Country Manor La Mesa Healthcare Center

F-F699

Findings:

On 1/16/25 at 1:32 P.M., a concurrent interview with the Administrator (ADM), the Infection Preventionist (IP) and the Director of Nursing (DON) and a review of QAPI program was conducted. The ADM stated that the main areas that the QAPI team were monitoring were falls, pressure ulcers and infection control monitoring of hand hygiene and PPE usage. During the recertification survey, deficient trends in basic grooming (nailcare and beard care) and the staff's lack of knowledge about caring for Post Traumatic Stress Disorder residents were found. The ADM stated that neither of these trends had been identified by the QAA Committee and/or included in the QAPI plan.

On 1/16/25 at 1:40 P.M., an interview with the ADM was conducted. The ADM stated that the expectation was the QAA Committee should have identified the trends that were identified by the surveyors. In addition,

the ADM stated the deficient trends should have been included in the QAPI plan. The ADM stated the importance of QAA Committee identifying deficient trends and including them in the QAPI plan was to promote the highest standard of care for their residents.

On 1/16/25 at 1:50 P.M., an interview with the DON was conducted. The DON stated that the expectation was that the QAA Committee should have identified the trends identified by surveyors. In addition, the DON stated the deficient trends should have been included in the QAPI plan. The DON stated the importance of QAA Committee identifying trends was to maintain residents' dignity (for grooming/hygiene) and to promote

the highest standard of care for their residents with PTSD.

Review of facility policy titled Quality Assurance and Performance Improvement dated February 2020 indicated .The objectives of the QAPI Program are to 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build effective systems and processes related to the delivery of quality care and services. 4. Establish systems through which to monitor and evaluate corrective actions .The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: .C. Identifying and prioritizing quality deficiencies

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 055910 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055910 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Manor LA Mesa Healthcare Center 5696 Lake Murray 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40610 potential for actual harm Based on observations, interview, and record review the facility failed to ensure infection control procedures Residents Affected - Few were followed when a Licensed Nurse (LN) 12 did not wear a gown for Resident 55 with enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]), and perform hand hygiene (the practice of cleaning hands to remove germs, dirt, or other harmful substances) consistently after removing his gloves while passing medication (med/s) during med pass observation.

These failures had the potential for cross contamination, spread of infection and Resident 55's decline of health.

Findings:

A review of Resident 55's Admission Record indicated Resident 55 was admitted to the facility on [DATE REDACTED], with diagnoses which included Resident 55 had a gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings/ meds to be administered directly to the stomach common for people with swallowing problems).

On 1/15/25 at 8 A.M., an observation and an interview were conducted with Licensed Nurse (LN) 12 while preparing medications for Resident 55. There was an EBP sign attached to Resident 55's door. LN 12 stated

he will check Resident 55's vital signs. LN 12 checked Resident 55's vital signs without putting a gown.

On 1/15/25 at 8:12 A.M., another observation of LN 12 was conducted. LN 12 went back to Resident 55's room and checked Resident 55's g-tube placement without putting a gown.

On 1/15/25 at 8:36 A.M., an observation was conducted of LN 12 while preparing Resident 55's medications. LN 12 put gloves on, removed a gown from the wall, took out the gown from the plastic package, placed the plastic package in the trash bin with his gloves, opened the trash bin with gloved hands, put the gown to himself, moved the trash bin with gloved hand, did not remove his gloves, went to Resident 55's room and proceeded to give the medications to Resident 55.

LN 12 instilled medication drops to Resident 55's eyes then gave the medications to Resident 55 via the g-tube.

On 1/15/25 at 12:30 P.M., an interview was conducted with LN 12. LN 12 stated when providing care to residents with EBP, staff were required to wear PPE, such as giving meds, checking residents' vital signs and peri care to prevent cross contamination. LN 12 stated any direct contact to residents with EBP required PPE use. LN 12 stated he forgot to wear a gown when he checked Resident 55's vital signs and g-tube placement. LN 12 stated he did not realize he did not perform hand hygiene and changed gloves when he touched the trash bin and gave Resident 55 his medications. LN 12 stated the trash bin was considered dirty.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 055910 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055910 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Country Manor LA Mesa Healthcare Center 5696 Lake Murray 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 0880 On 1/15/25 at 3:40 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated

the expectation was for the staff to follow the procedures on EBP, to perform hand hygiene and changed Level of Harm - Minimal harm or gloves when gloves were contaminated to prevent infection because residents were prone to getting an potential for actual harm infection.

Residents Affected - Few A review of the facility's policy titled, Enhanced Barrier Precautions, revised August 2022, indicated, .1. Enhanced barrier precautions (EBP) are used as an infection prevention and control interventions to reduce

the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities .3. Examples of high-contact resident care activities . include .g. device care or use ( .feeding tube .) .

A review of the facility's policy titled, Handwashing/ Hand Hygiene, revised October 2023, indicated, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections . Indications for hand hygiene .e. after touching the resident's environment .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 055910