COUNTRY HILLS POST ACUTE
1580 BROADWAY
EL CAJON, CA, 92021
6194418745
CCN: 555431
1
Overall1
Health3
Staffing3
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| PROVIDENCE GROUP NH, LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| PACS GROUP, INC. | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| PACS HOLDINGS, LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| HANCOCK, MARK | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| MURRAY, JASON | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| MICHLIN, BERNARD | CONTRACTED MANAGING EMPLOYEE | NOT APPLICABLE |
| APT, FREDERICK | CORPORATE OFFICER | NOT APPLICABLE |
| HANCOCK, MARK | CORPORATE OFFICER | NOT APPLICABLE |
| JERGENSEN, JOSHUA | CORPORATE OFFICER | NOT APPLICABLE |
| MITCHELL, JOHN | CORPORATE OFFICER | NOT APPLICABLE |
| GRAF, ZACHARY | W-2 MANAGING EMPLOYEE | NOT APPLICABLE |
Health Deficiencies (67)
2025-08-27 · Health
D
F573 · Resident Rights Deficiencies
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
2025-07-29 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F761 · Pharmacy Service Deficiencies
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.
D
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
2025-06-10 · Health
E
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2025-04-07 · Health
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F726 · Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
2025-03-14 · Health
D
F925 · Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
D
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
E
F847 · Administration Deficiencies
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
E
F813 · Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F761 · Pharmacy Service Deficiencies
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.
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
E
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
E
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F640 · Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
D
F625 · Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
D
F584 · Resident Rights Deficiencies
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.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
E
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2025-02-21 · Health
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2024-03-29 · Health
E
F925 · Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
D
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
D
F908 · Environmental Deficiencies
Keep all essential equipment working safely.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F803 · Nutrition and Dietary Deficiencies
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.
F
F802 · Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F732 · Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
D
F726 · Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
D
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
D
F699 · Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F584 · Resident Rights Deficiencies
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.
2024-01-24 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
2023-10-19 · Health
D
F622 · Resident Rights Deficiencies
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.
2023-06-08 · Health
D
F622 · Resident Rights Deficiencies
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.
2023-04-12 · Health
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2023-03-09 · Health
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2022-04-21 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F758 · Pharmacy Service Deficiencies
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.
D
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
D
F693 · Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
E
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F640 · Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
4.03
RN Hrs/Resident/Day0.54
0.29
LPN Hrs/Resident/Day0.81
1.24
CNA Hrs/Resident/Day2.33
2.50
PT Hrs/Resident/Day0.12
0.11
Data as of 2026-03-01