Health inspection·December 2, 2025

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 develop a discharge care plan for one of three sampled residents (Resident 1).As a result, this deficient practice placed Resident 1 at risk for an unsafe or uncoordinated discharge, unmet care needs, and delays in services during any transition out of the facility.Findings:A review of Resident 1's admission Record indicated, Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included history of Cerebrovascular Disease (conditions that affect blood flow to the brain).A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 9/5/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of two points out of 15 possible points which indicated Resident 1 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 12/2/25 at 12:30 P.M., an interview and record review was conducted with the Social Service Designee (SSD). The SSD stated they had planned on Resident 1 to discharge to a sister facility (same company of facility) that was out of state in Arizona before finding out Resident 1's family member contact information. The SSD stated she had reached out to Resident 1's primary care physician (PCP) on 11/7/25 who had Resident 1's family member (FM) current contact information, and spoke to Resident 1's FM who stated he wanted Resident 1 to move closer to him in El Centro, California and not Arizona. The SSD stated the interdisciplinary team (IDT: nurses, doctors, therapists, social workers, nutrition and other staff involved who work together to create one cohesive plan for a resident's care) had a care conference for Resident 1 on 11/6/25 but was unable to find a current and/or revised discharge care plan. The SSD stated it should have been developed after Resident 1's re-admission [DATE]) to the facility.On 12/2/25 at 12:51 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectations were, discharge planning and discharge care plans must be initiated and updated timely so all staff understand the resident's goals and needs starting from admission. The DON stated discharge care planning should be personalized to each resident and coordinated with the IDT and discussed with the resident and/or representative to ensure it reflected their goals and supports a safe discharge from the facility. The DON further stated that discharge care plans must be continuously updated based on the resident's level of care, condition changes, significant events, quarterly reviews and revised as needed. The DON acknowledged that timely discharge planning was essential to prevent delays, ensure resident safety, and support a coordinated transition out of the facility. A review of the facility's policy and procedure titled, Care Planning-Interdisciplinary Team dated March 2022, indicated .Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary (IDT) . 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: 555659 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 555659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Diego Post-Acute Center 1201 South Orange Ave. El Cajon, CA 92020 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)