Grossmont Gardens Healthcare Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

CMS has not published payroll-based (PBJ) staffing hours for this facility yet — this can happen for newer, hospital-based, or recently-certified homes. It can also mean the home simply did not file, which CMS does not distinguish in this data, so treat the gap as unexplained rather than benign. Staffing is one of the three parts of the CMS star rating; where it’s missing, weigh the independent health-inspection score most, and ask the facility directly about its nurse-to-resident ratios and weekend RN coverage.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.

• Potential for harm · E2026-02-12 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure written information regarding an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) was provided to 10 of 12 sampled residents (14, 8, 12, 19, 15, 7, 20, 5, 6 and 2). This failure resulted in Residents 14, 8, 12, 19, 15, 7, 20, 5, 6 and 2 not having the opportunity to express wishes for care should they lose decision-making capacity.Findings: On 2/10/2026, a review of the clinical records for Residents 14, 8, 12, 19, 15, 7, 20, 5, 6 and 2 was conducted. There was no documentation that the facility provided these residents or their representatives with Advance Directive information. On 2/10/2026 at 12:25 P.M., an interview and record review was conducted with the Social Services Director (SSD). The SSD stated the facility did not provide written information regarding the Advance Directive to residents or their representatives and they should have. On 2/11/2026 at 11:49 A.M., an interview was conducted with the Director of Nursing (DON) and the Administrator (ADM).…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-12 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement resident-specific written care plans for five of 12 residents (11, 16, 20, 14, and 5) when:1. Resident 20's preference for personal belongings was not developed in her care plan.2. Resident 11's written care plan for skin and the use of the low air loss mattress (LAL, a specialized mattress that uses air flow to prevent pressure injuries) was not implemented.3. Resident 16 did not have a care plan developed for his use of the LAL mattress.4. Resident 14's use of clip alarm (a device used to alert staff when a resident was getting up unassisted) was not developed in the fall care plan.5. Resident 5 did not have a care plan developed for continuous oxygen administration. These failures to develop and/or implement residents' written care plans had the potential to cause confusion in the delivery of care. In addition, there was the potential for residents' preferences and goals to be unmet.1. A review of Resident 20's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when: The cool down process for time, temperature control for safety (TCS) food, food that needs to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored. 2. Gloves were not used appropriately. 3. Facial hair was not covered. These failures posed the risk for foodborne illnesses in a highly susceptible resident population of 21 facility residents who received food prepared in the kitchen. Findings: 1.On 02/10/2026 at 9:50 AM, a concurrent kitchen observation and interview was conducted with Food Services Director (FSD). Ground beef labeled with the day's date and prepared at 8 am was found in the reach in refrigerator. FSD stated that there was no cool down log to monitor the product's temperature during the cooling process. On 02/10/2026 at 9:50 AM, an interview was conducted with [NAME] (CK). CK was asked how food temperatures and cooling are monitored and confirmed he does not monitor cooled…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0557 — isolated
  Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 12 residents (Resident 20) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 moved the resident's personal belongings without the resident's permission. As a result of this failure, Resident 20 expressed frustration and was upset.A review of Resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (paralysis and weakness affecting one side of the body) following a stroke and aphasia (communication disorder resulting from brain damage). On 2/9/26 at 10:20 A.M., an observation was conducted inside Resident 20's room. Resident 20 appeared upset when asked how she was feeling. Resident 20 had difficulty communicating and stated all her belongings were gone without her knowledge. She pointed to her dresser in front of her claiming someone had entered her room and moved her belongings. On 2/9/26 at 10:23 A.M., a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure that one out of five sampled residents (Resident 14) was free from unnecessary psychotropic (affecting brain activities associated with mental processes and behavior) medication when Resident 14 was prescribed a psychotropic medication as needed for more than 14 days. This failure had the potential for Resident 14 to receive an unnecessary psychotropic medication which can lead to side effects, such as sedation and falls, physical dependence (experiencing unpleasant symptoms if a medication is suddenly stopped), respiratory depression (slowed or shallow breathing) and a decline in psychosocial (how a person feels about themselves and their environment) well-being.Findings:A review of Resident 14's medical records indicated she had active orders for lorazepam (a medication for anxiety, a condition characterized by excessive worrying), including lorazepam 0.5 milligrams (mg, unit of measure) every six hours prn (as needed) end of life anxiety exhibited by agitation with sob (shortness of breath)/fear for 6 months. No…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure interventions to prevent the development of pressure injuries (tissue injuries that develop from prolonged pressure) were utilized according to physician's orders for two of three residents (11 and 16) when low air loss mattresses (LAL, a specialized mattress that uses air flow to prevent pressure injuries) were not set to the residents' weight.These failures had the potential to cause pressure injuries. Cross reference F656.Findings: 1. A review of Resident 11's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include adult failure to thrive and encounter for palliative care (comfort focused care toward the end of life). A review of Resident 11's physician's order dated 8/4/25, indicated, Pressure Redistribution Mattress- Low Air Loss setting per weight range or per resident's personal preference check function.every shift. A review of Resident 11's Braden Scale (assessment used to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure safe and effective pharmaceutical services when:Random controlled medication (medications with a high abuse potential) use audit for three of six sampled residents (Residents 7, 1, 4,) indicated medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR, section of the medical record where all medications given to the resident are recorded to ensure patient safety) to indicate they were administered to the residents.In addition, one of one sampled resident (Resident 8), administrations were documented on the MAR, but not signed out on the CDR.These failures had the potential for diversion (unlawful distribution or use), inadequate narcotic accountability, and the potential to not meet the needs of the residents in the facility.Medications for diabetes (a condition characterized by impaired blood sugar control) were not given in accordance with professional standards of practice and/or…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 15% when six medication errors occurred out of 40 opportunities during the medication administration for three of six randomly observed residents (Residents 1, 4, and 16). These failures had the potential for the residents not to get the full therapeutic benefit of their medications or to experience negative health outcomes, such as harm from exposure to medication errors.Findings:During a medication administration observation on 2/9/26 at 8:19 A.M., Licensed Nurse (LN) 21 was observed preparing and administering seven medications for Resident 1. LN 21 stated Resident 1 received her medications crushed and mixed with pudding.LN 21 crushed all of Resident 1's tablets together in one bag and mixed the medications with pudding. The medications included the following tablets:levetiracetam (a medication used to treat seizures) oral tablet 500 milligrams (mg, unit of measurement) - give 1 tablet by mouth two times…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0761 — failed to label and store drugs safely — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure safe medication labeling in accordance with accepted professional standards when Licensed Nurse (LN) 21 administered an opened and unlabeled inhaler mouthpiece to one of six residents (Resident 16) observed during medication administration. This failure had the potential for residents to receive the wrong inhaler, which could result in adverse resident outcomes, infections from accidental cross-contamination (germs), and medication errors.Findings:During a medication administration observation on 2/9/26 at 9:41 A.M., LN 21 was observed preparing and administering 13 medications to Resident 16. One of the administered medications was fluticasone/vilanterol (a medication for asthma or chronic obstructive pulmonary disease [COPD], respiratory conditions that affect breathing). The inhaler was inside a box that had the prescription label from the pharmacy, but the inhaler mouthpiece inside the medication carton did not have any labels attached to it.During a concurrent observation and interview with LN 22…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0801 — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and facility document review, the facility failed to ensure that the Food Services Manager (FSM), who oversees the kitchen serving the skilled nursing facility, was qualified to manage the day-to-day operations of the food services department. This failure had the potential to negatively affect the health and well-being of 21 residents who received the food prepared in the kitchen.Findings:On 02/10/2026 at 11:50 AM, an interview was conducted with the Food Services Manager (FSM) and the Food Services Director (FSD). FSM stated shared responsibility with Food Services Director (FSD) for overseeing the kitchen that provides meals for the Skilled Nursing Facility (SNF), Independent Living, Assisted Living and Memory Care. FSM stated that she did not have the Certified Dietary Manager or the Dietary Services Supervisor credential. FSD agreed with the FSM statement of responsibilities. On 02/10/2026 at 3:56 PM, an interview was conducted with the Administrator (ADM) who confirmed that the current structure of the kitchen is that FSD and FSM oversee the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 13 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

What families pay in CA