Health inspection·September 20, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm 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** 2. This failure had the potential to result in further decline in hand contractures for Resident 10. Residents Affected - Few Findings: Resident 10 was admitted to the facility on [DATE] with diagnoses which included contracture (shortening and hardening of muscles and tendons, often leading to deformity and limited movement in the hand) and poliomyelitis (disease that causes temporary or permanent paralysis; inability to move parts of the body), per the facility's admission Record. Resident 10's record was reviewed. Resident 10 did not have the capacity to understand and make decisions, per the history and physical examination dated 7/5/19. Observations were conducted on: 9/17/19 at 9:20 A.M. and 4:55 P.M., 9/18/19 at 6:50 A.M., 9/19/19 at 8:17 A.M., and 4:48 P.M. Resident 10 was lying in bed. Resident 10 did not have a therapeutic hand carrot in either of her hands. A review of Resident 10's record was reviewed. Per the care plan titled, Risk for spontaneous/pathological fracture (bone breaks in an area that was already weakened by another disease or condition), revised 5/1/19 was conducted. This record included an intervention to Apply carrot finger orthosis to bilateral (both) hand at all times . A record review of Resident 10's record was conducted. Per Resident 10's care plan titled, ADL (activities of daily living) maintenance was revised on 6/13/19. This record included an intervention for .carrot finger orthosis to LT (left) and RT (right) hand at all times may remove for hygiene . A concurrent observation and interview was conducted on 9/19/19 at 5:12 P.M. with LN 3. Resident 10 was lying in bed. Resident 10's right hand was closed in a fist. Resident 10's fingers on her left hand were partially bent and closed. Resident 10 was not holding therapeutic hand carrots. LN 3 stated Resident 10's hands were contracted and she needed to check her record to find out if she used anything for the contractures. Page 1 of 8 055910 055910 09/20/2019 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A concurrent interview and record review of Resident 10's care plans were conducted with LN 1 on 9/19/19 at 5:20 P.M. LN 1 stated the care plan listed the use of hand carrots for Resident 10 as a nursing intervention. An interview was conducted on 9/20/19 at 7:32 A.M. with LN 1. LN 1 stated the hand carrots were supposed to be on Resident 10's hands at all times. An interview was conducted on 9/20/19 at 1:42 P.M. with CNA 2. CNA 2 stated she was familiar with Resident 10's care. CNA 2 stated .sometimes staff might forget to put them (referring to the therapeutic hand carrots) on .but we are all responsible to make sure they're on . An interview was conducted on 9/20/19 at 1:53 P.M. with the DON. The DON acknowledged the hand carrots for Resident 10 should have been on at all times as indicated in Resident 10's nursing care plans. The facility's policy, titled Care Plans - Comprehensive, revised 10/10, indicated, .care plan for each resident .identifies the highest level of functioning .expected to attain .3. Each resident's .care plan is designed to .g. Aid in preventing or reducing declines in .functional status .h. Enhance the optimal functioning .by focusing on a rehabilitative program . The facility's undated policy titled, Rehabilitative Nursing Care, indicated, .1. General rehabilitative nursing care is that which does not require the use of a qualified Professional Therapist to render such care .Our facility has an active program .developed and coordinated through the resident's care plan .care is performed daily .includes .Maintaining good body alignment and proper positioning . Assisting .to use .devices .5. Through the resident care plan .the goals of rehabilitative nursing care are reinforced . Based on observation, interview, and record review, the facility failed to develop and implement care plans for two of 25 sampled residents (54,10). 1. As a result Resident 54's interventions and goals for self administration of medications was not identified or addressed Findings: Resident 54's facility's admission Record was reviewed. Resident 54 was admitted on [DATE]. On 9/17/19 at 8:50 A.M., Resident 54's room located on station 4 was observed. Menthol ointment and antacid medication was observed on Resident 54's bedside table. On 9/17/19 at 8:55 A.M., Resident 54 was interviewed. Resident 54 stated she applied the menthol ointment to her legs and she took the antacid when needed. Resident 54 stated the medication was kept on top of her bedside table. On 9/17/19 at 9:16 A.M., an interview was conducted with LN 20. LN 20 stated she administered medications to all the residents in station 4. LN 20 stated she was not aware of any resident on station 4 who were allowed to self-administer medications. On 9/17/19 at 11:25 A.M., an interview with Resident 54 was conducted. Resident 54 stated she was 055910 Page 2 of 8 055910 09/20/2019 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unsure if she needed to place the menthol ointment in her locked bedside table drawer. Resident 54 stated she remembered staff telling her to lock up the ointment. Resident 54 then locked up the menthol ointment and left the bottle of antacids on top of her bedside table. On 9/17/19 at 12:13 P.M., an observation of Resident 54's bedside table was conducted. A bottle of antacids was on top of Resident 54's bedside table. Resident 54 asked CNA 20 if her bottle of antacids should be locked in her bedside table drawer. On 9/17/19 At 12:20 P.M., an observation between Resident 54 and LN 21 (medication nurse) was conducted. Resident 54 asked LN 21 if it was wrong for her antacid medication to be on top of her bedside table and not locked. LN 21 reminded Resident 54 that she had encouraged her in the past to not leave her medication out and not locked. On 9/17/19 at 12:25 P.M., LN 21 was interviewed. LN 21 stated the facility had put a lock on Resident 54's bedside drawer to ensure Resident 54 would put all her medications into the locked drawer. LN 21 stated Resident 54 ordered a lot of things from the internet and she was unsure what medications were in Resident 54's bedside table. LN 21 stated nurses did not inventory Resident 54's beside table medication and the LN's did not monitor Resident 54's bedside table medications. On 9/19/19 at 10:30 A.M., an interview and record review with the ADON was conducted. The ADON stated Resident 54's menthol ointment and antacids should have been locked up at all times and the LN's should have developed a care plan for Resident 54 to self-administer medications. 055910 Page 3 of 8 055910 09/20/2019 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 39 was re-admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (a problem with your body that causes blood glucose (sugar) levels to rise higher than normal), Diabetic Neuropathy (nerve damage that is caused by diabetes). and Peripheral Vascular Disease (a disease that causes restricted blood flow to the arms, legs, or other body parts), per the facility's admission Record. Residents Affected - Few Observations of Resident 39 were conducted: On 9/17/19 at 9:26 A.M. On 9/18/19 at 7:19 A.M. On 9/19/19 at 8:30 A.M. On 9/20/19 at 7:25 A.M. Resident 39 was lying in bed without her Z-flex boots on both feet. Observations of Resident 39 sitting in her wheelchair with one z-flex boot on her left foot and none on her right foot. On 9/18/19 at 11:40 A.M On 9/19/19 at 11A.M. On 9/19/19 at 11:30 A.M. an interview and record review were conducted with LN 1. LN 1 stated per the physician's order of 2/6/19, Resident 39 should had had z -flex boots to bilateral foot at all times. LN 1 stated the Care Plan indicated to apply bilateral z-boots at all times. On 9/20/19 at 7:35 A.M. an interview was conducted with CNA 1. CNA 1 stated Resident 39 should have had boots on at all times. CNA 1 stated when Resident 39 was assigned to her, it was her responsibility to apply Resident 39's boots. On 9/20/19 at 10 A.M., an interview was conducted with the DON. The DON stated it was her expectation that all physician orders be followed as written. The DON stated in Resident 39's case it was important to apply the z-flex boots to prevent further skin breakdown. A review of the facility's undated policy, titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, indicated Treatment/Management 1. The physician will order pertinent wound treatments, including pressure ulcer reduction surfaces . Based on observation, interview, and record review, the facility failed to ensure physician's orders related to the use of therapeutic boots (heel boot worn to prevent pressure ulcers by lifting the heel) were followed for two of three residents (10, 39) reviewed for skin integrity/pressure ulcers. This failure had the potential to result in further decline in the Resident 10 and Resident 39's 055910 Page 4 of 8 055910 09/20/2019 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0684 skin integrity. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Few 1. Resident was admitted to the facility on [DATE] with diagnoses which included poliomyelitis (disease that causes temporary or permanent paralysis; inability to move parts of the body), per the facility's admission Record. Resident 10's record was reviewed. Per the history and physical examination dated 7/5/19, Resident 10 did not have the capacity to understand and make decisions. Observations were conducted on: 9/17/19 at 9:20 A.M. and 4:55 P.M., and 9/18/19 at 6:50 A.M. Resident 10 was lying in bed. Resident 10 was not wearing therapeutic boots. A review of Resident 10's current order summary report was conducted. This record included a physician's order dated 6/22/16 for Resident 10 to wear .Z-flex boots (therapeutic boots) on both foot @ (at) all times . every shift . A review of Resident 10's care plan for skin integrity, revised 5/1/19 was conducted. This record included interventions for Resident 10 to wear .Z-flex boots on both foot @ all times . An interview was conducted on 9/20/19 at 9:26 A.M. with LN 1. LN 1 stated that the z-flex boots were supposed to be on at all times. An interview was conducted on 9/20/19 at 1:42 P.M. with CNA 2. CNA 2 stated she was familiar with Resident 10's care. CNA 2 stated that .sometimes staff might forget to put them (referring to the therapeutic boots) on .but we are all responsible to make sure they're on . An interview was conducted on 9/20/19 at 1:53 P.M. with the Director of Nursing (DON). The DON stated that the z-flex boots were used to prevent skin breakdown on Resident 10's feet, and acknowledged that the boots should have been worn at all times as ordered by the physician. The facility's undated policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, indicated, .staff .will assess and document an individual's .risk factors for developing pressure ulcers .describe and document/report the following .d. current treatments, including support surfaces .Treatment/Management 1. The physician will order pertinent .treatments, including pressure reduction surfaces, . 055910 Page 5 of 8 055910 09/20/2019 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure 1 of 25 sampled residents' medications were were not locked in a bedside table drawer. As a result there was potential for theft, diversion, and access by other residents, staff or visitors. Findings: Resident 54's facility's admission Record was reviewed. Resident 54 was admitted on [DATE]. On 9/17/19 at 8:50 A.M., Resident 54's room located on station 4 was observed. Menthol ointment and antacid medication were observed on Resident 54's bedside table. On 9/17/19 at 8:55 A.M., Resident 54 was interviewed. Resident 54 stated she applied the menthol ointment to her legs and she took the antacid medication as needed. Resident 54 stated the medication was kept on top of her bed side table. On 9/17/19 at 11:25 A.M., an interview with Resident 54 was conducted. Resident 54 stated she was unsure if she needed to place the menthol ointment in the locked drawer. Resident 54 stated she remembered staff telling her to lock up the ointment. Resident 54 then locked up the menthol ointment and left the bottle of antacids on top of her bed side table. On 9/17/19 at 12:13 P.M., an observation of Resident 54's medication and interview with Resident 54's nurse was conducted. A bottle of antacids was on top of Resident 54's bedside table. Resident 54 asked CNA 20 if her bottle of antacids should be locked in her bedside drawer. LN 21 entered Resident 54's room and Resident 54 asked LN 21 if it was wrong for her Tums medication to be on top of her bedside table and not locked. LN 21 reminded Resident 54 that she had encouraged her in the past to not leave her medication out and not locked. LN 21 stated the facility had put a lock on Resident 54's bedside drawer to ensure Resident 54 would put all her medications into the locked drawer. On 9/19/19 at 10:30 A.M., an interview with the ADON was conducted. The ADON stated Resident 54's menthol ointment and antacids (medications) should have been locked up at all times. Per the facility's undated policy titled, Storage of Medications, .8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. 055910 Page 6 of 8 055910 09/20/2019 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide diet preferences for 4 of 25 sampled residents (12,13, 21,77). As a result substitutions of equal nutritive value were not offered to Residents 12, 13, 21, and 77. Findings: Resident 12 was admitted to the facility on [DATE] with diagnosis which included anemia per the facility's admission Record. Resident 13 was admitted to the facility on [DATE] with diagnosis which included hypokalemia, iron deficiency, and dysphagia per the facility's admission Record. Resident 21 was admitted to the facility on [DATE] with diagnosis which included dysphagia per the facility's admission Record. Resident 77 was admitted to the facility on [DATE] per the facility's admission Record. On 9/17/19 at 7:56 A.M., an observation of Resident 21's breakfast food was conducted. Resident 21's breakfast plate was observed to have two pureed food items, one item was light yellow and the other was light brown in color. Resident 21's diet slip listed three pureed food items, p-sausage, p- pancakes, p-eggs. On 9/17/19 at 12:15 P.M., an observation and interview was conducted with Resident 54. Resident 54 stated she had asked staff to not give her pudding, but she kept receiving pudding on her tray. Resident 54's diet slip was on her meal tray and under preferences was listed, no pudding. Yellow pudding was observed on Resident 54's lunch tray. On 9/18/19 at 8:13 A.M., an observation of Resident 13's breakfast food was conducted. Resident 13's breakfast plate was observed to have two pureed items which were yellow and light brown. Resident 13's diet slip listed four pureed food items, p-oatmeal, p-egg of the day, p-sausage patty, p-bread/jelly. On 9/18/19 at 8:20 A.M., an interview was conducted with CNA 21 who was assisting Resident 13 with eating. CNA 21 stated the pureed sausage was missing from the tray and explained the pureed bread/jelly and the pureed egg were the only pureed items on the plate. On 9/18/19 at 8:33 A.M., an observation and interview was conducted with CNA 22. CNA 22 stated there was only two pureed items on Resident 12's plate. CNA 22 stated, Resident 12's meal ticket did not include pureed sausage. CNA 22 stated Resident 12's pureed sausage had not been included in Resident 12's breakfast meal. CNA 22 stated the meal percent she had calculated was not accurate because she had not included the pureed sausage in the total amount of food on Resident 12's plate. On 9/18/19 at 8:35 A.M., an interview was conducted with the DON. The DON stated she had not noticed the missing pureed sausage from Resident 12 and 13's meal tray when she had checked the food on the meal tray with the food listed on Resident 12 and 13's diet slips. 055910 Page 7 of 8 055910 09/20/2019 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/18/19 at 8:41 A.M., an interview with cook 1 was conducted. [NAME] 1 stated he did not provide pureed sausage for Resident 13 because the family had requested no pork. On 9/18/19 at 8:45 A.M., an interview was conducted with the food service manager (FSM). The FSM stated the cook was aware of Resident 13's preference for no pork products but this information was not entered into the computer under diet preferences and therefore would not be captured on Resident 13's diet slip. The FSM stated she should have identified the missing sausage puree on Resident 13's meal tray when she checked the food trays before the meal tray had left the kitchen. On 9/18/19 at 2:25 P.M., an interview was conducted with FSM. FSM stated Resident 12's meal preferences included no hotdog and the cook assumed this to mean no pork products and did not provide the sausage puree on Resident 12's breakfast plate. The FSM stated there was a problem with the accuracy and interpretation of the food preferences. On 9/19/19 at 10:12 A.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 77 took coumadin (an anti-coagulant used to prevent blood clots ). LN 1 stated residents prescribed coumadin were to avoid eating dark green leafy vegetables. LN 1 stated Resident 77's dietary profile did not mention avoidance of dark green leafy vegetables. On 9/19/19 an interview was conducted with LN 22. LN 22 stated possible food interactions with medications were communicated to the kitchen by nursing by completion of a Diet Order Form which listed the food to avoid with certain medications under preferences. On 9/19/19 at 11:50 A.M., an interview was conducted with the RD (Registered Dietician). The RD stated she had included Resident 77's use of coumadin medication in her dietary assessment. The RD stated Resident 77 was not to have Vitamin K rich food such as dark green leafy vegetables. The RD stated the kitchen should have included a list of Vitamin K rich foods under preferences within Resident 77's dietary profile. The RD stated Resident 12, 13 and 21's diet preferences should have been accurate and she was unaware the residents had not received sausage puree on their breakfast trays. The RD stated because she was not aware residents had not received their pureed sausage she was unable to provide a protein substitute. The RD stated when the dietary profile, preferences are accurate in the computer than the meal tray slips will also be accurate. 055910 Page 8 of 8