Health inspection·June 5, 2023

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 ensure care plans related to urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) and refusal of care were developed for two of nine residents (Resident 3 and Resident 8). This failure had the potential for Resident 3 ' s catheter care and needs, as well as Resident 8 ' s refusal of care, to not be communicated to all healthcare providers which could result in delay in treatment or lack of treatment. Findings: 1. A review of Resident 3 ' s face sheet, (a summary of resident name, birth date, prior address, insurance information, diagnosis, etc.), dated 6/2/23 indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses that included: Paraplegia (the loss of muscle function in the lower half of the body, including both legs) and Urinary Tract Infection. A concurrent interview and record review was conducted with the Director of Nursing (DON) and the Director of Staff Development (DSD) on 6/5/23 at 2:40 P.M. The DON and DSD stated Resident 3 had a urinary catheter but were unable to locate a care plan for Resident 3's urinary catheter care. The DON and DSD stated it was important to develop a care plan related to Resident 3's urinary catheter to ensure care was provided. The facility ' s undated policy and procedure titled Urinary Catheter Care was reviewed with the DON and DSD. The policy indicated, Review the resident ' s care plan to assess for any special needs of the resident . 2. Resident 8 was admitted to the facility on [DATE] with diagnosis including: Multiple Sclerosis (a disabling disease of the brain and spinal cord); Neuromuscular Dysfunction of the Bladder (a lack of bladder control due to brain, spinal cord or nerve problems); Urinary Tract Infection. A record review of Resident 8 ' s physician orders indicated the following orders: · Urinary Suprapubic (SP) catheter (a hollow flexible tube that is inserted into the bladder through an opening in the abdomen that allows urine to drain from the bladder into a collection bag); 16 fr (standard designation of size of catheter), 10 milliliters (ml) balloon (a part of the catheter to keep it in place in the bladder), dated 4/18/23. · May irrigate (flush fluids through) the SP catheter with Sterile Water as needed if clogged, order dated 4/3/23. · Flush (irrigate) the SP catheter with 60 ml of NS (Normal Saline-a medical fluid with many uses, including treating dehydration, cleansing wounds, drops for dry eyes, and contact lens storage) BID (twice daily), dated 5/20/23. · Urology (physician office specializing in the care of problems of the urinary tract) follow up (every) month for SP catheter exchange, dated 4/4/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of Resident 8 ' s nursing notes from 5/28/23 through 6/4/23 indicated, numerous refusals of Resident 8 to have his SP catheter irrigated/flushed twice daily as ordered by the physician. A concurrent interview and record review was conducted with the Director of Nursing (DON) and the Director of Staff Development (DSD) on 6/5/23 at 2:40 P.M. Resident 8 ' s care plan for the SP catheter was reviewed. The DON and the DSD acknowledged that a care plan was not developed related to Resident 8 ' s refusal for catheter care. The DON and the DSD stated it was important to have a care plan developed related to Resident 8 ' s refusal for catheter care to ensure the resident's needs were met. The facility ' s undated policy and procedure titled Urinary Catheter Care was reviewed with the DON and DSD. The policy indicated, Review the resident ' s care plan to assess for any special needs of the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 3 of 3