Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Country Manor La Mesa Healthcare Center during CMS and state inspections, most recent first.
A resident with a lower leg fracture had their weight-bearing status changed to weight-bearing as tolerated, but this was not communicated to the rehabilitation team. As a result, the resident did not receive timely physical therapy, which could delay recovery. The Director of Rehabilitation and the Director of Nursing acknowledged the communication gap.
A facility failed to notify a resident's representative about critical changes in the resident's medical care, including new lab and medication orders, a new insulin order, and the unavailability of insulin. This resulted in the representative being unaware of the resident's condition and care plan.
A resident with diabetes experienced elevated blood sugar levels, but the facility failed to administer the prescribed insulin due to unavailability. The licensed nurse did not promptly notify the physician or check the emergency kit, and there was no documentation of notifying the physician or pharmacy. The facility's policy did not address procedures for unavailable medications, leading to a potential decline in the resident's condition.
A resident with multiple health conditions experienced severe weight loss due to the facility's failure to notify the RD and physician of the resident's poor meal intake for over three days. Despite policies requiring such notifications, the RD was not informed, and the physician only learned of the issue upon the resident's hospital transfer. This lack of communication prevented timely intervention and contributed to the resident's health decline.
The facility failed to assist three residents with activities of daily living, resulting in long, dirty fingernails and untrimmed facial hair. Despite care plans indicating the need for assistance, residents with conditions like hemiplegia and paraplegia were not provided with adequate grooming, impacting their comfort and hygiene.
The facility did not ensure kitchen staff followed standardized recipes, potentially affecting food taste. During pureed food preparation, a staff member used a 1/4 tsp measuring spoon instead of the required 1/8 tsp for margarine. The Dietary Manager acknowledged that not following recipes could impact food taste. The facility's policy requires adherence to standardized recipes.
The facility's QAA Committee did not identify or include deficient trends in grooming and PTSD care in their QAPI plan, as found during a recertification survey. The surveyors noted issues with basic grooming and staff's lack of knowledge in managing PTSD, which were not recognized by the QAA Committee. Interviews with the ADM and DON highlighted the expectation for these trends to be identified and included in the QAPI plan to maintain residents' dignity and care standards.
A resident with hemiplegia and hemiparesis was found with an electric fan covered in thick, gray dust, indicating a failure to maintain a clean and homelike environment. Despite a deep cleaning schedule, the fan was not cleaned, as confirmed by the infection preventionist and maintenance director. The facility's policy emphasized cleanliness, which was not followed in this case.
The facility failed to provide trauma-informed care for two residents with PTSD, as their conditions were not properly identified and addressed. Staff were unaware of the residents' PTSD diagnoses and triggers, which are crucial for preventing aggressive behaviors. The facility's policy on Trauma Informed Care was not effectively implemented, leading to a deficiency in providing appropriate care.
A facility failed to specify the indication for Apixaban use for a resident with atrial fibrillation. The physician's order listed Apixaban as a blood thinner without mentioning the specific condition it was intended to treat. A nurse acknowledged the need for a clear indication, and the DON confirmed the expectation for correct diagnosis and indication for medications. The facility's policy lacked a requirement for verifying medication indications.
The facility failed to specify appropriate target behaviors for psychotropic medications for two residents, leading to potential unnecessary medication use. One resident was prescribed risperidone for a vague 'repetitive health concern,' while another was given divalproex sodium for non-specific mood changes. Staff interviews revealed a lack of clear, measurable behaviors to justify the medications, which the DON acknowledged should be specific to assess necessity.
A facility failed to provide coordinated hospice services for a resident with chronic respiratory failure. The deficiency included a lack of documentation of hospice staff visits, no schedule for visits, and no agreement with the hospice agency. Interviews revealed inconsistencies in documentation, and the facility's policy required a written agreement that was not in place.
A Licensed Nurse failed to follow infection control procedures by not wearing a gown for a resident under enhanced barrier precautions and neglecting hand hygiene after glove removal. The resident, with a gastrostomy tube, required specific precautions to prevent infection. The Director of Nursing confirmed the expectation for staff to adhere to these procedures.
A facility failed to notify a physician when a resident's blood sugar exceeded 250 mg/dl, as required by the physician's orders. Additionally, nursing staff did not use standard medical abbreviations for insulin injection sites for two residents, leading to repeated injections in the same area. The facility's policy lacked guidance on medical abbreviations for injection sites, and despite training, documentation standards were not consistently followed.
A resident developed a deep tissue injury (DTI) due to the facility's failure to implement adequate preventive measures and monitor changes in the resident's condition. Initially assessed with no risk for pressure ulcers, the resident's condition deteriorated, leading to moisture-associated skin damage (MASD) and eventually a DTI. The care plan lacked interventions for turning, repositioning, hydration, and protein needs, and the facility did not update treatment orders despite the resident's declining condition.
A resident with diabetes mellitus received insulin injections at the same sites repeatedly, contrary to standard nursing practices, leading to potential complications. The facility's MAR showed repeated use of the same injection sites, and interviews with staff confirmed the importance of site rotation. The DON noted that some nurses involved were not present at training sessions, and the facility's policy lacked specific guidance on site rotation.
Failure to Communicate Change in Weight-Bearing Status
Penalty
Summary
The facility failed to coordinate the care needs of a resident with rehabilitation services following a change in the resident's weight-bearing status. The resident, who was admitted with a lower leg fracture, initially had a no weight-bearing (NWB) order and was receiving physical therapy (PT) services until the status changed. On 11/27/24, the resident's weight-bearing status was updated to weight-bearing as tolerated (WBAT) by the orthopedic doctor, but this change was not communicated to the rehabilitation services team. As a result of this communication gap, the physical therapist was not informed of the change and did not see the resident until 1/3/25, over a month later. The Director of Rehabilitation Services confirmed that they were unaware of the status change, and the Director of Nursing acknowledged the lapse in communication. This failure to promptly address the resident's updated care needs could potentially lead to a slower recovery process.
Failure to Notify Resident's Representative of Care Changes
Penalty
Summary
The facility failed to notify the representative of a resident, who was readmitted with diabetes mellitus, about several critical changes in the resident's medical care. The resident's daughter, who holds power of attorney, was not informed of new lab and medication orders, a new insulin order, or the fact that insulin was not administered as per the Nurse Practitioner's (NP) order. This lack of communication resulted in the resident's representative being unaware of the resident's condition and the plan of care. The report details specific instances where the facility did not document notifying the resident's representative about changes in the resident's condition and treatment. These include a change in the resident's blood sugar levels, the unavailability of prescribed insulin, and new orders given by the NP. The Director of Nursing acknowledged that the family should have been informed to ensure they were fully aware of the resident's care. The facility's policies require prompt notification of changes in a resident's condition to the resident, their physician, and their representative.
Failure to Administer Insulin for Elevated Blood Sugar
Penalty
Summary
The facility failed to provide a necessary medication for a resident with diabetes mellitus, leading to a potential decline in the resident's medical condition. The resident, who was readmitted to the facility with a diagnosis of diabetes, experienced an elevated blood sugar level of 297. Despite this change in condition, there was a delay in obtaining physician orders, and the necessary insulin medication, Humalog KwikPen, was not available. The licensed nurse did not follow up promptly with the physician or check the facility's emergency kit for the medication, resulting in the resident's elevated blood sugar not being addressed in a timely manner. The physician's orders for insulin administration were not executed because the medication was unavailable, and there was no documentation indicating that the physician or pharmacy were notified of this issue. The Director of Nursing confirmed that the nurse should have notified the physician if the medication was not available. The attending physician was unaware of the medication unavailability and stated that an alternative method of insulin administration could have been used. The facility's policy on administering medications did not address procedures for when a medication is unavailable, contributing to the deficiency.
Failure to Notify RD and Physician of Resident's Poor Intake
Penalty
Summary
The facility failed to promptly notify the registered dietitian (RD) and physician when a resident with a compromised medical status consumed less than 50% of his meals for more than three consecutive days. This oversight was contrary to the facility's policy and standards of practice. The resident, who had been admitted with diagnoses including diabetes mellitus, chronic kidney disease, hypertension, and Parkinson's, experienced a severe unintentional weight loss of 16 pounds (7.83%) in just 16 days. Upon admission, the resident was alert, walking, talking, and eating, as noted by a family member. However, the resident's meal intake significantly decreased, with records showing consumption of only 26% to 50% of meals over several days, and even less in subsequent days. Despite these indicators, the RD was not informed of the resident's poor intake, and the physician was only made aware of the situation when the resident was transferred to the hospital for the second time. The facility's policies required that residents with poor food intake for three or more days should have their condition reported to the RD and physician. However, this protocol was not followed, leading to a lack of timely intervention. The resident's nutrition care plan aimed to maintain adequate nutrition status, but the failure to communicate the resident's declining intake and weight loss prevented necessary adjustments to the care plan, contributing to the resident's further decline in health.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents who were unable to perform self-care activities such as grooming, bathing, and toileting. Resident 21, who was admitted with hemiplegia and hemiparesis following a stroke, was observed with long, dirty fingernails and expressed a desire for them to be trimmed. A licensed nurse acknowledged that the resident's fingernails had not been trimmed weekly as expected, which could lead to infection since the resident used his hands to eat. The care plan for Resident 21 indicated a need for extensive assistance with personal hygiene, but this was not adequately provided. Similarly, Resident 57, also with hemiplegia and hemiparesis following a stroke, was found with long fingernails on a hand that he could not open. The Infection Preventionist noted that the resident's grooming was missed, despite the care plan indicating a need for extensive assistance with personal hygiene. Resident 67, who was receiving palliative care and had paraplegia, was observed with a thick beard and moustache causing discomfort. The resident expressed a need for grooming assistance, which was confirmed by a CNA who stated that grooming should occur twice a week. The Director of Nursing emphasized the importance of regular grooming to maintain residents' self-esteem and presentability, but the facility's policy was not followed, resulting in the observed deficiencies.
Failure to Follow Standardized Recipes in Food Preparation
Penalty
Summary
The facility failed to ensure that kitchen staff adhered to standardized recipes during food preparation, which could potentially affect the taste of the food served to residents. During an observation of pureed food preparation, a kitchen staff member was seen using a 1/4 teaspoon measuring spoon instead of the required 1/8 teaspoon to add margarine, stating that she used less than the 1/4 teaspoon to measure the margarine. The Dietary Manager confirmed that not following the recipe could impact the taste of the food. The facility's policy on standardized recipes, revised in April 2007, mandates the use of standardized recipes in food preparation.
QAA Committee Fails to Identify Deficient Trends in Grooming and PTSD Care
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to identify and include deficient trends in their Quality Assurance Performance Improvement (QAPI) plan, as discovered during a recertification survey. The surveyors found issues related to basic grooming, such as nail care and beard care, and a lack of staff knowledge in managing residents with Post Traumatic Stress Disorder (PTSD). These trends were not recognized by the QAA Committee and were absent from the QAPI plan, which primarily focused on monitoring falls, pressure ulcers, and infection control. Interviews with the Administrator (ADM) and the Director of Nursing (DON) revealed that the expectation was for the QAA Committee to identify such trends and incorporate them into the QAPI plan. The ADM and DON both acknowledged the importance of identifying these trends to maintain residents' dignity and ensure a high standard of care, particularly for those with PTSD. The facility's policy on Quality Assurance and Performance Improvement, dated February 2020, outlines the objectives of the QAPI program, which include identifying and prioritizing quality deficiencies, but these were not adhered to in this instance.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as Resident 57, who was observed with an electric fan filled with thick, gray dust. This deficiency was noted during an observation and interview on January 13, 2025, where the resident, who was admitted with hemiplegia and hemiparesis following a stroke, stated that the fan had not been cleaned but did not wish to complain. The resident was cognitively intact, as indicated by a BIMS score of 15 on the Minimum Data Set dated November 11, 2024. Further observations and interviews with the infection preventionist and the maintenance director confirmed the presence of dust on the fan, which was acknowledged as a failure in maintaining a sanitary environment. The maintenance director admitted that the cleaning of the fan was missed, despite a deep cleaning schedule that included such tasks. The director of nursing also confirmed that electric fans should be cleaned weekly to ensure a homelike environment. The facility's policy on maintaining a homelike environment emphasized the importance of cleanliness and orderliness, which was not adhered to in this instance.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents diagnosed with PTSD, as their conditions were not properly identified and addressed. Resident 26, who had hemiplegia and PTSD following a stroke, expressed distress when war movies were shown, yet staff were unaware of his PTSD diagnosis. Interviews with staff, including CNAs and a licensed nurse, revealed a lack of awareness about the resident's PTSD and its triggers, which are crucial for preventing aggressive behaviors. Similarly, Resident 46, diagnosed with PTSD and major depressive disorder, had a history of trauma from military service. Despite this, staff were not informed of his PTSD diagnosis, as evidenced by interviews with CNAs and a licensed nurse who were unaware of the resident's condition. The Social Service Director confirmed that PTSD information should be documented in the care plan and accessible to staff, but the Kardex used by CNAs did not list PTSD for either resident. The Director of Nursing emphasized the importance of staff being aware of PTSD triggers to avoid re-traumatization. The facility's policy on Trauma Informed Care, which outlines the need for culturally sensitive and person-centered care, was not effectively implemented, as staff were not trained to recognize or address the residents' PTSD. This oversight in identifying and managing PTSD diagnoses led to a deficiency in providing appropriate care for the affected residents.
Lack of Clear Indication for Anticoagulant Use
Penalty
Summary
The facility failed to provide a clear indication for the use of anticoagulant medication, Apixaban, for one resident, identified as Resident 51. Resident 51 was admitted with a diagnosis of atrial fibrillation, which typically requires anticoagulation therapy. However, the physician's order dated 9/30/23 only indicated the use of Apixaban as a blood thinner without specifying the underlying condition, such as atrial fibrillation, as the reason for its use. During an interview, Licensed Nurse 11 acknowledged that there should have been a clear indication for the medication and that the attending physician should have been consulted to verify the intended use of Apixaban. The Director of Nursing confirmed that the expectation was for every medication to have the correct diagnosis and indication. A review of the facility's medication administration policy revealed it did not include a requirement for verifying the indication of medications.
Failure to Specify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to specify appropriate and measurable target behaviors for the use of antipsychotic and psychotropic medications for two residents, leading to potential unnecessary medication use. Resident 6 was readmitted with a diagnosis of psychosis and was prescribed risperidone for a vague target behavior described as 'repetitive health concern.' Interviews with staff revealed that Resident 6 was unable to communicate needs and exhibited no specific behaviors that warranted the medication. The Director of Nursing (DON) acknowledged that the target behavior should be specific and measurable to determine the necessity of the medication. Similarly, Resident 52, diagnosed with major depressive disorder, was prescribed divalproex sodium for non-specific behaviors described as 'feeling happy and upbeat to feeling sad and impulsiveness.' Observations and interviews indicated that Resident 52 was non-communicative and exhibited behaviors such as pinching and scratching staff, but the specific target behavior for the medication was unclear. The DON confirmed that the target behavior should match the resident's manifested behavior to assess the continued need for the medication. The facility's policy requires that psychotropic medications be clinically indicated for specific conditions, which was not adhered to in these cases.
Failure to Ensure Provision of Hospice Services
Penalty
Summary
The facility failed to ensure the provision of hospice services for a resident, identified as Resident 67, who was admitted with chronic respiratory failure with hypercapnia. The deficiency was identified through observation, interview, and record review, revealing that the facility did not have documentation of hospice staff visits, lacked a schedule for hospice staff visits, and did not have an agreement with the hospice agency. This lack of coordination had the potential to result in uncoordinated medical care for Resident 67. During the review of Resident 67's records, it was found that the physician's orders indicated admission to hospice, but there was no documentation of hospice staff visits in the hospice binder or nursing progress notes. Interviews with licensed nurses revealed inconsistencies in the documentation of hospice visits, with one nurse stating that a hospice nurse visited but did not document the visit. The hospice licensed nurse confirmed that visits were documented in the hospice electronic medical record but acknowledged that documentation was missed in the hospice binder. Additionally, the facility did not have a formal agreement with the hospice agency, as confirmed by the Director of Nursing. The facility's policy required a written agreement outlining the responsibilities of the facility and the hospice agency, but this was not in place. The lack of a hospice agreement and proper documentation of visits and care plans contributed to the deficiency in providing coordinated hospice care for Resident 67.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control procedures when a Licensed Nurse (LN) did not wear a gown while attending to a resident under enhanced barrier precautions (EBP). The resident, who had a gastrostomy tube, required specific precautions to prevent cross-contamination and infection. During medication administration and vital sign checks, the LN neglected to don a gown, which is a requirement for residents with EBP, as indicated by the sign on the resident's door. Additionally, the LN did not perform hand hygiene consistently after removing gloves, particularly after touching a trash bin, which is considered contaminated. This oversight occurred while the LN was preparing and administering medications to the resident. The Director of Nursing confirmed that the expectation was for staff to follow EBP procedures and perform hand hygiene to prevent infections, as residents are prone to infections. The facility's policies on EBP and hand hygiene emphasize the importance of these practices in preventing the spread of infections.
Failure to Notify Physician and Document Injection Sites
Penalty
Summary
The facility failed to adhere to professional nursing standards by not notifying the physician when a resident's blood sugar levels exceeded 250 mg/dl, as per the physician's orders. This oversight occurred for one resident, who had six out of eighteen blood sugar checks recorded over 250 mg/dl without any documented evidence of physician notification. The facility's policy required immediate notification of the physician for blood glucose levels over 250 mg/dl, but this protocol was not followed, as confirmed by interviews with the Licensed Nurse and the Director of Nursing. Additionally, the nursing staff did not use standard medical abbreviations to document specific body sites for insulin injections for two residents. This lack of specificity in documentation led to repeated injections in the same area, potentially causing decreased absorption, bruising, and pain. The MAR entries for insulin administration were often vague, with only one entry using a medically accepted abbreviation. Interviews with nursing staff and the DON revealed that the use of standardized medical abbreviations was a nursing standard of practice that was not consistently followed. The facility's policy on the care of older adults with diabetes did not provide guidance on the use of medical abbreviations for injection sites. The DON acknowledged the importance of documenting specific injection sites to ensure proper rotation and prevent complications. Despite training provided to nurses on medication administration, there was a lack of adherence to these standards, as evidenced by the incomplete documentation and the absence of one nurse from the training session.
Failure to Prevent Deep Tissue Injury in Resident
Penalty
Summary
The facility failed to prevent the development of a deep tissue injury (DTI) in a resident who was initially admitted with intact skin, except for some bruising. Upon admission, the resident was assessed with a Braden Scale score indicating no risk for pressure ulcers. However, the resident's condition changed over time, with the development of moisture-associated skin damage (MASD) in the groin and buttocks areas, which was documented by a certified nursing assistant and a licensed nurse. Despite the documentation of these skin issues, there was no evidence of a low air loss mattress being ordered or a dermatology consult being recommended. The resident's care plan did not include interventions for turning and repositioning every two hours, hydration, or protein needs, which are critical for preventing pressure ulcers. The resident's condition deteriorated, with increased incontinence and decreased mobility, leading to a decline in food intake and weight loss. Despite these changes, the facility's treatment administration record showed no updates or changes in the physician's orders for skin treatments, and the resident continued to receive the same treatment for MASD without any adjustments. Interviews with staff revealed that the resident became more dependent on care and exhibited signs of confusion and weakness. The facility's wound consultant nurse confirmed that the MASD and DTI are distinct conditions, with the latter developing from prolonged pressure. The resident was eventually sent to the hospital, where a DTI was identified, measuring 15 cm by 17 cm, indicating that the injury had developed over time due to inadequate preventive measures and monitoring by the facility.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure proper rotation of insulin injection sites for a resident with diabetes mellitus, leading to potential issues such as increased bruising, pain, and decreased absorption of medication. The resident was admitted with a diagnosis of diabetes mellitus and was prescribed insulin injections using a Humalog Kwik Pen. The Medication Administration Record (MAR) revealed that the same injection sites were repeatedly used over several days, contrary to standard nursing practices. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the rotation of injection sites is a standard practice to prevent complications, yet it was not consistently followed. The DON acknowledged that the facility's nurses were trained on medication administration, including insulin injections, but noted that some nurses involved in the deficiency were not present at the training sessions. The Pharmacy Consultant also confirmed that rotating injection sites is a standard practice and noted that the resident's medication record was not reviewed in time to catch the issue. The facility's policy on diabetes care did not provide specific guidance on rotating insulin injection sites, contributing to the oversight.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near La Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Hills Nursing Center | 0.6 mi | ★★★★★ | 8 | 0 |
| Parkway Hills Nursing & Rehabilitation | 0.6 mi | ★★★★★ | 34 | 0 |
| Grossmont Gardens Healthcare Center | 0.7 mi | — | 22 | 0 |
| Grossmont Post Acute Care | 1.2 mi | ★★★★★ | 3 | 0 |
| Grossmont Hospital D/p Snf | 1.2 mi | ★★★★★ | 0 | 0 |
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