Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Community Care Center during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A facility failed to provide adequate pressure ulcer care for three residents at risk. One resident was not repositioned every two hours as required, and a low air loss mattress was not used. Additionally, there were missing entries in the wound treatment logs for all three residents, raising concerns about whether treatments were performed as ordered. Interviews with staff highlighted the importance of documentation to ensure treatments were completed, but the facility did not adhere to its policies, resulting in deficiencies.
The facility failed to maintain food safety and sanitation standards in the kitchen, as observed with cutting boards that had deep cuts and stains stored in the clean area. A dietary worker acknowledged the need for replacement, and the Food Services Director emphasized the importance of avoiding contamination. The facility's policy requires utensils and equipment to be clean and in good repair, but this was not followed, exposing residents to potential foodborne illness.
A resident with chronic respiratory failure and a tracheotomy was administered oxygen at a rate of 5 L/min instead of the prescribed 2 L/min. This error was observed over several days and confirmed by a licensed nurse, who acknowledged the risk of excessive carbon dioxide accumulation. The facility's policy on verifying and documenting physician orders was not followed, leading to this deficiency.
The facility failed to ensure kitchen staff properly calibrated food thermometers, as observed when a staff member incorrectly demonstrated the calibration process. The Dietary Supervisor confirmed the expectation for staff to know proper calibration methods to prevent foodborne illnesses. The facility's policy requires using ice water for accurate calibration, which was not followed.
A facility failed to accurately document antibiotic administration for a resident with osteomyelitis and MRSA. The MAR showed discrepancies for Daptomycin and Teflaro administration, which were not recorded as given on a specific date, although the IV Administration Record indicated they were administered. Interviews with LNs and the DON highlighted the importance of consistent documentation to ensure accurate clinical records.
A resident was administered psychotropic medications without appropriate diagnoses or reassessment. Quetiapine was prescribed for schizophrenia without supporting documentation, and alprazolam was given beyond the 14-day PRN limit without physician reassessment. The facility's policy on medication use was not followed.
The facility failed to implement proper infection control measures in two instances involving Enhanced Barrier Precaution (EBP) rooms. A housekeeper removed PPE in the hallway instead of inside the room, and a visitor provided care without wearing the required PPE. Both actions were contrary to the facility's infection prevention policy, which mandates PPE removal before exiting the room and proper education for visitors.
A facility failed to follow a physician's plan of care for a resident, neglecting to perform weekly weights and notify the physician of vital sign deviations. The resident, with Down syndrome and severe constipation, had only two weights recorded and experienced multiple instances of abnormal vital signs without physician notification. Staff interviews revealed lapses in monitoring and communication responsibilities.
A resident admitted with a foley catheter did not have a care plan implemented until several months later, despite the presence of a physician's order. This delay in care planning placed the resident at risk for urinary tract infections. The infection preventionist nurse and DON acknowledged the oversight, which was contrary to the facility's catheter care policy.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents identified as being at risk for pressure injuries. Resident 99, who was admitted with a Stage 4 pressure ulcer on the left heel, was not turned and repositioned every two hours as required by his care plan. Observations showed that Resident 99 remained in the same position for extended periods, and a low air loss mattress, which could have helped prevent further skin breakdown, was not utilized. Additionally, there were missing entries in Resident 99's daily wound treatment log, indicating that wound care may not have been consistently provided. Resident 11, admitted for physical therapy, developed a right heel ruptured blister. Despite having a physician's order for daily wound treatment, the Treatment Administration Record (TAR) showed that treatments were missed on two occasions. The lack of documentation raised concerns about whether the treatments were performed as ordered. Similarly, Resident 12, who had Stage 4 pressure ulcers on the left buttock and right hip, also had missing entries in her wound treatment log, with treatments not documented for three days. Interviews with staff, including the Treatment Nurse and Director of Nursing, revealed that the facility's policy required documentation of all treatments to ensure they were completed. The absence of documentation meant there was no assurance that the necessary wound care was provided, potentially leading to additional or worsening skin injuries. The facility's failure to adhere to its own policies and care plans resulted in deficiencies in pressure ulcer care and prevention for these residents.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to ensure food safety and sanitation practices were adhered to in the kitchen, as observed during a survey. Two green cutting boards with deep cuts and food stains were found stored in the clean area, along with one red and one brown cutting board that also had deep cuts. These cutting boards were observed by a dietary worker and were noted to have been recently washed, yet still exhibited visible stains and knife cuts. The dietary worker acknowledged that the green cutting board needed to be changed. An interview with the Food Services Director confirmed the importance of not using stained cutting boards due to the risk of contamination from residue in the cuts. The facility's policy on sanitation, dated 2023, requires all utensils and equipment to be kept clean and in good repair, free from breaks, corrosions, and other defects. The policy also mandates the disposal of plastic ware that becomes unsanitary or hazardous. The failure to adhere to these standards exposed residents to the risk of foodborne illness due to contaminated food surfaces.
Oxygen Administration Error for Resident
Penalty
Summary
The facility failed to administer the correct amount of oxygen to a resident, as per the physician's order. Resident 99, who was admitted with chronic respiratory failure with hypoxia and had undergone a tracheotomy, was observed on multiple occasions receiving oxygen at a flow rate of 5 liters per minute, contrary to the physician's order of 2 liters per minute via trach mask continuously. This discrepancy was noted during observations on February 10 and 11, 2025, and confirmed by a licensed nurse on February 12, 2025. The licensed nurse acknowledged the error and recognized the risk of excessive carbon dioxide accumulation in the resident's bloodstream due to the higher oxygen flow rate. The respiratory therapist and the Director of Nursing both emphasized the importance of adhering to the physician's orders to prevent potential harm. The facility's policy on oxygen administration, which requires verification and documentation of the physician's order, was not followed, leading to this deficiency.
Improper Calibration of Food Thermometers by Kitchen Staff
Penalty
Summary
The facility failed to ensure that the kitchen staff competently performed and carried out the functions of the Food and Nutrition Service department. During an observation and interview, a staff member, referred to as [NAME] 1, was unable to properly demonstrate how to calibrate an analog food thermometer. [NAME] 1 incorrectly attempted to adjust the thermometer by twisting the probe and stated that it was unnecessary to place the thermometer in water if it was already set to 32 degrees Fahrenheit. This incorrect method of calibration was contrary to the facility's policy, which requires the thermometer to be submerged in ice water to ensure accurate calibration. The Dietary Supervisor confirmed that it was expected for all kitchen staff to know how to properly calibrate both digital and analog thermometers. The supervisor emphasized the importance of using a calibrated food thermometer to ensure accurate food temperature readings and prevent undercooked food, which could lead to foodborne illnesses. A review of the facility's policy on thermometer use and calibration outlined the correct procedure, which involves using a mixture of crushed ice and water to calibrate the thermometer. The failure to adhere to this policy had the potential to result in food contamination and posed a risk of foodborne illnesses for all residents consuming food from the kitchen.
Inaccurate Documentation of Antibiotic Administration
Penalty
Summary
The facility failed to accurately document the administration of antibiotics for Resident 88, who was admitted with osteomyelitis and MRSA. The resident's clinical record showed discrepancies in the Medication Administration Record (MAR) for the administration of Daptomycin and Teflaro on January 28, 2025. These medications were not recorded as administered in the MAR, although the facility's IV Administration Record indicated they were given. This inconsistency in documentation could lead to an incomplete and inaccurate clinical record for Resident 88. Interviews with Licensed Nurses (LN) 1 and 2 revealed that the MAR did not reflect the actual administration of the antibiotics, and there were no notes explaining the absence of documentation. LN 2 acknowledged the importance of consistent medication administration to maintain the medication threshold for fighting the infection. The Director of Nursing (DON) expected the MAR to match the IV Administration book to ensure accurate and complete documentation. The facility's policy on Charting and Documentation requires that medications administered be documented in the resident's medical record.
Failure to Ensure Resident is Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary drugs, as evidenced by the administration of psychotropic medications without appropriate diagnoses or reassessment. Resident 1, who was admitted with diagnoses including respiratory failure and cerebral palsy, was prescribed quetiapine for schizophrenia, despite lacking documentation or symptoms to support this diagnosis. Interviews with a licensed nurse and the resident's family member confirmed that the resident did not exhibit behaviors indicative of schizophrenia, and the psychiatrist acknowledged that the diagnosis was used to justify the medication's continued use, despite the resident being nonverbal and unable to be properly diagnosed. Additionally, the facility did not adhere to the 14-day limit for PRN orders of the anti-anxiety medication alprazolam, as it was administered to the resident multiple times beyond this period without reassessment by a physician. The licensed nurse admitted that the medication should have been reassessed and a new order issued if continued use was necessary. The facility's policy on antipsychotic medication use was not followed, as it requires PRN orders to be reassessed and documented for continued use beyond 14 days.
Infection Control Lapses in EBP Rooms
Penalty
Summary
The facility failed to implement proper infection control measures in two instances involving Enhanced Barrier Precaution (EBP) rooms. In the first instance, a housekeeper was observed exiting an EBP room while wearing personal protective equipment (PPE) and subsequently removing the PPE in the hallway, rather than inside the room. This action was contrary to the facility's infection prevention policy, which requires PPE to be doffed and discarded before exiting the room to prevent the spread of infection. The Infection Preventionist confirmed that the housekeeper's actions were inappropriate and highlighted the risk of contamination from handling items with dirty gloves. In the second instance, a visitor was observed providing care to a resident in an EBP room without wearing the required PPE, except for a surgical mask. The visitor was unaware of the need to wear a gown and gloves, despite the presence of an EBP sign outside the room. The visitor expressed concern about potentially bringing infections home, especially with a pregnant family member. The Infection Preventionist emphasized the importance of educating visitors about PPE requirements to prevent infection spread. The facility's policy mandates infection control measures for both employees and visitors, but these were not adhered to in this case.
Failure to Follow Physician's Plan of Care for Resident
Penalty
Summary
The facility failed to adhere to the physician's plan of care for a resident, specifically regarding the monitoring of weekly weights and the notification of the physician when vital signs were outside the set parameters. The resident, who was admitted with diagnoses including Down syndrome and severe constipation, required weekly weights and specific vital sign monitoring as per the physician's orders. However, the facility did not perform weekly weights consistently, with only two weights recorded between admission and discharge. Additionally, the facility did not notify the physician when the resident's vital signs were outside the prescribed parameters. The resident's heart rate exceeded 90 beats per minute eight times, and the systolic blood pressure was below 100 seven times, yet there was no documentation indicating that the physician was informed of these deviations. Interviews with staff, including CNAs and LNs, revealed that the responsibility for monitoring and reporting these metrics was not adequately fulfilled, leading to a lack of communication with the physician. The Director of Nursing acknowledged the oversight, stating that the weights should have been documented weekly and that the physician should have been notified of any vital sign deviations. The facility's policies on acute condition changes and comprehensive care plans emphasize the importance of following physician orders and documenting any changes, which were not adhered to in this case.
Failure to Implement Foley Catheter Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident who was admitted with an indwelling foley catheter. The resident, who had a surgical amputation of the right leg and stage 4 pressure ulcers, was admitted on April 13, 2024. However, a physician's order for the foley catheter was not entered until April 23, 2024, and a care plan was not implemented until July 24, 2024. This oversight placed the resident at risk for complications, including urinary tract infections, due to the presence of the foley catheter. During a joint interview and record review, the infection preventionist nurse acknowledged the delay in entering the physician's order and implementing the care plan. The Director of Nursing also confirmed that the care plan should have been in place upon the resident's admission, as it serves as a guide for the resident's care. The facility's policy on catheter care emphasizes the importance of having a care plan to prevent catheter-associated urinary tract infections and to address any special needs of the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near La Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grossmont Hospital D/p Snf | 0.6 mi | — | 0 | 0 |
| Grossmont Post Acute Care | 0.8 mi | — | 2 | 0 |
| Parkway Hills Nursing & Rehabilitation | 1.2 mi | — | 34 | 0 |
| Arbor Hills Nursing Center | 1.2 mi | — | 8 | 0 |
| Brighton Place Spring Valley | 1.4 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.