Country Manor LA Mesa: Infection Control Failures - CA
The violations occurred at Country Manor LA Mesa Healthcare Center during a federal inspection on January 15, when inspectors observed Licensed Nurse 12 repeatedly failing to follow infection control protocols for Resident 55, who had a gastrostomy tube and required enhanced barrier precautions.
Enhanced barrier precautions involve wearing gowns and gloves during high-contact care activities for residents with medical devices like feeding tubes. A sign on Resident 55's door indicated these special precautions were required.
At 8 a.m., inspectors watched LN 12 check Resident 55's vital signs without putting on a gown. Twelve minutes later, the nurse returned to check the resident's feeding tube placement, again without wearing the required protective equipment.
The most serious breach occurred at 8:36 a.m. during medication administration. LN 12 put on gloves and removed a gown from the wall dispenser. He took the gown out of its plastic package and threw the package in the trash bin while still wearing the same gloves. He then opened the trash bin with his contaminated gloves, put on the gown, and moved the trash bin again with the same gloves.
Without removing his gloves or performing hand hygiene, LN 12 went to Resident 55's room and proceeded to give medications. He instilled drops into the resident's eyes, then administered medications through the feeding tube.
When questioned later that day, LN 12 acknowledged the violations. He stated that staff were required to wear personal protective equipment when providing any direct contact care to residents with enhanced barrier precautions, including giving medications, checking vital signs, and personal care.
"I forgot to wear a gown when I checked Resident 55's vital signs and g-tube placement," LN 12 told inspectors. He also admitted he "did not realize" he had failed to perform hand hygiene and change gloves after touching the trash bin before administering medications.
LN 12 acknowledged that the trash bin "was considered dirty."
The Director of Nursing confirmed that staff were expected to follow enhanced barrier precaution procedures and perform hand hygiene when gloves became contaminated "to prevent infection because residents were prone to getting an infection."
Resident 55 had been admitted to the facility with multiple diagnoses and required the gastrostomy tube due to swallowing problems. The surgical opening allows feedings and medications to be administered directly to the stomach.
The facility's Enhanced Barrier Precautions policy, revised in August 2022, specifies that these measures "are used as an infection prevention and control interventions to reduce the spread of multi-drug resistant organisms to residents." The policy requires "targeted gown and glove use during high contact resident care activities" and specifically lists "device care or use (feeding tube)" as an example requiring these precautions.
The facility's hand hygiene policy, updated in October 2023, states that "hand hygiene [is] the primary means to prevent the spread of healthcare-associated infections" and requires hand cleaning "after touching the resident's environment."
The inspection also revealed broader quality assurance failures. During interviews with facility leadership, the Administrator acknowledged that the facility's Quality Assurance and Performance Improvement program had failed to identify deficient trends that federal surveyors discovered during their visit.
The Administrator stated that surveyors had found "deficient trends in basic grooming (nailcare and beard care) and the staff's lack of knowledge about caring for Post Traumatic Stress Disorder residents." Neither of these problems had been identified by the facility's quality assurance committee or included in their improvement plan.
"The expectation was the QAA Committee should have identified the trends that were identified by the surveyors," the Administrator told inspectors. The Administrator emphasized that identifying and addressing deficient trends was important "to promote the highest standard of care for their residents."
The Director of Nursing echoed these concerns, stating that the quality assurance committee should have caught the trends identified by surveyors. The DON said identifying these issues was crucial "to maintain residents' dignity (for grooming/hygiene) and to promote the highest standard of care for their residents with PTSD."
According to the facility's Quality Assurance and Performance Improvement policy from February 2020, the program's objectives include providing "a means to measure current and potential indicators for outcomes of care and quality of life" and establishing "performance improvement projects to correct identified negative or problematic indicators."
The policy describes a process for "identifying and prioritizing quality deficiencies" as a key component of maintaining care standards.
Federal inspectors noted that the infection control failures "had the potential for cross contamination, spread of infection and Resident 55's decline of health." The violations occurred despite clear facility policies requiring proper protective equipment use and hand hygiene protocols.
The inspection found that Country Manor LA Mesa Healthcare Center's quality monitoring focused primarily on falls, pressure ulcers, and basic infection control monitoring of hand hygiene and personal protective equipment usage. However, the facility's oversight system failed to detect the specific infection control breaches that posed risks to vulnerable residents requiring enhanced precautions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Manor La Mesa Healthcare Center from 2025-01-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
COUNTRY MANOR LA MESA HEALTHCARE CENTER in LA MESA, CA was cited for violations during a health inspection on January 16, 2025.
Enhanced barrier precautions involve wearing gowns and gloves during high-contact care activities for residents with medical devices like feeding tubes.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.