Country Manor La Mesa Healthcare Center
COUNTRY MANOR LA MESA HEALTHCARE CENTER in LA MESA, CA — inspection on January 16, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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
055910
Form Approved OMB
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