La Mesa Healthcare Center

In the surveyor’s words

From the most serious findings on record at La Mesa Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Jul 22, 2026

  Based on interview and record review, the facility failed to develop and implement individualized, person-centered discharge care plans that reflected each individualized, person-centered discharge for three of five sampled residents (Resident 1, 3 and 4) with the same generic and identical goals and interventions for each resident.These deficient practices placed three residents (Resident 1, 4 and 5) at risk for unmet healthcare needs, poor coordination of care, ineffective discharge planning, interruption in continuity of care, and avoidable health complications after discharge. Cross Reference F627 and F628. Findings:1. […]

• No harm, potential for more than minimal, patternF690Mar 27, 2025

  Based on observation, interview, and record review, the facility staff failed to consistently monitor and document urine output (UO) per the facility's policy, for four of six sampled residents (7, 10, 11 and 12) with a urinary catheter (a tube inserted into the bladder to aid in urine flow). In addition, there was no urinary catheter care order for Residents 7, and 12. These failures had the potential for residents 7, 10, 11 and 12 to have urinary retention and develop urinary tract infection (UTI). Findings: 1a. Resident 7 was readmitted to the facility on [DATE], with diagnoses which included sepsis (a serious condition in which the body responds improperly to an infection), per the facility's Admission Record. […]

• No harm, potential for more than minimal, patternF812Mar 27, 2025

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations, according to standards of practice when: 1. One outdated container of sour cream was not discarded and still stored for use and consumption. 2. Personal clothing items that belonged to staff were hanging on the food container carts. These failures had the potential to expose residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses. Findings: 1. On 3/24/25 at 8:19 A.M., a concurrent observation and interview was conducted with the Certified Dietary Manager (CDM). One container of sour cream was labeled with a use by date (when food should be consumed) of 3/22/25. […]

• No harm, potential for more than minimal, patternF880Dec 2, 2021

  Based on observation, interview and record review, the facility failed to ensure infection control policies were followed when: 1. Oxygen tubing was not changed weekly for three of three residents reviewed for oxygen therapy (17, 52, and 53), 2. A Licensed Nurse (LN) did not perform hand hygiene between glove changes and did not ensure scissors were clean and sanitized before use during a dressing change for one sampled resident (21). These deficient practices had the potential for cross-contamination, and placed the residents, staff, and visitors at risk for facility acquired infections. Findings: 1a. On 11/29/21 at 10:42 A.M., an observation was conducted with Resident 53. Resident 53 was on the bed and actively receiving oxygen therapy. […]

• No harm, potential for more than minimal, isolatedF627Jul 22, 2026

  Based on interview and record review, the facility failed to prepare a safe and coordinated discharge for one of five sampled residents (Resident 1) by not providing necessary equipment for a continuous tube feeding(TF-way to give liquid food, water, and medicine directly into the stomach or small intestine through a soft plastic tube when a person cannot safely chew or swallow) order and/or necessary teaching to administer a bolus (a way to give liquid food or formula through a feeding tube like a meal, using a large syringe several times a day) feeding as revised due to no feeding pump (machine used to deliver tube feedings).These deficient practices placed Resident 1 at risk for missed needed nutrition, delayed feeding, poor nutritional status, dehydration, re-hospitalization, and… […]