Health inspection·November 19, 2021

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interviews, the facility failed to ensure food was served in a safe manner when [NAME] 1 (C1) did not use appropriate hand hygiene or change gloves between tasks. Residents Affected - Some As a result, there was a potential to place residents at risk for food borne illness. Findings: On 11/18/21 at 11:48 A.M., an observation of the facility's tray line was conducted. C1 was observed picking up a plastic bag from the counter behind the tray line. C1 removed a thermometer from a plastic bag and wiped it with an alcohol swab. C1 began taking the temperatures of the food on the tray line. Once finished, she cleaned the thermometer and put it back in the plastic bag but did not change her gloves between these tasks. C1 proceeded to use her gloved hand to pick up a plate. C1 then touched tongs to pick up the meat patty, a ladle to serve pureed meat, another ladle to serve pureed potatoes, another ladle to serve chopped meat, a ladle to serve vegetables, and another ladle to serve gravy. C1 used her gloved hand to pick up the bread roll to put on the plate. C1 used her gloved hand to place a parsley garnish on the plate. At 12:10 P.M., during tray line, C1 picked up a bag of chips and poured them onto a plate then returned the bag to a nearby container using her gloved hand. At 12:11 P.M., C1 touched a drawer handle when she opened the drawer to remove a ladle. At 12:25 P.M., C1 put 2 oven mitts on over her gloved hands to remove a hot container out of the oven and placed it in the steam table. C1 then removed the oven mitts and used her gloved hand to open a drawer to remove a ladle. C1 continued to serve meals from the tray line without changing her gloves or washing her hands. At 12:45 P.M., C1 again used oven mitts to remove a tray of beef patties out of the oven. C1 did not change her gloves or wash her hands. At 12:48 P.M., C1 went to the drawer behind the tray line using her gloved hand to open the drawer to remove a ladle. On 11/18/21 at 1:45 P.M., Dietary Aide (DA1) was interviewed. DA1 said, The cook should have changed her gloves when she left the tray line and touched the drawer handles and put the oven mitts on Page 1 of 6 055910 055910 11/19/2021 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0812 over her gloves because her gloves could be contaminated. Level of Harm - Minimal harm or potential for actual harm On 11/18/21 at 2 P.M., the Dietary Supervisor (DS) was interviewed. The DS acknowledged the severity of possible cross-contamination when C1's gloves were not changed during tray line. Residents Affected - Some According to the 2017 Federal Food Code, section 2-301.14, titled When to Wash, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation . (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 055910 Page 2 of 6 055910 11/19/2021 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

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 staff and visitors followed the protocol for transmission-based precautions for residents under investigation for COVID-19. Residents Affected - Many This failure had the potential to allow COVID-19 to infect staff, visitors, and residents. Findings: On 11/16/21 at 8:04 A.M., an observation was conducted of Station Four. No signs were observed on the unit which denoted transmission-based precautions (measures used to protect individuals from spreading contagious illnesses, such as COVID-19) were in place. Staff was observed to be entering resident rooms without donning gowns or gloves. On 11/16/21 at 9:09 A.M., an observation was conducted of room [ROOM NUMBER]. A staff member and a visitor were both in the room, interacting with the resident in Bed C. Neither the staff member nor the visitor wore a gown or gloves. On 11/16/21 at 12:58 P.M., an observation was conducted of staff delivering trays to residents in Station Four. Multiple staff delivering trays were observed not wearing gloves while in resident rooms. On 11/16/21 at 1:13 P.M., certified nursing assistant (CNA) 6 was observed to enter room [ROOM NUMBER] B (on Station Three) with a tray. CNA 6 was observed to be wearing no gown or gloves. An interview was conducted with CNA 6 at that time. CNA 6 stated it was only necessary to wear a gown and gloves while she performed resident care. CNA 6 stated staff were not required to wear a gown or gloves while they delivered trays to residents. On 11/16/21 at 1:27 P.M., an observation was conducted at the entrance to Station 3. Station 3 had signs posted denoting the area to be a Yellow Zone (an area in which residents are being closely observed because they could be infected with COVID-19). On 11/18/21 at 10:52 A.M., an interview was conducted with the Infection Preventionist (IP). The IP stated all residents in all stations of the facility were considered to be in the Yellow Zone, because the facility had a recent outbreak of COVID-19. The IP stated anyone who entered any resident room was required to wear Personal Protective Equipment (PPE) at all times. The IP stated the PPE required was a gown, gloves, N95 respirator (protective device worn over the mouth and nose to filter out possible germs), and a face shield. The IP stated staff was informed of these precautions during one-on-one training and facility-wide in-service training. On 11/18/21 at 12:11 P.M., a concurrent observation and interview was conducted with the IP and the Director of Nursing (DON). There were no signs which denoted a Yellow Zone or PPE requirements posted at the entrance to Stations 1 or 4, nor were any signs posted outside of any individual resident rooms. The IP stated the signs should be in place. The DON stated staff was expected to wear PPE in every resident room at all times. A record review was conducted of the facility's in-service log. According to the log, staff was provided PPE training on 11/12/21 and 11/15/21. 055910 Page 3 of 6 055910 11/19/2021 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0880 Level of Harm - Minimal harm or potential for actual harm According to the facility's undated COVID-19 Mitigation Plan, .3.5 .Yellow Zone .Healthcare workers should wear full COVID-19 level PPE (gloves, gown, mask [N95], goggle or face shields) when taking care of these residents . Residents Affected - Many 055910 Page 4 of 6 055910 11/19/2021 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 6 out of 78 sampled residents (28, 29, 31, 37, 68 and 97) had access to their call light button when they were not within reach. Residents Affected - Few As a result, there was a potential to put residents 28, 29, 31, 37, 68 and 97 at risk for injury. Findings: 1. Per the facility's admission record, Resident 37 was admitted on [DATE] with diagnoses which included cerebral palsy (a disorder that effects a person's muscle movement). On 11/16/21 at 8:45 A.M., Resident 37 was observed in bed on her left side. Resident 37's call bell cord (a cord that connects the call button to the facility's communication system) was clipped on the top right side of the mattress, the call button (the part of the call bell which activates the call bell) was on the floor and out of Resident 37's reach. 2. Per the facility's admission record, Resident 29 was admitted on [DATE] with diagnoses including muscle weakness and epilepsy (seizure disorder). On 11/16/21 at 9 A.M., Resident 29 was observed in bed. Resident 29's call bell was observed on the floor out of resident 29's reach. 3. Per the facility's admission record, Resident 68 was admitted on [DATE] with diagnoses including, fracture of the right femur (upper leg bone). On 11/16/21 at 9:01 A.M., Resident 68 was observed in bed on her right side. Resident 68's call bell was hanging off the bed on her left side out of Resident 68's reach. On 11/16/21 at 9:05 A.M., a joint observation and interview of residents 29, 37, and 68 were conducted with CNA 1. CNA 1 stated, These call buttons should not be on the floor. They should be near the residents where they could reach it to call in case they need something. 4. Per the facility's admission record, Resident 28 was admitted on [DATE] with diagnoses which included traumatic subdural hemorrhage (bleeding in the brain). On 11/16/21 at 9:15 A.M., Resident 28 was observed in bed. Resident 28's call button was observed on the floor near the head of the bed out of reach. 5. Per the facility's admission record, Resident 97 was admitted with diagnoses which included COVID. On 11/16/21 at 9:20 A.M., Resident 97 was observed in her room. Resident 97's door was closed. Inside the room, Resident 97 was observed on her left side. Resident 97's call bell was on the floor. During a joint interview and observation with CNA 2, CNA 2 stated, The call button should be within reach in case the resident needs help. 6. Per the facility's admission record, Resident 31 was admitted on [DATE] with diagnoses which 055910 Page 5 of 6 055910 11/19/2021 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body). On 11/16/21 at 9:45 A.M., an interview with Resident 31 was conducted. The resident stated, I can't find my call bell. Resident 31 stated, I'm weak on my left side, it takes me a long time to find my call bell sometimes. Resident 31's call bell was observed between the mattress and the siderail and not within reach. Per the facility's policy titled, Answering the Call Light, .Purpose- The purpose of this procedure is to respond to the resident's requests and needs.5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . 055910 Page 6 of 6