Health inspection·December 31, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the physician plan of care related to weekly weights and notification of the physician when the vital signs (blood pressure, heart rate, respiratory rate, and temperature) were outside of the parameters set (a measurable limit), for one of three residents (Resident 1), reviewed for care plans. This failure had the potential for the physician to be uninformed of changes, which could have negative consequences on Resident 1's overall health. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included down syndrome (a genetic condition which affects the brain and normal development) and severe constipation (hard, dry stool, that is difficult to pass), per the facility's admission Record. A review of Resident 1's clinical record was reviewed on 12/18/24: According to the admission Minimum Data Set (MDS-a clinical assessment tool), dated 11/11/24, the cognitive assessment score was 00, indicating cognition was severely impaired. The Functional Abilities assessment indicated Resident 1 required maximum assistance with rolling from side to side, transferring, eating, grooming, and sitting. According to the Bladder and Bowel assessment, a urinary catheter (an indwelling rubber, flexible plastic tube that drains urine into an external collection bag), was present, and Resident 1 had bowel in continence. According to the physician's order, dated 11/4/24, Resident 1 was to have weekly weights. According to the facility's Weights and Vitals Summary, Resident 1 had weekly weights performed on 11/4/24 and 11/9/24, by a mechanical lift, (a device that assist staff with moving a resident from one place to another). No additional weights were performed between 11/9/24, until Resident 1's discharge on [DATE]. According to the physician's order, dated 11/4/24, Notify Medical Doctor if the patient has ANY of the following symptoms: Temperature less than 96.8 or greater than 99.0 (normal 98.6). Heart rate greater then 90, respiratory rate greater then 20, systolic (the top number) blood pressure less than 100. Record every shift. A review of the facility's Medication Administration Record (MAR) was conducted. Vital signs (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055873 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 12/31/2024 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)