Kearny Mesa Convalescent and Nursing Home

In the surveyor’s words

From the most serious findings on record at Kearny Mesa Convalescent and Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF689Jul 22, 2026

  Based on interview and record review, the facility failed to provide adequate supervision for one of two residents reviewed for falls (Resident 1).As a result, Resident 1 was left unsupervised, fell and sustained a hip fracture. Findings:According to the undated admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include abnormalities of gait (a person's manner of walking) and mobility (the ability to move freely and easily) and dementia (a progressive state of decline in mental abilities).According to the physician's History and Physical (H&P), dated 6/26/26, Resident 1 had impaired mobility due to multiple hospital stays. The H&P indicated Resident 1 had poor recall, poor memory, and had no capacity to understand her medical condition. […]

• No harm, potential for more than minimal, isolatedF641Jun 25, 2026

  Based on interview and record review, the facility failed to accurately code a resident's fall on the Minimum Data Set (MDS - a federally mandated resident assessment tool) for one of five sampled residents (Resident 2). This deficient practice placed all fall risk residents at risk for inaccurate plan of care triggers necessary for individualized safety precautions, quality measure (QM-grades clinical outcomes and physical well-being provided by the facility) calculations and reimbursement adjustments being reported to CMS.Findings:A review of Resident 1's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included history of Abnormalities of Gait (walking) and Mobility, and Mild Cognitive (pertaining to memory, judgement and reasoning… […]

• No harm, potential for more than minimal, isolatedF755Apr 1, 2026

  Based on interview and record review, the facility failed to ensure a medication was administered as ordered, and to ensure unattended medications were not accessible to residents for one of five sampled residents (1). As a result, Resident 1 had an increased risk of pain from the missed medication, and residents were at risk of accidental ingestion or exposure to unattended medications left on the floor.Findings: Per the facility's admission Record, resident 1 was admitted to the facility on [DATE] with diagnoses to include anxiety. Per the facility's Progress Notes, there were no notes documented for Resident 1 on 3/11/26. […]

• No harm, potential for more than minimal, isolatedF657May 8, 2025

  Based on interview, record review, and facility policy review, the facility failed to ensure the comprehensive care plan was revised to accurately reflect the information in the comprehensive assessment, which affected 1 (Resident #61) of 4 residents reviewed for advance directives. Specifically, the facility failed to revise Resident #61's care plan to reflect the resident's code status listed in the comprehensive assessment. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy revealed, 2. […]

• No harm, potential for more than minimal, isolatedF695May 8, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to obtain orders for the use of a non-invasive mechanical ventilator (specifically, continuous positive airway pressure; CPAP) timely, which affected 1 (Resident #184) of 3 residents reviewed for respiratory care . Findings included: A facility policy titled, CPAP/BiPAP [bilevel positive airway pressure] Support, revised 03/2015, directed staff under a Preparation section to 2. Review the physician's order to determine the oxygen concentration and flow and the PEEP [positive end-expiratory pressure] pressure (CPAP, IPAP [inspiratory positive airway pressure] and EPAP [expiratory positive airway pressure]) for the machine. […]