Health inspection·December 8, 2023

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pain and 10 indicates severe pain), give morphine sulfate 20 mg by mouth every four hours for severe pain 7-10. According to the facility's Alert Charting, initiated 10/30/23 at 2:19 P.M., LN 1 documented Resident 1 complained of pain to her right hip, with bruising noted at the site. A pain scale of 10 out of 10 was reported and the Resident 1 was provided morphine 5 mg orally on two occasions that shift. According to the Medication Treatment Record (MAR), reviewed from 10/31/23 through 11/11/23, Resident complained of pain five times out of 36 nursing shifts for pain assessment. Resident 1 received morphine sulfate for severe pain six times and received tramadol for moderate pain five times over the 12-day period. According to the nurses note, dated 11/11/2023 12:23, family requested Resident 1 be sent to hospital for MRI (magnetic resonance imaging) due to continued right hip pain. According to the nurses note, dated 11/12/23 at 11:07 A.M., Resident 1 was admitted to the hospital after having surgery for a right hip fracture. During an interview and record review with LN 1 on 11/20/23 at 12:32 P.M., LN 1 stated she initiated the alert charting on Resident 1 due to Resident 1's level of pain and recent fall, so staff were aware and would continue to monitor. LN 1 stated when resident fell, the physician, responsible party (RP) and hospice agency needed to be informed, so everyone knew what was going on. LN 1 stated she did notify the physician and RP at the time of the alert charting, but she did not inform the hospice agency of the resident's increased pain. During an interview with H (hospice) LN 1 on 11/29/23 at 2:15 P.M. H-LN 1 stated she visited Resident 1 for the first time on 11/3/23 at 3:02 P.M. H-LN 1 stated the hospice agency was never informed of Resident 1's having a fall on 10/29/23, and they were never informed of the resident having increased pain after the fall. H-LN 1 stated this would be important for them to know, so they could conduct their own assessment and determine if additional pain medication was required. H-LN 1 stated when she arrived at the facility, she first contacted the charge nurse to see if there had been any changes or increase in pain. H-LN 1 stated she was told by the charge nurse there were no new concerns and no changes in pain. H-LN 1 stated she relies on the nurses to inform her of changes and does not review the facility's MAR or nurses note. H-LN 1 stated Resident 1 did not complain of any pain during her visit. During an interview with Hospice Health Aide (HHA 1) on 11/29/23 at 3:04 P.M., HHA 1 stated he regularly sees Resident 1 twice a week and visits were made to the facility on [DATE], 11/3/23, and 11/7/23. HHA 1 stated he normally assist with bathing and personal care, which he did on those days. HHA 1 stated he was never informed by staff of a recent fall or any pain. HHA 1 stated Resident 1 did not complain of any pain during those visits and stated he had rolled the resident from side to side, with no complaints. HHA 1 stated it would have been important for him to be informed of the fall and increased pain and might have handled the Resident 1 differently. During an interview with H-LN 2 on 11/29/23 at 3:53 P.M. H-LN 2 stated she has cared for Resident 1 several times in the past. H-LN 2 stated she visited Resident 1 on 11/7/23, and she did not complain of any pain. H-LN 2 stated she would contact the facility nurses first before going in to see the resident, and asked if there were any new issues or changes in pain. H-LN 2 stated staff informed her there were no issues or changes. H-LN 2 stated Resident 1 did not complain of any pain and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care Center 8665 LA Mesa Blvd. LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appeared her usual self. H-LN 2 stated if the resident did have a fall prior to her visit, she expected staff to inform her. H-LN 2 stated it was important for the hospice staff and the facility staff to communicate, so the highest level of care for Resident 1 could be provided. During an interview with the Director of Nursing (DON) on 12/1/23 at 11:49 A.M., the DON stated the staff were communicating with the Hospice nurse practitioner (NP) and the NP was aware of the fall and pain, because the NP ordered the x-ray and new pain medications. The DON stated she expected her staff to communicate with all hospice staff if any resident had any changes or new issues. The DON stated communication between entities was important for consistent care. According to the facility's policy, titled Hospice Program, dated July 2017, .9. In general, it is the responsibility of the hospice to manage resident's care .b. Changing the level of services provided when it is deemed appropriate .10. In general, it is the responsibility of the facility to meet the resident's needs . c. Notifying the hospice about the following (1) A significant change in the resident's physical .d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 3 of 3