Health inspection·December 2, 2021

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few As a result, Residents 14, 36, and 47 were at risk for unsafe medication administration. Findings: 1. Resident 14 was re-admitted to the facility on [DATE] with diagnoses which included rheumatoid arthritis and osteoarthritis (joint inflammation), per the facility's Resident Face Sheet. On 11/29/21 at 10:07 A.M., an observation and interview was conducted with Resident 14. Resident 14 was on the bed with the bedside table in front of her. On top of the bedside table, there were two medicine cups which contained an opaque white cream. There was no staff observed in the room. Resident 14 stated the licensed nurse (LN) left the creams so she can apply it any time. Resident 14 further stated she applied the cream to her hands, elbows and knees where it hurts. A review of Resident 14's medical record was conducted. There was no record of assessment for Resident 14 to self-administer medication, or had a physician's order for self-administration of medications. The Physician Order, dated 11/1/21 through 11/30/21 indicated, apply Diclofenac Sodium gel (an NSAIDs [nonsteroidal anti-inflammatory drugs] - used to relieve osteoarthritis pain in the knees) two grams twice a day to left and right knee. 2. Resident 47 was admitted to the facility on [DATE] with diagnoses which included diabetes (abnormal blood sugar level), per the facility's Resident Face Sheet. On 11/29/21 at 10:04 A.M., an observation and interview was conducted with Resident 47. Resident 47 was on the bed with the bedside table in front of her. On top of the bedside table was a medicine cup containing a round pink pill. Resident 47 stated she did not know what the pill was and unable to identify the staff who left the medication on the table. Resident 47 further stated she had a problem with her vision and unable to see everything on the table. No staff were observed in the room. A review of Resident 47's medical record was conducted. There was no record of assessment for Resident 47 to self-administer medication, or had a Page 1 of 13 055488 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0554 physician's order for self-administration of medications. Level of Harm - Minimal harm or potential for actual harm 3. Resident 36 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), per the facility's Resident Face Sheet. Residents Affected - Few On 11/29/21 at 12:01 P.M., an observation and interview was conducted with Resident 36. Resident 36 was on the bed with the bedside table to the left side of his bed. On top of the bedside table was a medicine cup containing seven and a half pills. Next to the pills were two bottles labeled with multivitamin and fish oil. Resident 36 stated the two bottles were supplements provided to him by a family member months ago, and was unaware that there was a medicine cup containing medications next to the bottles. Resident 36 was unable to identify the staff who left the medication on the table and no staff were observed in the room. A review of Resident 36's medical record was conducted. There was no record of assessment for Resident 36 to self-administer medication or had a physician's order for self-administration of medications. On 11/29/21 at 4:20 P.M., an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated no residents in the facility had assessment for self-administration, therefore medications should not be left unattended at the bedside. On 11/30/21 at 3:30 P.M., an interview was conducted with LN 1. LN 1 stated he administered medications to Resident 14, 36, and 47 yesterday morning (11/28/21). LN 1 further Resident 14, 36, and 47 do not have assessment or physician's order for self-administration. LN 1 stated the process when administering medication was to ensure resident consume the pills before leaving the room, and not to leave the medication unattended. LN 1 stated he left the medications for Resident 14 and 47 and should not have left the medications unattended. LN 1 stated the pills on Resident 36's table were medications from the evening shift. LN 1 further stated the medications should have been disposed. On 12/1/21 at 10:28 A.M., an interview and joint record review was conducted with the Director of Nursing (DON). The DON stated her expectation was for the LNs to give the medications to the residents, and to ensure the medications were swallowed or for the LNs to apply the topical creams/gel to resident's skin. The DON further stated the medications should have not been left unattended. Resident 14, 36 and 47 did not have a self-administration assessment and physician's order for self-administrations. On 12/1/21 at 1:47 P.M., an interview was conducted with LN 2. LN 2 stated he gave the medication to Resident 36 the evening of 11/28/21. LN 2 stated Resident 36 asked him to leave the medications on the table. LN 2 further stated he forgot to return to Resident 36's room to check if Resident 36 had consumed the medications. LN 2 stated he should have not left the medications unattended because Resident 36 could had choked on pills. Per the facility's policy and procedure, revised 4/19, titled Medication Administration, .Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Medications will not be left unattended unless resident has been determined as capable 055488 Page 2 of 13 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0554 to self-administer medication safely . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055488 Page 3 of 13 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: On [DATE] at 1:29 P.M., Resident 189's health record was reviewed. Resident 189 was admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease (a brain disorder that affects movement) according to the Resident Face Sheet. An assessment conducted on [DATE] indicated Resident 189 had the ability to communicate needs and understood others. The Brief Interview for Mental Status (BIMS-a screening test used to assess cognitive function) indicated mild cognitive impairment. Resident 189 required limited assistance from staff with most activities of daily living, and extensive assist with ambulation and transfers. The physician's order report dated, [DATE] - [DATE] indicated, Resident 189 was a Full Code, and should be provided all life-saving measures including cardiopulmonary resuscitation (CPR) to restore heartbeat and breathing. The POLST, created on [DATE], signed and dated by the physician on [DATE], indicated, Resident 189 wanted comfort measures only, allowing natural death. The code status on Resident 189's face sheet continued to be listed as Full Code. On [DATE] at 1:40 P.M., a concurrent interview and record review of Resident 189's health record (HR) was conducted with Licensed Nurse (LN) 3. LN 3 stated the full code status listed in the HR did not match with the Do Not Resuscitate (DNR) status directed by the POLST. LN 3 stated the code status should match on all documents. LN 3 further stated if orders do not match, there would be an issue if the resident became unresponsive, because staff or emergency personnel would not know which order to follow. On [DATE] at 9:31 A.M., Resident 189's Responsible Party (RP) was interviewed via telephone. The RP stated Resident 189's preferred end-of-life treatment was for comfort measures only. On [DATE] at 1:45 P.M., the Director of Nursing (DON) was interviewed. The DON stated when Resident 189 was admitted , the POLST had not been signed by the physician. Resident 189 was considered a full code. Once the signed POLST was received by medical records, it should have been given to the LN to transcribe the order, and to update Resident 189's health record to reflect the change to DNR. On [DATE] at 2:43 P.M., the MRD was interviewed. The MRD stated Resident 189's signed POLST was filed directly in the resident's chart because it was received [via fax] late in the day. The MRD stated it should have been given to the nurse because it was a doctor's order. 055488 Page 4 of 13 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0578 According to the facility's policy, Advance Directives, revised 12/16, . 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055488 Page 5 of 13 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: 1. Resident 36 was admitted to the facility on [DATE] with diagnoses that included infection and inflammatory reaction due to internal fixation device of spine, per the facility's Resident Face Sheet. On 11/29/21 at 12:01 P.M., an observation and interview was conducted with Resident 36. Resident 36 was laying in bed on a LAL mattress with the head of the bed slightly elevated. Resident 36's was under a blanket with a silhouette of his heels together and knees bent outward. Resident 36 stated he was six feet and four inches tall, and his bed was too short. Resident stated he could not straighten his legs or they would hang over the foot board. Resident also stated the staff can not lift him higher in the bed or else his head would be off the mattress. Resident 36 described his bed as hard and uncomfortable. Resident 36 further stated he had mentioned his concern to the staff but no one addressed his concerns. Upon further observation, Resident 36's LAL mattress had eight air pressure settings based on weight, less than 250, 300, 350, 400, 450, 500, 550, and [PHONE NUMBER] pounds. All the indicators in the panel were illuminated in green which meant the mattress was inflated for a resident that weighed more than 600 pounds. Per the Vitals Report, dated 7/5/21 through 12/1/21. Resident 36's latest weight was 297 pounds, and six feet five inches tall. A review of Resident 36's medical record was conducted. The Physician Order Report, dated 9/2/21 indicated an order for a LAL mattress. Per the Care Plan History, dated 7/5/21, under approach, .pressure relieving device for bed as indicated . On 11/30/21 at 9:30 A.M., an observation and interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the mattress was set to 600 pounds and Resident 36 was not that heavy. CNA 1 further stated only the licensed nurses can adjust the mattress setting. On 11/30/21 at 3:30 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated the LAL mattress should have been programmed to Resident 36's weight. LN 1 stated he had not checked if Resident 36's LAL setting was correct and had not noticed that the bed was too small. 055488 Page 6 of 13 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0656 Level of Harm - Minimal harm or potential for actual harm On 12/01/21 at 10:28 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectation was for the LNs to ensure that the LAL mattress should have been on the correct setting according to the resident's weight every shift. The DON further stated it was important for the setting to be correct for resident's comfort. In addition, the DON stated with the correct setting, the mattress surface area would be evenly distributed and Resident 36 was able to fit on the mattress. Residents Affected - Few Per the (Device's) Manufacturers Guidelines, dated 2016, .(devices) are designed and constructed to reduce the incidence of pressure ulcers while optimizing patient comfort The WEIGHT SETTING Button (+) and (-) can be used to adjust the pressure of the inflated cells based on the patient's weight . 2. Resident 82 was admitted to the facility on [DATE] with diagnoses which included right femur fracture (broken bone), per facility's Resident Face Sheet. A review of Resident 82's MDS (minimum data set- an assessment tool) indicated, Resident 82 had a BIMS (Brief Interview for Mental Status- cognitive assessment) score of 7 which indicated severe cognitive impairment. Section G (functional status), indicated Resident 82 was totally dependent on staff for activities of daily living. On 11/29/21 at 8:40 A.M., Resident 82 was observed laying on a LAL mattress. The LAL relieving mattress was set for the body weight of 375 to 450 lbs. (pounds). On 11/29/21 at 8:45 A.M., a concurrent observation and interview with CNA (Certified Nursing Assistant) 6 was conducted. CNA 6 confirmed Resident 82's LAL relieving mattress was set for the body weight of 375 to 450 lbs. CNA 6 stated the LAL relieving mattress should have been set according to the resident's weight. On 12/1/21 at 7:40 A.M., a second observation was conducted. Resident 82 was observed laying on a LAL relieving mattress. The LAL relieving mattress was set for the body weight of 375 to 450 lbs. A record review of the Resident 82's weight dated 11/27/21 indicated, Resident 82 was 147 lbs. According to the Skin Care Plan, dated 11/5/21, Pressure Relieving Devices on Chair & Bed As Indicated. On 12/1/21 at 7:52 A.M., a concurrent observation and interview with the DSD (Director of Staff Development) was conducted. The DSD confirmed Resident 82's LAL relieving mattress was set for the body weight of 375 to 450 lbs. The DSD stated the LAL relieving mattress should have been set according to the resident's weight to prevent further skin breakdown and to promote healing on the existing wound. The DSD proceeded to change the setting of the LAL relieving mattress to 85 - 150 lbs. On 12/1/21 at 1 P.M., an interview with the DON was conducted. The DON stated the importance of adjusting the settings of the LAL relieving mattress according to the Resident's weight was to help reduce pressure, provide comfort, maintain the integrity of the skin, and prevention of pressure ulcer from worsening. The DON stated nurses were expected to check the settings frequently and adjust the settings of the LAL relieving mattress according to resident's weight. On 12/2/21 at 10 A.M., an interview with Resident 82 was conducted. Resident 82 stated, My bed is more comfortable since yesterday, it is softer, and I was able to sleep more. A review of the (Device) Operation Manual, version 3 dated 6/09, introduction, general 055488 Page 7 of 13 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0656 .specifically designed for prevention of bedsores . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055488 Page 8 of 13 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based 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 %. Residents Affected - Few As a result, the facility failed to ensure medications were administered according to the manufacturer's instructions and physician's orders. Findings: 1a. On 11/30/21 at 8:00 A.M., a medication pass observation was conducted. Licensed Nurse (LN) 6 prepared ten oral medications and inhalers for Resident 139 for administration which included: 1. Amlodepine 2.5mg (milligram), 1 tablet 2. Austedo 12mg, 1 tablet 3. Divalproex 500mg, 1 tablet 4. Metformin ER 500mg, 1 tablet 5. Naproxen 500 mg, 1 tablet 6. Quetiapine Fumarate 200 mg, 1 tablet 7. Ropinirole 2mg, 1 tablet 8. Senna plus 8.5mg/50mg 2 capsules 9. Symbicort 4.5 mcg (microgram)/puff, 2 puffs 10. Combivent Respimat 20-100 mcg/actuation, 1 puff LN 6 put the tablets and capsules on separate medication cups and handed each cup to Resident 139 for oral intake with sips of water in-between. LN 6 handed the Symbicort 4.5 mcg/puff without shaking the cartridge to Resident 139 for oral inhalation. A visual inspection of the Symbicort 4.5 mcg/puff cartridge label indicated the cartridge should be shaken before inhalation. 1b. On 11/30/21 at 8:30 A.M., a medication pass observation was conducted for Resident 78. Licensed Nurse (LN) 6 prepared 11 medications for Resident 78 for oral administration and topical solution application which included: 055488 Page 9 of 13 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0759 1. Calcium citrate with vitamin D 500mg, 1/2 tablet Level of Harm - Minimal harm or potential for actual harm 2. Cyclobenzapine 5mg, 1 tablet 3. Flucticasone 50 mcg, 2 spray Residents Affected - Few 4. Folic acid, 1tablet 5. Gabapentine 100mg, capsule 6. Lactulose 10mg/15ml (milliliters), 15ml 7. Miralax 1 cup, dissolve 4-8 ounces water 8. Multivitamin with minerals 1 tablet 9. prednisone 5mg, 1 tablet 10. Senna ,2 capsules 11. Diclofenac topical solution 2 gms., applied to a paper administration scale. LN 6 put the tablets, capsules, liquids on separate medication cups and handed each cup to Resident 78 for oral intake with sips of water in-between. LN 6 applied the Diclofenac topical solution on the right knee. A review of the physician's orders on Diclofenac topical solution for arthritis pain was conducted. The physician's orders indicated special instructions to apply the solution on bilateral (both) lower legs. On 11/30/21 at 9:21 A.M., an interview with LN 6 was conducted. LN 6 stated Symbicort was supposed to be shaken before giving the cartridge to Resident 139 for inhalation. LN 6 stated the importance of shaking the cartridge was to disperse the medication evenly when inhaled. In addition, LN 6 stated the topical solution should have been applied to Resident 78's both lower legs as per physician's special instructions. LN 6 stated the importance of following the physician's special instructions was to meet the needs of the resident. On 12/1/21 at 9:35 A.M., an interview with the DON (Director of Nursing) was conducted. The DON stated the importance of shaking the Symbicort inhaler was to disperse equal amount of medication on aerosol to the resident. The DON further stated the importance of administering a medication according to the physician's orders/instruction was to benefit and address the resident's needs. The DON stated nursing staff were expected to verify the physician's orders/instructions and labels before administering a medication. A review of the facility's Administering Medication policy, revised 4/19 was conducted. The policy indicated, . 3. Medications are administered in accordance with prescriber orders . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the 055488 Page 10 of 13 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0759 medication . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055488 Page 11 of 13 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control policies were followed when: Residents Affected - Some 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. Findings: 1a. On 11/29/21 at 10:42 A.M., an observation was conducted with Resident 53. Resident 53 was on the bed and actively receiving oxygen therapy. Resident 53 had nasal cannula placed in her nostrils and the oxygen tubing had a label dated, 11/15/21. In addition, the oxygen tubing was attached to the empty humidifier bottle. 1b. On 11/29/21 at 10:54 A.M., an observation of Resident 17 was conducted. Resident 17 was sitting on the wheelchair. The oxygen concentrator was located by the corner of Resident 17's room with cloudy (not clear) oxygen tubing and had a label dated 11/15/21. 1c. On 11/29/21 at 12:16 P.M., an observation was conducted with the Resident 52. Resident 52 was on the bed and actively receiving oxygen therapy. Resident 52 had nasal cannula placed in her nostrils, the oxygen tubing was cloudy, and had a label dated, 11/15/21. In addition, the oxygen tubing was attached to the empty humidifier bottle. On 11/30/21 at 2:06 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated the oxygen tubing was scheduled to be changed weekly and dated by the night shift nurse. LN 1 stated he had not noticed that the oxygen tubings were not changed. On 11/30/21 at 3:30 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the oxygen tubing should have been change every week on Sunday by the night shift. The DSD further stated the LNs should be checking resident's oxygen therapy every shift and change the oxygen tubing when due or soiled, and replaced the humidifier when it was empty. The DSD stated Resident 17, 52 and 53's oxygen tubing should have been changed on 11/22/21 and 11/29/21 for infection control purposes. On 12/1/21 at 10:28 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectation was for the LNs to change the oxygen tubing and the humidifier every seven days or as needed. Per the facility's policy and procedure, revised 2/18, titled Oxygen Administration, .Change and date the oxygen tubing every seven days and as needed .Be sure there is water in the humidifying bottle .the water level is high enough that the water bubbles as oxygen flows through .Observe the 055488 Page 12 of 13 055488 12/02/2021 LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941

F 0880 resident upon setup and periodically thereafter .Humidifier bottle changed every seven days . Level of Harm - Minimal harm or potential for actual harm 2. On 12/1/21, Resident 21's health record was reviewed. Resident 21 was admitted to the facility on [DATE] with diagnoses to include surgical aftercare following lumbar laminectomy (surgery on the lower spine). A skin assessment upon admission indicated Resident 21's surgical incision had dehisced (surgical complication where the edges of the incision separate), requiring treatment of the open wound. Residents Affected - Some On 11/30/21 at 10:50 A.M., a concurrent observation of Resident 21's wound care and dressing change was conducted with LN 4. With gloved hands, LN 4 proceeded to set up the workspace, and placed a protective towel on Resident 21's bed. LN 4 removed unpackaged, purple-handled bandage scissors from the front scrub pocket and placed them on the towel. After removing and discarding the old dressing, LN 4 doffed (removed) the gloves and put on new gloves. After cleansing the wound, LN 4 used the scissors that had been placed on the bed to cut a specialized dressing into a strip to pack into the wound. LN 4 covered the wound with a clean dressing. On 11/30/21 at 1:20 P.M., the Infection Control Nurse (IPN) was interviewed. The IPN stated hand hygiene should be performed using soap and water or hand gel before and after glove use, and between glove changes. On 11/30/21 at 2:30 P.M. LN 4 was interviewed. LN 4 stated I did not perform hand hygiene between the glove change after I removed the old dressing. LN 4 stated the facility's policy was to perform hand hygiene before and after donning (putting on) and doffing gloves. LN 4 also stated the scissors used [to cut the wound packing] were not cleaned at the bedside prior to use, and was unable to prove when the scissors had last been cleaned. On 12/1/21 at 1:45 P.M., the DON was interviewed. The DON stated the expectation was for staff to perform hand hygiene before donning and after doffing gloves, and between glove changes. The DON stated any equipment or supplies used to perform dressing changes should be cleaned prior to use. The DON further stated they were unable to determine the cleanliness of the scissors because they were unpackaged when removed from the LN's pocket and were not cleaned at the bedside before being used to cut the dressing packing. According to the facility's policy, Handwashing/Hand Hygiene, revised 8/15, . 7. Use an alcohol-based hand rub . or, alternatively soap . and water for the following situations: . m. After removing gloves. According to the facility's policy, Wound Care, revised 10/10, . 4. Put on gloves. remove dressing. 5. Pull glove over dressing and discard Wash and dry your hands thoroughly. 6. Put on gloves. 055488 Page 13 of 13