Lemon Grove Care and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lemon Grove Care and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 12, 2023

  Based on interview, and record review, the facility failed to ensure one of three residents (Resident 1) did not gain access to illegal substances. As a result, Resident 1 died at the facility. The Medical Examiner's report indicated Resident 1 had fentanyl (a potent synthetic opioid drug) and methamphetamine (a potent central nervous system stimulant) in his system. Findings: A record review of Resident 1's undated Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included low back pain, other psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), insomnia (the presence of an individual's report of difficulty with sleep), and… […]

• No harm, potential for more than minimal, widespreadF865Dec 18, 2025

  Based on interview and record review, the facility's Quality Assurance Agency (QAA) failure to identify, monitor, and address problem areas identified by the State Survey team for their Quality Assurance and Performance Improvement (QAPI) plan, during their annual recertification.This failure put all residents at risk for medication errors and equipment failures.(See F-759, F-761, and F-908)An interview was conducted with the Administrator (ADM) and Director of Nursing (DON) on 12/18/25 at 5:31 P.M. The ADM and DON stated they both started at the facility three months ago. The ADM and DON stated they had reviewed last year's recertification and recognized medication administration and medication storage were both issues. […]

• No harm, potential for more than minimal, widespreadF880Dec 18, 2025

  Based on observation, interview and record review, the facility failed to implement their own Infection Control Program when: 1. There was no documented evidence regarding vaccine refusal, no documented hand hygiene surveillance and no documented evidence regarding antibiotic surveillance,Cross reference F881 2. Resident 178's oxygen tubing did not have a date, 3. Resident 8's oxygen tubing and nebulizer (liquid medication delivered as a fine mist inhaled into the lungs through a mouthpiece or mask) mask were not dated and stored properly. These failures could potentially contribute to the spread of microorganisms. 2. […]

• No harm, potential for more than minimal, patternF677Dec 18, 2025

  Based on observation, interview, and record review, the facility failed to provide assistance for 6 of 6 dependent residents with their Activities of Daily Living (ADLs, activities related to mobility and personal care) when: 1. Resident 23 was not assisted in getting up and out of bed. Cross Reference F- 679. 2. Two residents (Resident 71 and Resident 163) who were cognitively impaired were not cued to perform hand hygiene before meals. 3. Routine nail care was not provided to three residents (Residents 90, 6 and 112). As a result, the residents were at risk for skin injury, infection and overall quality of life. Findings: 1. […]

• No harm, potential for more than minimal, patternF684Dec 18, 2025

  Based on observation, interview, and record review, the facility failed to ensure: 1.Timely assessment, monitoring and immediate physician notification in response to significant clinical changes, including suspected gastrointestinal (referring to the stomach and intestines) bleeding and ongoing nausea or vomiting for one of three sampled residents reviewed for closed record (Resident 1). Cross Reference F 580. 2. A physician's order was obtained from the attending physician prior to blood sugar checks on a resident (Resident 9) who was on insulin (antidiabetic medication). In addition, blood sugar checks was obtained without proper time interval. […]