La Mesa Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to develop and implement individualized, person-centered discharge care plans that reflected each individualized, person-centered discharge for three of five sampled residents (Resident 1, 3 and 4) with the same generic and identical goals and interventions for each resident. These deficient practices placed three residents (Resident 1, 4 and 5) at risk for unmet healthcare needs, poor coordination of care, ineffective discharge planning, interruption in continuity of care, and avoidable health complications after discharge. Cross Reference F627 and F628.

Inspectors wroteBased on interview and record review, the facility failed to prepare a safe and coordinated discharge for one of five sampled residents (Resident 1) by not providing necessary equipment for a continuous tube feeding(TF-way to give liquid food, water, and medicine directly into the stomach or small intestine through a soft plastic tube when a person cannot safely chew or swallow) order and/or necessary teaching to administer a bolus (a way to give liquid food or formula through a feeding tube like a meal, using a large syringe several times a day) feeding as revised due to no feeding pump (machine used to deliver tube feedings). These deficient practices placed Resident 1 at risk for missed needed nutrition, delayed feeding, poor nutritional status, dehydration, re-hospitalization, and complications related to not receiving prescribed TFs after discharge. Cross Reference F628 and F656.

Inspectors wroteBased on interview and record review, the facility failed to coordinate a safe and effective discharge for one for five sampled residents (Resident 1) by ensuring caregivers received education on prescribed tube feeding (TF-way to give liquid food, water, and medicine directly into the stomach or small intestine through a soft plastic tube when a person cannot safely chew or swallow), providing necessary equipment for TF feeding pump (machine used to deliver tube feedings) before discharge, communicating updated physician orders to the receiving Home Health Agency (HHA), and transferring complete clinical information necessary for continuity of care. These deficient practices placed Resident 1 at risk for interruption of prescribed TF feedings, inadequate nutrition, weight loss, dehydration, worsening health status, delayed continuity of care, and avoidable rehospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive person-centered discharge care plan for one of five sampled residents (Resident 2) within the required timeframe following the comprehensive assessment and failed to develop, implement, or revise Resident 2's discharge care plan before discharge. These deficient practices placed Resident 2 at risk for inadequate discharge planning, poor communication among the Intradisciplinary Team (IDT- a group of different experts, such as doctors, therapists, nurses and social workers, who work closely together) and post-discharge providers, interruption of needed services, and avoidable health decline or re-hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan to protect Resident 1 from further claims of lost personal funds when the resident alleged his cash was stolen from his personal locked safe. As a result, Resident 1 was potentially exposed to feeling decreased sense of security.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff adhered to infection prevention and control practices for one of three sampled residents (Resident 2) when:Resident 2's urinary catheter and tubing (a flexible, hollow tube inserted into the bladder to drain and collect urine) was touching the floor and was not placed inside the catheter bag (fabric bag used to conceal urinary collection bag). This failure had the potential for cross-contamination (spread of germs and bacteria) and posed an infection to residents, staff, and visitors.

Inspectors wroteDeficient Practice StatementBased on observation, interview, and record review, the facility failed to ensure staff report an allegation of financial abuse one of two residents (Resident 1) reviewed for abuse. As a result, Resident 1's report of stolen money was not reported to the Department in a timely manner, which delayed the investigation.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to consistently monitor and document urine output (UO) per the facility's policy, for four of six sampled residents (7, 10, 11 and 12) with a urinary catheter (a tube inserted into the bladder to aid in urine flow). In addition, there was no urinary catheter care order for Residents 7, and 12. These failures had the potential for residents 7, 10, 11 and 12 to have urinary retention and develop urinary tract infection (UTI).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations, according to standards of practice when: 1. One outdated container of sour cream was not discarded and still stored for use and consumption. 2. Personal clothing items that belonged to staff were hanging on the food container carts. These failures had the potential to expose residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address resident's needs for one of three sampled residents (Resident 2) when Resident 2's lower denture was not applied during meals. This failure had the potential to affect Resident 2's well-being, comfort, and safety while dining.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the central venous catheter (a tube inserted into a large vein near the heart to allow for long-term access to the bloodstream for medications, fluids, blood draws, and other treatments) was changed and monitored for two of two sampled residents (292 and 297). This failure had the potential for complications related to intravenous (IV - method of delivering fluids, medications, or nutrients directly into the bloodstream through a vein) therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide interventions to prevent the redevelopment of pressure injuries (skin damaged by lack of movement for staying in a position for too long) and accurately assessed residents for skin injury for two of three residents reviewed for pressure injuries (Resident 16 and Resident 20). As a result, Resident 16 redeveloped a pressure injury on her left buttock and Resident 20 developed a new pressure injury on her left buttock.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment related to activity of daily Living (ADL - everyday task) for one of three sampled residents (Resident 59) when Resident 59 used a disposable razor while unsupervised. This failure had the potential to affect Resident 59's safety and well- being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen (O2) was administered per physician's order for one of three sampled residents (Resident 19) reviewed for O2 therapy. This failure had the potential to affect Resident 11's respiratory health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to indicate the appropriate and measurable target behavior of antidepressant (medication used to treat depression, sad mood and lack of interest) for one of five sampled residents reviewed for unnecessary psychotropic (mind-altering medications) medication use (Resident 11). This failure had the potential for unnecessary psychotropic medication use, its side effects, and a decline for residents psychological and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an inhaler was labeled after it was opened and used for one resident (300). This failure had the potential for the resident to receive an ineffective medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper resident cohorting (the grouping of individuals with the same condition in the same location) for one resident (298) when Resident 298 was admitted into a room that was on isolation transmission-based precautions related to Resident 54's exposure to Influenza A (flu-respiratory infectious disease). This failure had the potential for Resident 298 to be exposed to an infectious disease.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents ' (Resident 1) written care plan for activities of daily living (ADL, self-care activities such as moving in bed and toileting) was completed within seven days of the Minimum Data Set Assessment (a comprehensive assessment). As a result, Resident 1 ' s ADL care plan did not match the comprehensive assessment and there was the potential for the resident to receive care that was not individualized to meet her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided in a safe and comfortable manner for one of three residents (Resident 1) when activities of daily living (ADL, self-care activities such as moving in bed) were preformed by one staff instead of two staff as was required on the resident ' s Minimum Data Set Assessment (MDS, a comprehensive assessment). As a result of this deficient practice, Resident 1 experienced discomfort and felt the care provided to her was rough.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control policies were followed when: 1. Oxygen tubing was not changed weekly for three of three residents reviewed for oxygen therapy (17, 52, and 53), 2. A Licensed Nurse (LN) did not perform hand hygiene between glove changes and did not ensure scissors were clean and sanitized before use during a dressing change for one sampled resident (21). These deficient practices had the potential for cross-contamination, and placed the residents, staff, and visitors at risk for facility acquired infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three residents (14, 36, and 47) were assessed for self-administration of medication when medications were left unattended at the bedside. As a result, Residents 14, 36, and 47 were at risk for unsafe medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure Physician's Orders for Life Sustaining Treatment (POLST- an Advanced Directive legal document that indicated a person's wishes about end-of-life treatment) was current for one of 22 residents sampled for Advanced Directives (189). This failure had the potential to provide care contrary to the resident's preferences.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan for two of three residents (36 and 82) reviewed for Low-Air-Loss (LAL- pressure relieving air mattress) when their air matress were not programmed based on resident's weight. As a result, Resident 36's level of comfort and positioning was negatively impacted when the mattress was hard and shortened, and Resident 82 had the potential for skin breakdown to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 % (percent) or greater. Two (2) medication errors out of 28 opportunities were identified during medication (med) administration for three randomly observed residents (78, 79, 139). The medication error rate was 7.14 %. As a result, the facility failed to ensure medications were administered according to the manufacturer's instructions and physician's orders.

Inspectors wroteBased on interview, and record review, the facility failed to treat six of six residents with respect and dignity (Resident 15, Confidential Resident 1, Confidential Resident 2, Confidential Resident 3, Confidential Resident 4, Confidential Resident 5). These failures had the potential to result in psychosocial harm for Resident 15 and Confidential Residents 1, 2, 3, 4, and 5.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 3 out of 3 residents were clinically appropriate for self-administration of medications. This deficient practice put Residents 22, 54 and 74 at risk for unsafe medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate and support the residents right for self-determination for one of 18 residents reviewed for choices (175). The facility failed to promote Resident 175's right to choose their pain medication.

Inspectors wroteBased on observation, interview and record review, the facility did not provide a clean, comfortable and homelike environment when a resident bathroom sink was clogged. This deficient practice created unsanitary conditions for 5 residents (17, 34, 58, 65, 68) who used the sink.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of the facility's bed hold policy (a policy of reserving a resident's bed while a resident was out of the facility for hospitalization or therapeutic leave) prior to, or within 24 hours of the resident's transfer to the acute hospital for one of three residents (276) reviewed for bed hold notices. This failure resulted in the potential for Resident 276 and/or the resident's responsible party to be unaware of their right to reserve a bed in the facility during the resident's first seven days of being admitted to the acute hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure the MDS assessment section for nutrition was accurately coded for one of four tube fed residents (Resident 38) reviewed for tube feeding. This failure had the potential to affect the nutritional plan of care and ultimately the overall quality of life for Resident 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure written care plans were developed timely or consistently implemented for two of 18 residents (22 and 47) reviewed for care plans. These failures had the potential to put residents at risk by not providing appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff completely and thoroughly assessed pressure injuries (localized damage to the skin and/or underlying tissue that occurs over a bony prominence as a result of prolonged pressure) according to professional standards for one of two residents (275) reviewed for pressure injuries. In addition, Resident 275 was not provided a low air loss mattress (LAL, uses alternating pressure to prevent and treat pressure injuries). These failures had the potential for Resident 275's pressure injuries to be misidentified and mistreated, and for wounds to deteriorate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a medical device (hand roll) for one of three residents (Resident 5) reviewed for limited range of motion. This failure had the potential to result in Resident 5 to have further decreased range of motion (ROM) in her left contracted hand.

Inspectors wroteBased on observation, interview, and record review, the facility did not supervise a resident (47) while smoking cigarettes. This failure put all residents at risk for potential fires and burns due to Resident 47's unsupervised smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and manage pain for one of three residents reviewed for pain management (Resident 56). This failure resulted in Resident 56 not receiving prescribed medication for pain.

Inspectors wroteBased on observation and interview the facility failed to ensure one of four carts containing medications was not left unattended or unlocked when reviewed for drug storage. In addition, medications were kept at the bedside for one resident (74). As a result, the medications were not safely stored and were easily accessible to residents, staff, and visitors.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure Dietary Services department staff effectively performed kitchen tasks safely, competently, and in a sanitary manner when: 1. A staff member was unable to accurately describe the correct method for thermometer calibration. 2. A staff member incorrectly washed produce in a 3-compartment sink used for washing, rinsing and sanitizing dishware. 3. A staff member was unable to verbalize and demonstrate the correct techniques related to testing sanitizer solution in the red buckets. These practices had the potential for residents to be exposed to food borne illness due to unsanitary practices related to lack of knowledge of kitchen tasks demonstrated by staff.

Inspectors wroteBased on observation, interviews and document review, the facility failed to ensure menus were followed to meet the needs of four of four residents on renal therapeutic diets. This failure negatively affected resident's nutritional needs and had the potential to further compromise their health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an appropriate alternative meal option of similar nutritive value was provided to one resident (17). This failure had the potential to affect this resident's meal intake and ultimately nutritional and health status.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure safe and sanitary conditions were met in the kitchen when: 1. A serving scoop for mashed potato flakes had hard, brown dried crusted substances on it. 2. A microwave, used to reheat resident food, was not maintained in a sanitary manner. 3. An ice machine, providing ice to residents, was not maintained in a sanitary manner. 4. Expired cheese sticks were found in a reach-in refrigerator. 5. Dirty and wet utensils were stored in a drawer, with a broken handle, containing crumbs and black grime. 6. Several utensils with burned and broken handles were used to prepare residents meal trays on the tray line. 7. Dirty light fixtures were above the food production and meal tray line areas. 8. A dirty floor area had trash, black and brown grime, and other particles under the dish sink area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's QAA committee failed to identify, develop, and implement action plans related to Resident 47's unsupervised cigarette smoking and facility's staff awareness of ongoing non-compliance with the facility's non-smoking policy. (see F689)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pest control recommendations and concerns were addressed. This failure had the potential to contaminate food stored in the kitchen and dining areas which could lead to widespread foodborne illness. The facility census was 81.