Grossmont Gardens Healthcare Center

In the surveyor’s words

From the most serious findings on record at Grossmont Gardens Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF578Feb 12, 2026

  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. […]

• No harm, potential for more than minimal, patternF656Feb 12, 2026

  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. […]

• No harm, potential for more than minimal, patternF812Feb 12, 2026

  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). […]

• No harm, potential for more than minimal, isolatedF557Feb 12, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF605Feb 12, 2026

  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… […]