by the CNA, who acknowledged the failure to use a gait belt. The resident's family member was informed by the Administrator that the resident did not have a gait belt on during the fall. The resident was subsequently diagnosed with a non-displaced acute medial tibial plateau fracture at the emergency department. The facility's undated Gait Belt Policy mandates that CNAs always have gait belts in their possession and use them when transferring and ambulating residents, which was not followed in this instance.
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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 Hospital D/p Snf | 0.2 mi | — | 0 | 0 |
| Community Care Center | 0.8 mi | — | 0 | 0 |
| Country Manor La Mesa Healthcare Center | 1.2 mi | — | 0 | 0 |
| Arbor Hills Nursing Center | 1.3 mi | — | 8 | 0 |
| Parkway Hills Nursing & Rehabilitation | 1.3 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.