Kearny Mesa Convalescent and Nursing Home

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one of two residents reviewed for falls (Resident 1). As a result, Resident 1 was left unsupervised, fell and sustained a hip fracture.

Inspectors wroteBased on interview and record review, the facility failed to accurately code a resident's fall on the Minimum Data Set (MDS - a federally mandated resident assessment tool) for one of five sampled residents (Resident 2). This deficient practice placed all fall risk residents at risk for inaccurate plan of care triggers necessary for individualized safety precautions, quality measure (QM-grades clinical outcomes and physical well-being provided by the facility) calculations and reimbursement adjustments being reported to CMS.

Inspectors wroteBased on interview and record review, the facility failed to ensure a medication was administered as ordered, and to ensure unattended medications were not accessible to residents for one of five sampled residents (1). As a result, Resident 1 had an increased risk of pain from the missed medication, and residents were at risk of accidental ingestion or exposure to unattended medications left on the floor.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the comprehensive care plan was revised to accurately reflect the information in the comprehensive assessment, which affected 1 (Resident #61) of 4 residents reviewed for advance directives. Specifically, the facility failed to revise Resident #61's care plan to reflect the resident's code status listed in the comprehensive assessment.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to obtain orders for the use of a non-invasive mechanical ventilator (specifically, continuous positive airway pressure; CPAP) timely, which affected 1 (Resident #184) of 3 residents reviewed for respiratory care .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment (specifically, continuous positive airway pressure; CPAP equipment) was stored appropriately, which affected 1 (Resident #184) of 3 residents reviewed for respiratory care .

Inspectors wroteBased on observation, interview and record review, the facility failed to perform abdominal assessment and verify Resident 1 ' s appointment prior to sending to Interventional Radiology (IR) clinic. As a result , Resident 1 was left outside of the clinic in a cold weather close to an hour and not needed to be seen at the clinic.

Inspectors wroteBased on interview and record review the facility failed to provide supervision for one of two residents (Resident 1) when Resident 2's wandering (moving from place to place) behavior was not identified which resulted to an altercation with Resident 1. This failure had the potential for Resident 1's safety and wellbeing.

Inspectors wroteBased on interview, and record review, the facility failed to develop a care plan for one of one resident (173) on dialysis (a process of cleaning blood) with fluid restriction. As a result Resident 173 had the potential for fluid overload.

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff followed a physician's orders for one of one resident (Resident 173) on dialysis (a process of cleaning blood) when: 1. The staff did not follow the fluid restriction order 2. The staff took blood pressure measurement on the resident's vascular access arm As a result, 1. Resident 173 was given more fluids than what was ordered 2. There was a potential for vascular access complication

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a pressure relieving mattress was set up according to the physician's order for one of five sampled residents (320) with pressure ulcers (areas of damaged skin caused by staying in one position for too long). This failure had the potential to cause Resident 320's pressure ulcer to deteriorate.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise fall specific preventative measures for one of one resident (Resident 61), after a fall. As a result, Resident 61 suffered another fall six days later after the initial fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff provided the services required for the care of one of one resident (Resident 173) on dialysis (a process of cleaning blood) when: 1. The staff did not remove the dressing on the dialysis vascular access per the dialysis center recommendation 2. The staff did not accurately identify the dialysis access' bruit (sound of blood flow) and thrill (vibrations of blood flow) As a result, there was a potential a dialysis access complication would not be identified.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff followed the physician's order for one of three sampled residents (20) for pain medication. This failure had the potential for Resident 20's pain to be unrelieved.

Inspectors wroteBased on observation, interview and record review, the facility failed to decrease the transmission of COVID-19 to residents when: 1. the facility's staff vaccination policy was not in accordance with federal regulation 2. an unvaccinated staff member did not wear the required protective facial covering. These failures had the potential to contribute to the transmission and spread of COVID-19 to residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents in a dignified manner when: 1. Staff did not answer call bells in a timely manner for 2 of 19 sampled residents (20, 21), 2. Staff did not knock prior to entering a residents' room and bathroom for one of 19 sampled residents (Confidential Resident 5), and; 3. A resident (34) waited 55 minutes before receiving pain medication. These failures resulted in Resident 20 having accidents, Resident 21 feeling unimportant, Confidential Resident 5 feeling embarassed and Resident 34 feeling neglected because her pain was not managed in a timely manner

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff followed the dietary cards during a meal observation for two of seven randomly observed residents (47, 49). This failure had the potential to cause aspiration (breathing foreign objects into the airways, such as food or liquids) for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's code status was formulated for 1 of 19 sampled residents (30). This failure had the potential to administer the incorrect care or treatment to Resident 30 during an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a nurse followed a physician's order when a Lidocaine (a medication that relieves pain and numbness) patch was not removed for one of four residents (219) observed during medication pass. This failure had the potential for the resident to be over medicated.

Inspectors wroteBased on observation, interview and record review, the facility failed to respond to the pharmacist's monthly MRR for one of five residents reviewed for unnecessary medications (10). This deficient practice had the potential to cause adverse consequences related to medication therapy.

Inspectors wroteThe facility failed to ensure a licensed nurse dated a multi-dose vial of Aplisol (a solution used to test for tuberculosis- a lung disease) when opening it. As a result, staff would not know when the Aplisol would be expired.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received specialized rehabilitative services as determined by the occupational therapy's comprehensive plan of care for 1 of 19 sampled residents (21). As a result, Resident 21 did not meet his goal of walking with a prosthetic leg.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure visitors followed the proper procedures when visiting a resident on contact precautions (a set of procedures to minimize the transmission of infectious organisms by direct or indirect physical contact with an infected resident) for 1 of 1 residents on transmission based precautions (29). In addition, the facility failed to ensure staff performed hand hygiene when assisting residents in the dining room. These failures had the potential to spread infection to other residents.