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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at La Mesa Healthcare Center during CMS and state inspections, most recent first.
A facility failed to develop individualized discharge care plans for three residents; staff described the plans as copy-and-paste and not revised or personalized. The residents had differing diagnoses and cognitive status, including CVA-related hemiplegia with severe cognitive deficits and a lumbar compression fracture with moderate cognitive deficits, yet their discharge plans used the same generic goals and interventions, including ADL/mobility, pain, mood, and DME/home health coordination.
A resident with a G-tube, severe cognitive deficits, and prior CVA was discharged without the Kangaroo pump needed for continuous TF, and the family reported the resident missed a scheduled feeding at home. The facility later changed the order to bolus TF, but the family and HHRN stated they were not taught bolus administration, and key discharge records such as the H&P, discharge summary, progress notes, and special instructions were not sent to HH.
A resident with a G-tube and severe cognitive deficits was discharged without the feeding pump needed for prescribed TF, and the family was not taught the revised bolus feeding method before leaving. Staff also failed to individualize the discharge care plan and did not send complete clinical records, including the H&P, face sheet, discharge summary, progress notes, AD, and TF instructions, to the HHA.
Failure to Complete Discharge Care Plan: A resident with DM II and intact cognition did not have a discharge care plan developed, implemented, or revised before discharge. SSA, LPN, ADON, and SSD confirmed the plan was never initiated even though discharge planning should have started on admission and been updated throughout the stay to address discharge goals, placement needs, medications, DME, and other services.
Failure to Develop a Personalized Care Plan for Resident Cash Management: A resident with PTSD and intact cognition repeatedly reported missing cash from his personal safe after bank withdrawals. He refused to use the facility safe, did not track the amount of cash he kept, and hid the safe and key in his room. The care plan only noted his refusal to use the safe and continued education, with no personalized plan for bank trips, cash inventory, or safe use, which the ASW, LN, DON, and ADM acknowledged.
A resident with acute kidney failure was observed with a Foley catheter drainage bag resting on the floor beside the bed for an undetermined period, contrary to facility policy requiring catheter tubing and drainage bags to be kept off the floor. During interviews, a CNA, the IP, and the DON all confirmed that Foley catheters should not touch the floor and that urine bags should be placed inside a catheter bag, and that staff are expected to follow infection control practices, yet the catheter drainage bag was not maintained accordingly.
A resident with mild cognitive impairment reported missing money to the Administrator, but the incident was not reported to the Department as required. The Administrator delayed reporting for 14 days, despite facility policy mandating notification within 24 hours and a written report within 5 working days. The DON confirmed the delay, and no evidence of timely reporting was provided.
Staff did not consistently monitor or document urine output for several residents with urinary catheters, despite physician orders and facility policy. There were also missing physician orders for catheter care and confusion among staff about who was responsible for providing and documenting catheter care. These failures were observed through record review, staff interviews, and resident observations, and had the potential to result in urinary retention and UTIs.
Surveyors found a container of sour cream stored past its use by date and personal clothing items belonging to staff hanging on food storage carts in the kitchen. The CDM and RD confirmed that the sour cream should have been discarded and that personal items should not be kept in the kitchen, in accordance with facility policy and food safety standards.
A resident with dementia and muscle weakness was observed eating without their lower denture, despite a care plan requiring dentures to be worn during meals. Staff interviews confirmed the denture was not applied, and the DON acknowledged the care plan was not followed, potentially impacting the resident's comfort and safety.
Two residents with central venous catheters did not have required measurements of arm circumference and catheter length performed or documented during dressing changes, as confirmed by record review and staff interviews. This failure was not in accordance with facility policy and standard practice for IV therapy management.
Two residents developed or redeveloped pressure injuries due to the facility's failure to provide timely interventions, accurate skin assessments, and appropriate documentation. Despite known risk factors and care plans indicating the need for preventive measures, staff did not initiate treatment or notify the wound care nurse or physician when wounds were first observed, and weekly summaries inaccurately reported skin conditions. Facility protocols for skin assessment and monitoring were not followed, resulting in preventable pressure injuries.
A resident with vision loss and on daily ASA for CVA prophylaxis was observed shaving her chin with a disposable razor without staff supervision. Nursing staff and the DON confirmed that, due to the resident's vision impairment and ASA use, she was at risk for bleeding and should have been assisted or supervised during shaving, in accordance with facility policy.
A resident with severe COPD and cognitive impairment was observed receiving oxygen at 4 LPM via nasal cannula, despite a physician order for 2 LPM. Staff interviews and record reviews confirmed that licensed nurses were responsible for following the order, but the resident consistently received a higher oxygen flow rate than prescribed.
A resident with chronic respiratory failure was found to have an opened inhaler in the medication cart that was not labeled with the date it was opened. An LPN admitted to opening the inhaler and forgetting to label it, and the DON confirmed that all opened multidose medications are expected to be dated according to facility policy.
A resident with mild intermittent asthma was admitted to a room under isolation precautions for Influenza A exposure, despite facility staff and policy indicating that such cohorting should not occur. Staff interviews confirmed the improper placement, and the resident was tested for Influenza A with results pending.
Generic Discharge Care Plans Not Individualized
Penalty
Summary
The facility failed to develop and implement individualized, person-centered discharge care plans for three sampled residents, with the discharge plans for those residents containing the same generic and identical goals and interventions. The report states that the discharge care plans were not updated and were described by staff as “cut and paste,” rather than personalized to each resident’s needs and discharge situation. Resident 1 was admitted with diagnoses including hemiplegia/hemiparesis following a CVA and had severe cognitive deficits on the MDS, with a BIMS score of 7. The discharge care plan for this resident contained broad, generic goals such as improving independence with ADLs and mobility, managing pain, minimizing isolation or anxiety, and coordinating DME, pharmacy, home health, and in-home support services, but the plan was not individualized to the resident’s specific discharge needs. The record review showed the same type of discharge planning language used across the sampled residents. Resident 5 was admitted with a history of a wedge compression fracture of the lumbar spine and had moderate cognitive deficits on the MDS, with a BIMS score of 11. The discharge care plan for this resident also contained the same generic goals and interventions, with dates showing initiation, revision, and cancellation, but without personalization to the resident’s discharge circumstances. Staff interviews confirmed that the discharge care plans for Residents 1, 4, and 5 were not revised or personalized, and that one resident had no discharge care plan at all despite discharge planning beginning on admission.
Discharge Not Coordinated for Resident Requiring Tube Feeding
Penalty
Summary
The facility failed to prepare a safe and coordinated discharge for a resident who had a history of hemiplegia/hemiparesis following a CVA and severe cognitive deficits on MDS assessment. The resident had a G-tube and was receiving continuous tube feeding orders before discharge, including Fibersource HN at 60 mL/hr for 20 hours, later changed to 60 mL/hr for 15 hours. The record also showed a revised order for bolus feeding entered the day after discharge. Family and home health staff reported that the resident was discharged without the Kangaroo feeding pump needed for the continuous tube feeding order. The family member stated she had told the SSA that the pump was needed before discharge, but the resident went without the ordered feeding at home the next morning because the pump had not been provided. The family later returned to the facility and received feeding supplies and an updated bolus order, but stated they were not given instructions or special training to administer bolus feedings. The home health RN stated the resident arrived home without the required pump and that the family had not been instructed on how to administer the revised bolus feeding. The SSA stated she initiated the discharge care plan but did not update or individualize it before discharge to reflect the resident’s discharge destination, caregiver support, tube feeding needs, durable medical equipment, and ongoing services. She also stated the facility failed to order the Kangaroo pump before discharge and left tube feeding education to nursing without confirming that the family had been instructed. Nursing staff stated they had taught the daughters how to use the Kangaroo pump for continuous feeding, but not bolus feeding, because the bolus order was not active at the time of discharge. The chart review showed no documentation that the face sheet, H&P, discharge summary, progress notes, rehab notes, special instructions, or advance directive were sent to home health, and the SSA acknowledged only limited faxed documents were transmitted after the resident had already gone home.
Failure to Coordinate Tube Feeding Discharge and Transfer Complete Clinical Information
Penalty
Summary
The facility failed to coordinate a safe and effective discharge for a resident with a history of hemiplegia/hemiparesis following CVA and severe cognitive deficits. The resident had been receiving enteral nutrition through a G-tube, with prior orders for continuous tube feeding using Fibersource HN at 60 mL/hr. The record also showed a later order for bolus feeding entered after discharge. Interviews and record review showed the discharge process did not ensure the resident’s caregivers received education on the revised feeding method before discharge, and the discharge care plan was not updated to reflect the resident’s specific discharge needs, caregiver support, tube feeding regimen, or equipment needs. The resident’s family member stated the facility discharged the resident without the Kangaroo feeding pump needed to deliver the prescribed tube feeding. The family member reported the resident did not receive tube feeding at home the next day because the pump was not available, and that the family later received feeding supplies and an updated bolus order without having been taught how to administer a bolus feeding. The home health RN stated the facility faxed only PT and OT orders on the day of discharge and did not provide the H&P, face sheet, discharge summary, discharge care plan, advance directive, progress notes, or instructions for ongoing tube feeding and wound care. The RN also stated the resident arrived home without the required feeding pump and the family had not been instructed on how to administer the bolus tube feeding. Facility staff acknowledged the discharge planning process was not completed as intended. The SSA stated she failed to update and individualize the discharge care plan before discharge and admitted she forgot to order the feeding pump. She also stated she only faxed limited information to the home health agency and had no documentation showing that the full clinical record was transmitted. The ADON, LN, and SSD each stated the discharge care plans were generic or copied, were not individualized to the resident’s needs, and that the revised bolus feeding order and related education were not provided before discharge. The record review also showed no documentation that the face sheet, physician orders, H&P, discharge summary, progress notes, rehab notes, special instructions, or advance directive were sent to the home health agency.
Failure to Complete Resident Discharge Care Plan
Penalty
Summary
The facility failed to complete a comprehensive person-centered discharge care plan for Resident 2 within the required timeframe after the comprehensive assessment and failed to develop, implement, or revise the discharge care plan before discharge. Resident 2 was admitted with diagnoses including a history of Diabetes Mellitus Type II, and the MDS dated 2/17/26 showed a BIMS score of 15 out of 15, indicating no cognitive deficits. During interview and record review on 7/22/26, the Social Service Assistant stated Resident 2 did not have a discharge care plan and that one was never developed during the stay, even though discharge planning should have begun on admission. The Social Service Assistant stated the IDT was actively seeking placement for Resident 2, but the care plan was never developed to identify discharge goals, anticipated discharge location, ongoing placement needs, or services required after discharge. Licensed Nurse 1, the Assistant Director of Nursing, and the Social Services Director each confirmed that Resident 2 did not have a discharge care plan and stated it should have been initiated early in the stay and revised throughout the resident's stay. The Social Services Director stated the discharge care plan is intended to identify and coordinate medications, DME, social services needs, discharge goals, and IDT responsibilities, and the facility policy stated the comprehensive person-centered care plan is developed within 7 days of completion of the required MDS assessment and no more than 21 days after admission.
Failure to Develop a Personalized Care Plan for Resident Cash Management
Penalty
Summary
The facility failed to develop a complete care plan for a resident who repeatedly reported missing cash from his personal safe. The resident was admitted with PTSD and had a BIMS score of 15 out of 15, indicating he was cognitively intact. During the investigation, he stated that he had lost cash several times at the facility and that this time he believed $2,500 had been stolen from his locked safe. He also stated that he did not trust anyone with his money and did not keep a record of how much cash he placed in the safe or the date he withdrew it from the bank. The resident described that after the facility provided a personal safe with a lock and key, he hid the safe in his nightstand and kept the key in an open-top glass pouch. He stated he could not find the key and later found the safe open and empty. The CNA stated he accompanied the resident to the bank by Uber to withdraw money, but did not know how much money the resident withdrew. The facility’s stated practice for personal funds was to keep them in the facility safe or send them home with family, but the resident refused to use the facility safe despite multiple offers and education about the risks of keeping cash on hand. The resident’s care plan only addressed that he preferred to keep his money and declined to keep it in the safe, with instructions to continue offering the social services safe and reeducating him about the risks of keeping money at bedside. No other care plans were found regarding his personal funds, including his bank visits, inventory of withdrawn money, or use of the personal safe. The ASW, LN, DON, and ADM all acknowledged that the facility did not develop a personalized care plan for the resident’s money withdrawals, inventory process, safe use, or expectations after returning from the bank.
Failure to Maintain Foley Catheter Drainage Bag Off the Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff adhered to infection prevention and control practices related to urinary catheter care for one resident. The resident was admitted with a diagnosis that included acute kidney failure. During a tour of the facility, the resident was observed in their room with a Foley catheter drainage bag touching the floor beside the bed, where it remained for an undetermined amount of time. The facility’s written policy on urinary catheter care stated that catheter tubing and drainage bags must be kept off the floor. In subsequent interviews, CNA 1 stated that the Foley catheter and tubing should not touch the floor and that the urine bag must be placed inside a catheter bag to prevent infections. The Infection Preventionist stated that Foley catheters should be hung on the low side of the resident’s bed so they do not touch the floor and that the urine bag should be placed inside a catheter bag, and reported that all nursing staff were expected to adhere to infection control practices. The DON similarly stated that Foley catheters should never touch the floor and should be maintained in a urine catheter bag to prevent cross-contamination, and that nursing staff were expected to strictly adhere to infection control practices. Despite these stated expectations and the written policy, the resident’s Foley catheter drainage bag was observed on the floor.
Failure to Timely Report Allegation of Financial Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of financial abuse involving a resident. The resident, who was mildly cognitively impaired, reported to the Administrator that a significant amount of money was missing from his room. Despite the resident informing the Administrator of the missing money, the facility did not report the incident to the Department as required. The Administrator stated that they were unaware of the need to report the incident since no specific individual was accused, and there was no evidence provided that the incident was reported until the surveyor began investigating. The delay in reporting resulted in the incident only being reported to the Department 14 days after the resident initially informed the Administrator. Facility policy required notification of the state licensing and certification agency within 24 hours of such incidents and a written report of findings within 5 working days. The Director of Nursing confirmed that the incident was not reported in a timely manner, and the facility's own records indicated the reporting requirements were not met.
Failure to Monitor and Document Catheter Care and Urine Output
Penalty
Summary
Facility staff failed to consistently monitor and document urine output for four of six sampled residents with urinary catheters, as required by both physician orders and facility policy. Multiple instances were identified where urine output was not recorded every shift, including specific dates and shifts for each resident. Staff interviews confirmed that the expectation was to measure and document urine output in milliliters every shift, but this was not consistently done. The Director of Nursing acknowledged that this monitoring was necessary to identify fluid retention and prevent urinary tract infections (UTIs). Additionally, there was a lack of physician orders for urinary catheter care for two residents with catheters. Staff interviews revealed confusion regarding responsibility for catheter care, with some licensed nurses stating they did not know how to perform catheter care and others indicating it was the responsibility of different staff members. The facility's policy required documentation of catheter care, including the date and time it was provided, but this was not found in the records for the affected residents. Observations confirmed that residents had urinary catheters in place, and some residents reported pain or were unable to communicate their needs. The failure to monitor and document urine output and to ensure proper catheter care orders and documentation were in place had the potential for residents to experience urinary retention and develop UTIs, as noted in the findings. Facility policies reviewed during the survey outlined the procedures for catheter care and urine output monitoring, but these were not followed as required.
Outdated Food and Staff Personal Items Stored Improperly in Kitchen
Penalty
Summary
During a survey, it was observed that a container of sour cream in the facility's kitchen was stored past its labeled use by date. The Certified Dietary Manager (CDM) confirmed that the sour cream should have been discarded on or before the use by date to prevent the risk of foodborne illness. The Registered Dietitian (RD) also acknowledged that the outdated sour cream should have been removed according to the label. Review of FDA guidelines indicated that ready-to-eat foods must be discarded if they exceed the appropriate date or temperature requirements. Additionally, personal clothing items belonging to staff were found hanging on food storage container carts in the kitchen. The CDM stated that personal clothes should be kept in lockers to maintain food safety, and the RD agreed that staff personal belongings should not be stored near food items or equipment. Facility policy also specified that personal items brought in by staff should not be kept in the kitchen.
Failure to Apply Denture During Meals
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, muscle weakness, and communication deficit was not provided with their lower denture during meals, as required by their nursing care plan. The care plan specified that both upper and lower dentures should be worn during meals and removed at night. Observations on two separate occasions found the resident eating without the lower denture in place, with the denture observed inside a denture cup on the bedside table. Interviews with a licensed nurse confirmed that the lower denture was not applied and that staff should have ensured the denture was in place to allow the resident to chew and eat properly. The DON acknowledged that the care plan was not followed, and facility policy indicated that residents should be encouraged to keep dentures in their mouths. This failure to implement the care plan had the potential to affect the resident's well-being, comfort, and safety during meals.
Failure to Monitor and Document Central Venous Catheter Measurements During Dressing Changes
Penalty
Summary
The facility failed to ensure that central venous catheters were properly monitored and maintained for two residents. Both residents had IV lines in their right upper arms and reported that their dressings had been changed the previous day. However, neither resident could recall if the nurse measured their arm circumference or the length of the IV catheter during the dressing change. Review of the IV Medication Administration Record for both residents confirmed that these measurements were not documented during the most recent dressing changes. Interviews with nursing staff and the Director of Nursing confirmed that measuring arm circumference and catheter length during dressing changes is a standard practice intended to ensure proper catheter placement and prevent complications. The facility's own policy on central venous catheter care and dressing changes also requires these measurements to be performed and documented with each dressing change. The omission of these steps constituted a failure to meet professional standards of quality for IV therapy management.
Failure to Prevent and Accurately Assess Pressure Injuries
Penalty
Summary
The facility failed to provide appropriate interventions to prevent the redevelopment and development of pressure injuries for two residents. One resident, who had a history of stage 3 pressure injury on her left buttock, was readmitted with generalized muscle weakness and required moderate staff assistance for mobility. Despite being placed on a low air loss mattress and having a known risk for skin breakdown, there was a lack of timely physician orders and treatment documentation when a new open wound was observed. Licensed nurses documented the presence of an open wound over several days but did not initiate treatment or notify the wound care nurse or physician, resulting in a stage 3 pressure injury being identified later. Weekly summary notes inaccurately indicated no skin injury during this period. Another resident, with a history of muscle weakness and abnormal mobility, was identified as being at risk for skin breakdown in the care plan. However, nursing documentation failed to accurately assess and report the resident's skin condition, with weekly summaries indicating no skin breakdown until a deep tissue injury (DTI) was discovered. The wound care nurse and licensed nurse both acknowledged that the DTI could have been prevented with accurate assessment, prompt communication, and appropriate treatment. Facility policy required comprehensive skin assessments, daily skin inspections during personal care, and prompt evaluation and reporting of potential skin changes. These protocols were not followed, as evidenced by the lack of timely assessment, documentation, and intervention for both residents, leading to the development and redevelopment of pressure injuries.
Failure to Supervise Resident During Shaving Increases Accident Risk
Penalty
Summary
A deficiency occurred when a resident with right eye vision loss and a physician order for daily aspirin, which increases bleeding risk, was observed shaving her chin with a disposable razor without staff supervision. The resident reported that she shaved herself daily. Licensed nursing staff confirmed that, due to the resident's vision impairment and aspirin use, she was at risk for bleeding and should have been supervised or assisted during shaving. The Director of Nursing acknowledged that staff should assist residents to prevent accidents and that the resident should not have been shaving independently given her condition. Facility policy required review of the care plan to assess for special needs prior to shaving, but this was not followed in this instance.
Failure to Administer Oxygen Therapy per Physician Order
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered according to the physician's order for a resident with severe chronic obstructive pulmonary disease (COPD) and cognitive impairment. The physician's order specified continuous oxygen at 2 liters per minute (LPM) via nasal cannula, but observations on multiple occasions found the resident receiving oxygen at 4 LPM. Interviews with staff confirmed that licensed nurses were responsible for managing the resident's oxygen therapy and were aware of the physician's order. Record reviews and staff interviews further established that the facility's policies required adherence to physician orders for medication and treatment administration, including oxygen therapy. Despite these policies, the resident consistently received a higher oxygen flow rate than ordered, as documented by both direct observation and photographic evidence. The Director of Nursing acknowledged that the physician's order should have been followed to prevent potential complications.
Failure to Label Opened Inhaler per Facility Policy
Penalty
Summary
The facility failed to ensure that an inhaler used for one resident was labeled with the date it was opened, as required by facility policy and professional standards. The resident, who had chronic respiratory failure, had a physician's order for a Fluticasone Furoate Vilanterol inhaler to be administered daily for shortness of breath and wheezing. During an observation of the medication cart, an opened box of the inhaler was found without an open date. The nurse present acknowledged that she had opened the inhaler the previous day and forgot to label it. The Director of Nursing confirmed that the facility's expectation is for all opened multidose medications to be dated upon opening. A review of the facility's policy also indicated that opened multidose vials must be dated and discarded within 28 days.
Failure to Cohort Residents on Isolation Precautions for Influenza A
Penalty
Summary
The facility failed to properly cohort residents in accordance with infection prevention and control protocols. Specifically, a resident with mild intermittent asthma was admitted into a room that was under isolation transmission-based precautions due to another resident's exposure to Influenza A. The signage for isolation contact precautions was observed outside the room, and staff confirmed that the resident exposed to Influenza A was placed on isolation precautions prior to the admission of the new resident. Interviews with facility staff, including a licensed nurse, the Infection Preventionist Nurse, and the Director of Nursing, confirmed that the new resident should not have been admitted to the same room as the resident on isolation precautions. The Infection Preventionist Nurse stated that the newly admitted resident was tested for Influenza A, but results were pending at the time. Facility policy indicated that prevention of seasonal influenza outbreaks requires coordinated efforts, which was not followed in this instance.
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Illustrative
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
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Illustrative
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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) |
|---|---|---|---|---|
| Bella Vista Health Center | 1 mi | ★★★★★ | 11 | 0 |
| Lemon Grove Care And Rehabilitation Center | 1.2 mi | ★★★★★ | 27 | 0 |
| Amaya Springs Health Care Center | 1.8 mi | ★★★★★ | 11 | 0 |
| Parkway Hills Nursing & Rehabilitation | 2 mi | ★★★★★ | 2 | 0 |
| Arbor Hills Nursing Center | 2 mi | ★★★★★ | 8 | 0 |
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