Health inspection·March 6, 2025

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** Based on observation, interview, and record review, the facility failed to coordinate resident's care needs with the rehabilitation (help residents regain strength and independence) services for one of three sampled residents (1) when Resident 1's weight-bearing status (amount of weight that can be put on an injured body part) was changed from NWB (no weight-bearing, not allowed to put any weight) to WBAT (weight-bearing as tolerated, may put weight on affected injured body parts). Residents Affected - Few As a result, the physical therapist (PT- helps residents regain function and manage pain and disabilities through various treatments) was not able to promptly address Resident 1's needs, which could lead to a slower recovery. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included a fracture (broken bone) of the lower leg, per the admission Record. A review of Resident 1's medical record was conducted. Per the PT Discharge summary, dated [DATE], Resident 1 was discharged from PT service until the weight-bearing status changed. Per the Progress Notes, dated 11/27/24, Licensed Nurse (LN) 1 documented that Resident 1 was seen by the orthopedic doctor (a branch of doctor focused on the musculoskeletal system, including bones, joints, ligaments, tendons, and muscles), with new orders. Per the Order Summary Report, dated 11/27/24, the physician ordered Resident 1 to be on WBAT status in the boot (walking boots - lower extremity boot that provides support, protection, and ankle immobilization). On 3/12/25 at 1:30 P.M., an interview was conducted with the Director of Rehabilitation [Rehab] Services (DRD). The DRD stated Resident 1 was admitted on [DATE] with an order not to put weight on the affected leg. The DRD further stated Resident 1 had rehabilitation services until 11/14/24. The DRD stated Resident 1 would be back on rehabilitation services when weight bearing status was changed. The DRD stated they (rehabilitation services) were unaware that the weight-bearing status had changed on 11/27/24 to weight-bearing as tolerated, and the PT did not see Resident 1 until 1/3/25. On 3/12/25 at 2:52 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the LN did not inform the PT that the weight-bearing status was changed to as tolerated. The DON further stated that a communication gap had occurred, and the PT had not seen Resident 1 since Page 1 of 2 055910 055910 03/06/2025 Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd LA Mesa, CA 91942

F 0684 Resident 1's weight bearing status had changed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055910 Page 2 of 2