Country Manor La Mesa Healthcare Center
COUNTRY MANOR LA MESA HEALTHCARE CENTER in LA MESA, CA — inspection on January 16, 2025.
Found 10 citations. 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 an interview and observation on 1/13/25 at 9:20 A.M., Resident 57 was in bed with a cell phone and speaker on top of the overbed table. A tall and round electric fan on the floor was turned on at the left side of the bed facing Resident 57.
The electric fan was observed with thick, gray dust on the blades and on the grill covers. Resident 57 stated nobody had cleaned the electric fan but did not want to complain about it.
During a review of Resident 57's Minimum Data Set (MDS-a clinical assessment tool) dated 11/11/24, the MDS indicated a Brief Interview of Mental Status (BIMS) score of 15, cognitively intact.
A joint interview and observation on 1/14/25 at 2:06 P.M. with the infection preventionist (IP) was conducted.
The electric fan was observed to be on and with thick, gray dust on the blades and on the grill covers.
The IP stated the electric fan facing Resident 57 was dirty and needed cleaning.
The IP stated the electric fan should be cleaned to prevent Resident 57 from inhaling dirt into Resident 57's lungs.
The IP further stated the electric fan should have been checked by housekeeping staff and the nursing staff during daily rounds.
An interview with the Maintenance Director (MN) was conducted on 1/16/25 at 9:23 A.M.
The MN stated each nursing station had a deep cleaning schedule which included cleaning of bed frames, mattresses, windows, electric fans, vents, TV, and the wall perimeter.
The MN stated the cleaning of resident 57's electric fan was missed.
The MN stated it was important to clean resident equipment such as an electric fan to provide a sanitary and homelike environment for the resident.
During an interview with the Director of Nursing (DON) on 1/16/25 at 2 P.M., the DON stated residents' electric fans should be free of dust, cleaned every week and appropriate for use for a home like environment.
A review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated February 2021 was conducted.
The P&P indicated, .The facility staff and management maximizes .the characteristics of the facility that reflect a personalized homelike setting.
These characteristics include .a. clean, sanitary and orderly environment .
055910 01/16/2025
Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942
During a review of a care plan for Resident 67, the care plan revised on 11/30/24 indicated, .ADL maintenance as manifested by .personal hygiene [supervision] with [1-] staff .Interventions .assist to wash face, brush teeth, comb hair, shave, apply lotion, etc .
An interview was conducted on 1/16/25 at 2 P.M. with the Director of Nursing (DON).
The DON stated staff needed to ensure residents' nails were trimmed every Sunday and shaved during shower days.
The DON stated it was important to increase residents' self-esteem with the expectation for residents to be presentable and well-groomed.
A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living [ADL], Supporting, dated March 2018 was conducted.
The P&P indicated, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .
055910 01/16/2025
Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942
2019, the P&P indicated, .Purpose .To guide staff in appropriate and compassionate care specific to
and person-centered .Caregivers are taught strategies to help eliminate, mitigate or sensitively
identify history of trauma or interpersonal violence .Identify past trauma or adverse experiences .
055910 01/16/2025
Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942
anticoagulant (blood thinner) medication for one of three residents (Resident 51) reviewed for
This failure had the potential for unnecessary medication use and had the potential to negatively impact the resident's well-being.
Findings
A review of Resident 51's admission Record indicated Resident 51 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (A-fib, irregular and rapid heartbeat).
On 1/13/25, a review of Resident 51's physician order dated 9/30/23 indicated the following order: - Apixaban (blood thinner medication) for blood thinner.
On 1/15/25 at 11:59 A.M., a concurrent review of Resident 51's clinical record and an interview with Licensed Nurse (LN) 11 was conducted. LN 11 stated there was a physician's order of Apixaban for Resident 51 on 9/30/23 and the indication for its use was for blood thinner. LN 11 stated there should be a clear indication for the use of Apixaban for Resident 51 like A-fib. LN 11 stated the LNs should have verified with the attending physician what was the Apixaban intended for.
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 every medication, there should be the right diagnosis and the right indication.
A review of the facility's policy titled, Administering Medication, revised April 2019, was conducted.
The policy did not indicate verification of indication of the medication.
055910 01/16/2025
Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942
persistent feeling of sadness and loss of interest).
Divalproex Sodium 3 capsules one time a day for feeling happy and upbeat to feeling sad and impulsiveness. - Divalproex Sodium 5 capsules at bedtime for feeling happy and upbeat to feeling sad and impulsiveness. - Monitor behaviors of feeling happy and upbeat to feeling sad and impulsiveness every shift.
On 1/13/25 at 10:12 A.M., an observation of Resident 52 was conducted in her room. Resident 52 laid in bed and did not respond to her name.
On 1/14/25 at 1:49 P.M., a follow up observation and an interview of Resident 52 was conducted in her room. Resident 52 was watching TV, was making incomprehensible sounds and was unable to express herself.
On 1/14/25 at 2:32 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 11. CNA 11 stated Resident 52 was unable to converse, and she talked to the television. CNA 11 stated Resident 52 would pinch, grab, and scratch the staff while staff provided care to Resident 52. CNA 11 stated the Licensed Nurses (LNs) measured the number of behaviors the resident exhibited.
On 1/15/25 at 12:07 P.M., a concurrent review of Resident 52's clinical record and an interview was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 52 barely reacted to people and that Resident 52 easily screams. LN 11 stated Resident 52 was on divalproex sodium and the target behavior for the staff to monitor was for feeling happy and upbeat to feeling sad and impulsiveness.
LN 11 stated she was confused as to what was the specific behavior Resident 52 exhibited. LN 11 stated there should be specific behavior the resident manifested to indicate if the resident still needed the medication.
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 to indicate the target behavior being monitored for the use of psychotropic medications.
The DON stated the target behavior should be measurable and should match what the resident manifested.
The DON stated these were important to identify if the resident still needed the medication.
A review of the facility's policy, titled Psychotropic Medication Use, revised July 2022, indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition 1.
A psychotropic medication is any medication that affects the brain activity associated with mental processes and behavior .2.
Drugs .are considered psychotropic medications and are subject to .monitoring, and review requirements specific to psychotropic medications .
055910 01/16/2025
Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942
serve food in accordance with professional standards.
during food preparation.
As a result, there was a potential the taste of the food was affected.
Findings
On 1/14/25 at 10:53 A.M., a concurrent observation of pureed (liquidized/crushed) food preparation, interview, and recipe review was conducted with [NAME] (CK) 1. A review of the recipe for the lunch menu indicated CK 1 was supposed to add 1/8 teaspoon (tsp) of margarine to the pureed food. CK 1 was observed to have used the ¼ tsp measuring spoon to add the margarine. CK 1 stated she just used less than the ¼ tsp to measure the margarine. CK 1 stated the recipe needed to be followed.
On 1/14/25 at 11:09 A.M., an interview with the Dietary Manager (DM) was conducted.
The DM stated if the staff did not follow the recipe, it can affect the taste of the food.
Per the facility's policy and procedure titled, Standardized Recipes revised April 2007, Policy Statement Standardized recipes shall be .used in the preparation of foods.
055910 01/16/2025
Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942
During a concurrent record review and interview on 1/14/15 at 1:50 P.M. with Licensed Nurse (LN) 1, LN 1 showed the hospice binder for Resident 67. LN 1 showed a December 2024 calendar which indicated signatures on 12/4/24, 12/17/24, 12/18/24 and 12/25/24.
The bottom of the calendar had a handwritten month of January 2025 and signatures for 1/8/25 and 1/9/25. LN 1 stated the signatures indicated the dates hospice staff visited Resident 67. LN 1 stated the calendar only indicated the hospice staff visited once a week or less.
During a phone interview on 1/14/25 at 3:11 P.M. with the Hospice Licensed Nurse (HLN), the HLN stated the hospice binder for Resident 67 had a calendar which outlined the expected days hospice staff were going to visit Resident 67.
The HLN stated a LN and HHA visited Resident 67 twice a week and documented their visits on the hospice electronic medical record (EMR).
The HLN stated for changes in schedule, the hospice staff would communicate to the facility staff and make the change on the calendar.
- During a review of the survey entrance records for hospice agreements, there was no agreement
found for Resident 67's hospice service.
During a concurrent record review and interview on 1/14/15 at 1:50 P.M. with Licensed nurse (LN) 1, LN 1 showed the hospice binder for Resident 67 and there was no hospice agreement in the binder.
An interview with the Director of Nursing (DON) was conducted on 1/16/25 at 2 P.M.
The DON stated it was important to have collaboration of care with hospice services.
The DON stated her expectation was to be in on the same page with hospice, collaborate the plan of care and to provide comfort for the resident.
The DON stated a schedule of visits on a calendar and documentation of care provided to the resident should be completed.
The DON further stated the facility should have an agreement with hospice agreeing to care for the resident, monitor, observe, implement procedures, and follow facility policies.
A review of the facility's policy and procedure (P&P) titled, Hospice Program, dated July 2017 was conducted.
The P&P indicated, .Hospice providers who contract with this facility .must have a written agreement with the facility outlining [in detail] the responsibilities of the facility and the hospice agency .Our facility has designated [this area was blank] .to coordinate care provided to the resident by our facility staff and the hospice staff .He or she is responsible for .Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services .Communicating with hospice representatives and other healthcare providers participating in the provision of care .to ensure quality of care for the residents and family .Obtaining the following information from the hospice .The most recent hospice plan of care specific to each resident .
055910 01/16/2025
Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942
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.
- 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 01/16/2025
Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942
.1.
Enhanced barrier precautions (EBP) are used as an infection prevention and control interventions
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 .
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
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.