Health inspection·February 29, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interviews, record review, and facility policy review, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR) Level I Screening for 1 (Resident #93) of 3 sampled residents reviewed for PASRR requirements. Specifically, the facility failed to ensure Resident #93's PASRR Level I Screening reflected the resident had diagnosed mental disorders, including depression, anxiety disorder, and schizophrenia. Residents Affected - Few Findings included: A review of facility policy titled, admission Criteria, revised in March 2019, revealed, All new admissions and readmission are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review process. A review of an admission Record revealed the facility admitted Resident #93 on 10/26/2023. According to the admission Record, Resident #93 had a medical history that included diagnoses of schizophrenia, depression, and anxiety disorder. A review of Resident #93's comprehensive care plan revealed a Focus area, initiated on 10/26/2023, that indicated the resident had an impaired mood state/depression as evidenced by behavioral manifestations related to diagnoses that included anxiety disorder, schizophrenia, and dementia. A review Resident #93's Physician's Progress Notes, dated 10/29/2023, revealed the resident had a diagnosis of unspecified schizophrenia. A review of Resident #93's Order Summary Report, listing active orders as of 02/28/2024, revealed orders dated 10/30/2023 for Risperdal (an anti-psychotic medication), 0.25 milligram (mg) two times a day and at bedtime for schizophrenia as evidenced by paranoia, and trazodone hydrochloride (HCl) (an antidepressant medication), 100 mg at bedtime for depression as evidenced by inability to sleep. A review of Resident #93's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 10/26/2023, revealed Question #10, Does the resident have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? was answered, No. The PASRR Level 1 Screening result was listed as, Negative, and a Level II was not required. During an interview on 02/29/2024 at 8:03 AM, Licensed Vocational Nurse (LVN) #11 stated PASRR screenings were completed when the resident was in the hospital. She stated she reviewed the screenings when the facility received residents' admission paperwork, and if the PASRR screening was not accurate, they completed another screening. LVN #11 stated Resident #93's diagnoses should have been documented on the resident's PASRR Level I Screening. During an interview on 02/29/2024 at 8:20 AM, the Director of Nursing (DON) stated she expected PASRR screenings to be accurate. She stated the facility should verify each screening was accurate by reviewing the resident's diagnoses, medications, and the resident's medical history. During an interview on 02/29/2024 at 9:17 AM, the Administrator stated he expected residents' PASRR screenings to be accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 2 of 13 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 02/29/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and facility policy review, the facility failed to document and monitor the implementation of physician prescribed fluid restrictions for 1 (Resident #162) of 1 sampled resident reviewed for dialysis and with a prescribed fluid restriction. Specifically, Resident #162, who received renal dialysis, had a physician's order for a 1500 milliliter (mL) fluid restriction each day, and the facility failed to document and monitor the amount of fluids Resident #162 consumed. Residents Affected - Few Findings included: A review of a facility policy titled, Encouraging and Restricting Fluids, revised in October 2010, revealed the facility should 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate when recording fluid intake. The policy further indicated, 7. When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. If the resident refuses to have the water pitcher removed, notify the supervisor and in turn, the physician. A review of Resident #162's admission Record revealed the facility admitted the resident on 02/14/2023 with diagnoses that included end stage renal disease and dependence on renal dialysis. A review of Resident #162's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. According to the MDS, the resident required supervision or touching assistance for eating and was on a therapeutic diet. A review of Resident #162's comprehensive care plan revealed a Focus area, initiated on 02/15/2024, that indicated the resident was at risk for dehydration related to fluid restriction. The facility developed interventions that directed staff to encourage and offer fluids if not contraindicated and encourage the resident to consume all fluids served on the meal tray and offered between care as long as not contraindicated. Another Focus area, initiated on 02/28/2024, indicated Resident #162 was noncompliant with care manifested by refusing fluid restriction. An intervention dated 02/28/2024 directed staff to explain the benefits of fluid restriction and the risks/consequences of their noncompliance to the resident and the resident's representative. A review of Resident #162's physician's orders revealed an order dated 02/17/2024 for a fluid restriction of 1500 mL of fluids per day. The physician's orders specified 1500 mL was to be divided between the nursing department and the dietary department and indicated the dietary department was to supply the resident with 240 mL of fluids with each meal (breakfast, lunch, and dinner), and the nursing department was to provide 360 mL of fluids during the 7:00 AM to 3:00 PM shift, 360 mL of fluids during the 3:00 PM to 11:00 PM shift, and 60 mL of fluids during the 11:00 PM to 7:00 AM shift. An interview with Resident #162 was held on 02/28/2024 at 2:43 PM. Resident #162 stated they had received dialysis for the last ten months, and they were aware they had an ordered fluid restriction. The resident stated they drank three, 16-ounce bottles (1419 mL) of water per day in addition to fluids served on their meal trays. Resident #162 stated they also had a water pitcher that staff filled every morning. The resident stated that once in a while staff asked what the resident had consumed, but staff did not ask every day or every shift. An observation made in Resident #162's room on 02/29/2024 at 8:45 AM revealed the resident had two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 3 of 13 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 02/29/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few full 16-ounce bottles of water (each 16-ounce bottle of water was equivalent to 473 mL) and another 16-ounce bottle of water that was approximately two-thirds of the way empty. The resident also had a 16-ounce insulated cup in their room that was three-quarters of the way empty. A review of the Fluid Intake task for Resident #162 for the timeframe from 02/14/2024 through 02/28/2024, revealed the resident's morning fluid intakes for 02/16/2024, 02/22/2024, and 02/26/2024 were not documented. Fluid intake documentation on 02/15/2024, 02/16/2024, 02/17/2024, 02/18/2024, 02/19/2024, 02/20/2024, 02/21/2024, 02/23/2024, 02/25/2024, 02/26/2024, and 02/27/2024 reflected the resident consumed more than 240 mL of fluids for two of three meals each day. A review of Resident #162's February 2024 Medication Administration Record (MAR) revealed that prior to 02/28/2024 at 11 PM, staff were not documenting the amount of fluids the resident consumed each shift on the resident's MAR. During an interview on 02/28/2024 at 2:28 PM, Certified Nursing Assistant (CNA) #1 said she was assigned to care for Resident #162. CNA #1 stated the nurses alerted staff if a resident was on a fluid restriction; however, according to CNA #1, there were no residents on the CNA's assignment that were on fluid restriction. According to CNA #1, the amount of fluids documented as consumed during meals included coffee, juices, and tea but did not include the amount of water a resident consumed. During an interview on 02/28/2024 at 3:19 PM, Licensed Vocational Nurse (LVN) #2 stated her assignment for the day included Resident #162. LVN #2 stated Resident #162 was on a fluid restriction of 1500 mL per day. LVN #2 stated the CNAs documented the fluids consumed with meals under Tasks in the electronic medical record, and nurses documented the number of fluids given with medications on the MAR. LVN #2 then reviewed the MAR for Resident #162 and stated the order for the fluid restriction was not on the MAR; therefore, there was no option available to record the amount of fluids the resident consumed during medication administration. She stated she was unsure why the ordered fluid restriction was not on the resident's MAR. LVN #2 further stated she was unsure who was responsible for adding the total amount of fluids consumed each day and notifying the physician if the resident exceeded the ordered fluid restriction amount. LVN #2 reviewed the orders for Resident #162 and confirmed the order for a fluid restriction was still active. During an interview on 02/28/2024 at 3:31 PM, LVN #3 stated there was no spot on the MAR or any other record to record the amount of fluid Resident #162 consumed. LVN #3 stated evening shift staff were responsible for calculating the total amount of fluids consumed in 24 hours, and the nurse who conducted the calculation was responsible for calling the physician if the resident exceeded the ordered amount of fluids. LVN #3 stated the danger of exceeding the ordered limit could be fluid overload. LVN #3 stated Resident #162 was alert and oriented and staff could ask the resident what they had consumed each shift but stated without documentation of daily intake there was no accurate way to know what the resident consumed. During an interview on 02/29/2024 at 9:44 AM, LVN #6 said she was assigned to care for Resident #162 but was unaware Resident #162 was on a fluid restriction. During an interview on 02/29/2024 at 8:23 AM, Registered Dietician (RD) #4 stated she was responsible for dividing the total amount of fluids for a resident between the nursing and dietary departments. RD #4 said she communicated the amount of fluid each department should give the resident, and nursing signed off on the recommendations. After the physician verified the recommendations, the nurses entered the fluid restriction order into the electronic medical record for implementation. The RD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 4 of 13 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 02/29/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the nurses were responsible for alerting the CNAs about the fluid restriction and the fluid restriction was printed on the resident's tray card that was sent with each meal. She further said if a resident was on fluid restrictions, there should not be a water pitcher at their bedside. The RD stated she expected the nurses to follow the physician's orders and document the amount of fluids the resident consumed. She stated she was not aware until 02/28/2024 that the staff were not documenting the amount of fluids Resident #162 consumed and was not aware until that date that Resident #162's fluid restriction was not being followed. RD #4 further stated Resident #162 was well aware of the fluid restriction but was not always compliant; however, RD #4 said there was no care plan for the resident's noncompliance with fluid restriction prior to 02/28/2024 (after the survey was initiated). A telephone interview was held with RD #5 at 8:47 AM on 02/29/2024. RD #5 worked at the dialysis center where Resident #162 received treatment. RD #5 stated it was imperative for someone on dialysis to maintain a fluid restriction to avoid excess fluid that would affect the pumping of the heart, increase dialysis time, and increase blood pressure. RD #5 stated Resident #162 had just returned to the dialysis clinic after being hospitalized . RD #5 stated Resident #162's post-dialysis weight variance was quite high, which indicated the resident was not adhering to the ordered fluid restriction. RD #5 stated he expected the facility nurses to accurately record the amount of fluid Resident #162 consumed. He stated he was unaware the facility had not been recording the number of fluids the resident consumed. The RD stated if Resident #162 exceeded the ordered fluid amount, he expected to be notified. The Director of Nursing (DON) was interviewed on 02/29/2024 at 8:02 AM. The DON stated fluids given with medications should be entered on the MAR. The DON stated the nurse who entered Resident #162's order for a fluid restriction forgot to push a button that would have populated the order onto the resident's MAR. The DON stated that when a resident was placed on a fluid restriction, the RD divided the amount of fluid the resident could have between the dietary department and the nursing department. The DON stated the fluid restriction information was communicated to the licensed nurses, and the Director of Staff Development (DSD) was the person responsible for conveying the information to the CNAs. The DON stated she was aware Resident #162 had fluid restriction orders but was not aware the fluid restriction was not followed. The DON stated that without the nurses' documentation of fluids provided by nursing, the resident's intake of fluid would not be accurate. The DON stated she expected the staff to follow physician's orders for Resident #162's fluid restriction. The Administrator was interviewed on 02/29/2024 at 9:05 AM. The Administrator stated he expected the nurses to record on the MAR the amount of all fluids residents consumed. The Administrator stated nurses communicated orders to direct care staff every shift. The Administrator stated he was unaware facility staff were not following an order for fluid restriction for Resident #162. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 5 of 13 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 02/29/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observations, interviews, record review, and facility policy review, the facility failed to ensure 2 (Resident #54 and Resident #85) of 2 residents observed receiving medications via feeding tubes (gastrostomy or G-tube) received appropriate treatment and services to prevent feeding tube complications. Specifically, the facility failed to follow physician's orders to flush Resident #54 and Resident #85's G-tube between administration of medications. Findings included: A review of a facility policy titled, Administering Medications through an Enteral Tube, revised in November 2018, revealed that staff should 5. Administer each medication separately and flush between medications. 1. A review of Resident #54's admission Record revealed the facility admitted the resident on 08/10/2022 with diagnoses that included dysphagia (difficulty swallowing) following a cerebral infarction (stroke) and encounter for attention to gastrostomy. A review of Resident #54's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2024, revealed the resident was in a persistent vegetative state with no discernible consciousness and received nutrition via a feeding tube. A review of Resident #54's comprehensive care plan revealed a Focus area, initiated on 01/24/2024, that indicated the resident required the use of a G-tube related to dysphagia. A review of Resident #54's Order Summary Report, listing active orders as of 02/28/2024, revealed the resident had orders dated 10/22/2023 to flush the resident's G-tube with 10 milliliters (mL) of water between each medication during medication administration and to flush the G-tube with 30 mL of water before and after medication administration. The Order Summary Report also reflected the following: -an order dated 10/23/2023 for baclofen (a muscle relaxer) 10 milligrams (mg), one tablet three times a day; -an order dated 10/22/2023 for cranberry tablet 450 mg, one tablet via G-tube one time a day for supplement; -an order dated 10/23/2023 for doxazosin mesylate 4 mg, one tablet via G-tube one time a day for hypertension; -an order dated 10/23/2023 for glycopyrrolate 2 mg, one tablet three times a day for hypersecretion (excess secretions); -an order dated 02/21/2024 for lacosamide 100 mg, one tablet via G-tube two times a day for seizures; -an order dated 10/23/2023 for levetiracetam 100 mg/mL, give 5 mL (500 mg) via G-tube two times a day for seizures; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 6 of 13 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 02/29/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -an order dated 10/23/2023 for omeprazole 20 mg, one capsule via G-tube one time a day before tube feeding starts for Gastro intestinal [sic]. Licensed Vocational Nurse (LVN) #7 was observed administering Resident #54's morning medications on 02/28/2024 at 8:25 AM via the resident's G-tube. LVN #7 flushed the resident's G-tube and administered Resident #54's physician-ordered baclofen, cranberry tablet, doxazosin mesylate, glycopyrrolate, lacosamide, levetiracetam, and omeprazole. After administering all the medications, LVN #7 flushed the residents G-tube with 30 mL of water. Observations revealed LVN #7 did not flush the resident's G-tube between administration of each medication as required by facility's policy and as specified by the resident's physician's orders. LVN #7 was interviewed on 02/28/2024 at 1:47 PM. LVN #7 stated he flushed Resident #54's G-tube before and after administering all of the medications. LVN #7 then reviewed the physician's orders for Resident #54, including the order that directed staff to flush the G-tube with 10 mL of water between each medication. LVN #7 stated he had forgotten to flush the G-tube between each medication due to nervousness. The Director of Nursing (DON) was interviewed on 02/28/2024 at 1:55 PM. The DON stated when residents received medications via G-tube she expected the nurses to follow the physician's order for flushing between medications. The Administrator was interviewed on 02/29/2024 at 9:15 AM. The Administrator stated he expected the physician's orders for G-tube flushes between medications to be followed as the physician ordered. 2. A review of Resident #85's admission Record revealed the facility admitted the resident on 06/28/2023 with diagnoses that included anoxic brain injury, unspecified quadriplegia, dysphagia (difficulty swallowing), and the use of a gastrostomy tube. A review of Resident #85's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/04/2024 revealed a Staff Assessment for Mental Status (SAMS) determined the resident had shortand long-term memory problems and severely impaired cognitive skills for daily decision making. According to the MDS, the resident had a feeding tube. A review of Resident #85's comprehensive care plan revealed a Focus area, initiated on 10/13/2023, that indicated the resident required the use of a feeding tube due to dysphagia. A review of Resident #85's Order Summary Report, listing active orders as of 02/28/2024, revealed the resident had orders dated 10/21/2023 to flush the resident's G-tube with 10 milliliters (mL) of water between each medication during medication administration and to flush the G-tube with 30 mL of water before and after medication administration. The Order Summary Report also reflected the following: -an order dated 02/27/2024 for pantoprazole delayed release 40 milligrams (mg), one packet dissolved in apple juice via G-tube one time a day for gastroesophageal reflux disease (GERD); and -an order dated 01/30/2024 for vitamin C 500 mg, one tablet via G-tube two times a day for supplement. Registered Nurse (RN) #8 was observed administering Resident #85's morning medications on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 7 of 13 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 02/29/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm 02/28/2024 at 8:08 AM via the resident's G-tube. RN #8 flushed the resident's G-tube with 30 mL water, then administered Resident #85's physician-ordered vitamin C and pantoprazole. After administering both medications, RN #8 flushed the residents G-tube with 30 mL of water. Observations revealed RN #8 did not flush the resident's G-tube between administration of each medication as required by facility's policy and as specified by the resident's physician's orders. Residents Affected - Few RN #8 was interviewed on 02/28/2024 at 11:49 AM. RN #8 stated the facility policy directed staff to flush G-tubes between each medication when administering medications. RN #8 stated he normally flushed G-tubes between medications but was nervous and forgot to do so when giving Resident #85 their medication. RN #8 reviewed the order for Resident #85 and stated the resident had an order to flush with 10 mL of water between each medication. The Director of Nursing (DON) was interviewed on 02/28/2024 at 1:55 PM. The DON stated when residents received medications via G-tube she expected the nurses to follow the physician's order for flushing between medications. The Administrator was interviewed on 02/29/2024 at 9:15 AM. The Administrator stated he expected the physician's orders for G-tube flushes between medications to be followed as the physician ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 8 of 13 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 02/29/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review, interview, and document and policy review, the facility failed to ensure the attending physician documented adequate response to pharmacy monthly medication review irregularities for 1 (Resident #53) of 5 residents reviewed for unnecessary medications. Findings included: A review of a facility policy titled, Psychotropic Medication Use, dated July 2023, revealed 12. Psychotropic medications are not prescribed or given on a PRN [pro re nata; as needed] basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. A review of Resident #53's admission Record revealed the facility admitted the resident on 09/28/2022 with diagnoses that included anxiety disorder and unspecified dementia. A review of Resident #53's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/04/2024, revealed the resident had severely impaired cognition per a Staff Assessment for Mental Status (SAMS). The MDS indicated Resident #53 had a diagnosis of anxiety. The MDS also revealed the resident had not received any antipsychotic, antianxiety, or antidepressant medications during the last seven days of the assessment period. A review of Resident #53's care plan focus area, initiated 10/13/2023, revealed the resident was taking nine or more medications and there was a potential for adverse drug effects and drug interactions. The facility's goal was for the resident to be free of drug interactions and adverse side effects and to have appropriate diagnoses to support the use of medications. The facility developed interventions that directed staff to administer medications as ordered, to observe for drug related side effects or negative drug reactions, and for the licensed pharmacist to conduct a monthly drug regimen review to recommend reduction or discontinuation of medications. The care plan revealed the pharmacist's recommendations should be forwarded to the physician with medication reduced or discontinued. A review of Resident #53's Order Summary Report revealed an active order that was started on 12/14/2023 for the administration of alprazolam (Xanax; anti-anxiety medication) 0.25 milligram (mg) every four hours as needed for agitation. There was no end date for the alprazolam medication order. A review of Resident #53's Note to Attending Physician/Prescriber, dated 01/28/2024, revealed the pharmacist indicated PRN psychotropic medication orders were limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication. The pharmacist's note revealed the provider should document their rationale in the resident's medical record and indicate the duration for the PRN use of the medication. The note revealed if the medication was not discontinued, nursing staff should transcribe the appropriate rationale to the care plan for reference. Further review of the note revealed that, on 01/30/2024, the physician/prescriber responded, no change per MD [medical doctor]. There was no documented evidence the physician evaluated the appropriateness of the medication, documented the rationale for continued use, or documented the duration for PRN use of the alprazolam. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 9 of 13 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 02/29/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #53's Medication Administration Record [MAR], dated 02/01/2024 to 02/29/2024, revealed the facility administered alprazolam to the resident on 02/02/2024 at 4:45 AM and 1:47 PM, and on 02/20/2024 at 8:45 AM. During an interview with Physician #10 on 02/29/2024 at 10:02 AM, he stated he had reviewed the monthly pharmacy reviews and agreed to take it [Resident #53's alprazolam] down to a PRN medication. He stated he worked with staff regarding psychotropic medications and if he did not agree with recommendations, he had a discussion with staff. Physician #10 stated Resident #53 needed to stay on alprazolam. During an interview with the Medical Director on 02/29/2024 at 12:04 PM, he stated he tried to discontinue PRN medications as soon as possible. He stated if the attending physician did not respond to a pharmacy review, the facility should notify the Medical Director. During an interview on 02/29/2024 at 8:20 AM, the Director of Nursing (DON) revealed Resident #53's PRN alprazolam needed to be reevaluated and, if extended beyond 14 days, needed to have an end date and reason. The DON noted the resident's alprazolam had been decreased from scheduled four times a day to PRN, stating that while the facility did not want the medication to be discontinued, it did need an end date. The DON stated Physician #10 was difficult, noting conversations about the issue had also been held with the resident's nurse practitioner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 10 of 13 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 02/29/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on record review, interviews, and facility policy review, the facility failed to ensure orders for as-needed (pro re nata, PRN) psychotropic medications were limited to 14 days and failed to document a rationale for continued use and the intended duration when the medication extended beyond 14 days for 2 (Resident #2 and Resident #53) of 6 sampled residents reviewed for psychotropic medications. Findings included: A review of a facility policy titled, Psychotropic Medication Use, dated July 2022, revealed 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1. A review of Resident #2's admission Record revealed the facility admitted the resident on 08/11/2022 with diagnoses that included chronic respiratory failure, encounter for attention to tracheostomy (a surgically created opening in the windpipe providing an alternative airway for breathing), schizophrenia, bipolar disorder, and anxiety disorder. A review of Resident #2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. According to the MDS, the resident received an antianxiety medication during the seven days prior to the assessment, and the MDS indicated an indication of use was noted. A review of Resident #2's comprehensive care plan revealed a Focus area, initiated on 01/12/2024, indicated the resident had increased restlessness during tracheostomy changes related to anxiety. The facility developed interventions that instructed staff to assess the resident for mood/behavior problems, convey an attitude of acceptance toward the resident, encourage the resident to verbalize feelings and fears, clarify misconceptions, identity relationships that the resident can draw on, establish a trusting relationship with the resident, report emergence of signs of isolation, and support appropriate moods/behavior. Interventions did not include the use of medications. A review of Resident #2's Order Summary Report, listing active orders as of 02/28/2024, revealed an order dated 01/10/2024 for lorazepam (a benzodiazepine medication used to treat anxiety) 0.5 milligrams (mg), one tablet by mouth PRN for anxiety as evidenced by agitation during tracheostomy care. The order did not specify a stop date for the medication. A review of Resident #2's January 2024 Medication Administration Record (MAR) revealed the PRN lorazepam was not administered. A review of Resident #2's February 2024 MAR revealed staff coded a 9, for Other/See Progress Notes for the resident's lorazepam on 02/17/2023 at 5:36 AM and on 02/22/2024 at 10:57 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 11 of 13 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 02/29/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm A review of nursing Progress Notes dated 02/17/2023 at 5:36 AM revealed Resident #2's lorazepam was administered for anxiety due to agitation during tracheostomy care. A review of Resident #2's Progress Notes dated 02/22/2022 at 10:57 AM revealed Resident #2 requested lorazepam prior to their tracheostomy change and the medication was effective. Residents Affected - Few A review of Resident #2's Medical Professional Progress Notes revealed notes dated 01/26/2024 at 12:08 AM and 02/13/2024 at 1:54 that indicated the provider reviewed the resident's medication orders. The Progress Notes did not reflect the rationale for extending Resident #2's PRN lorazepam beyond 14 days or indicate the intended duration of the PRN medication. During an interview on 02/29/2024 at 8:37 AM, Licensed Vocational Nurse (LVN) #9 stated Resident #2 took the lorazepam when they had to change the resident's tracheostomy equipment monthly. He stated the resident on occasion had to take the medication when they had increased anxiety, but it was not given very often. He stated he was aware that psychotropic medications needed to have a stop date after 14 days but was not sure why Resident #2's lorazepam did not have a stop date. During an interview on 02/29/2024 at 8:57 AM, the Director of Nursing (DON) stated it was her expectation that PRN psychotropic medication had a stop date, and the physician reassessed the resident for continued use. She stated she got resistance from some of the physicians regarding this practice. During an interview on 02/29/2024 at 9:21 AM, the Administrator stated he did not know the specific regulation related to having a stop date for a PRN psychotropic medication but stated that he expected the resident to have the assessments needed to continue the medication's use. During an interview on 02/29/2923 at 11:57 AM, the Medical Director stated he tried to get rid of PRN medications as soon as possible. He stated he did not think a PRN order for an anxiolytic that was being used for tracheostomy changes should need a stop date since it was being used every month. He stated the order should be changed to be a monthly routine order for when the tracheostomy was changed. 2. A review of Resident #53's admission Record revealed the facility admitted the resident on 09/28/2022. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder and unspecified dementia. A review of Resident #53's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/04/2024, revealed a Staff Assessment for Mental Status (SAMS) determined the resident had shortand long-term memory problems and severely impaired cognitive skills for daily decision making. The MDS indicated Resident #53 had active diagnoses that included anxiety disorder. According to the MDS, the resident had not received any antipsychotic, antianxiety, or antidepressant medications during the seven days prior to the assessment. A review of Resident #53's comprehensive care plan revealed a Focus area, initiated 10/13/2023, that indicated the resident had combative and aggressive behaviors as evidenced by hitting their face. The facility developed an intervention that directed staff to administer and monitor for the effectiveness and side effects of medications ordered by the physician. A review of Resident #53's Order Summary Report revealed an active order started on 12/14/2023 for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 12 of 13 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 02/29/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the administration of alprazolam (Xanax; anti-anxiety medication) 0.25 milligram (mg) every four hours as needed for agitation. There was no end date for the alprazolam medication order. A review of Resident #53's Medication Administration Record [MAR] for December 2023 revealed alprazolam was admitted routinely every four hours until 12/14/2023. A review of the January 2024 and February 2024 MARs revealed alprazolam could be administered every four hours as needed. The review revealed the facility administered the medication to Resident #53 on 02/02/2024 at 4:45 AM and 1:47 PM, and on 02/20/2024 at 8:45 AM. During an interview with the Director of Nursing (DON) on 02/29/2024 at 8:20 AM, she stated the facility had decreased Resident #53's alprazolam from scheduled to PRN. The DON confirmed the PRN alprazolam needed to have an end date and should be reevaluated if the medication extended beyond 14 days. During an interview on 02/29/2024 at 9:21 AM, the Administrator stated he did not know the specific regulation related to having a stop date for a PRN psychotropic medication, but stated he expected the resident to have the assessments needed to continue the medication's use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055873 If continuation sheet Page 13 of 13