Lemon Grove Care and Rehabilitation Center

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. Resident 178 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) according to the facility's admission Record. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. This deficient practice resulted in a delay in the resident receiving treatment to address Resident 1's necessary care and services and placed Resident 1's health at risk. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary medication when a resident (Resident 5) was receiving rivaroxaban (blood thinner that prevents and treat blood clots, one side effect is bruising or bleeding) and was not monitored for five months for signs and symptoms of bruising/ bleeding for one of two sampled residents reviewed for anticoagulant (AC, medicines that help prevent blood clots). This failure could result in AC medication related untoward side effects from inconsistent and poor management of medication therapy for Resident 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 19.51%. Eight medication errors were observed out of 41 opportunities, during the medication administration process for one of eight randomly observed residents (Resident 8). As a result, the facility could not ensure medications were correctly administered to all residents. In addition this deficient practice had the potential to affect the resident's health and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to follow its own policy and procedure to establish an antibiotic stewardship program when the Infection Preventionist (IP) did not comprehensively track and monitor appropriate use of antibiotics. This failure had the risk to affect the residents in the facility due to lack of oversight and monitoring that could lead to increased infections and preventable deaths from resistant infections. Cross reference F880Findings: On 12/18/25 at 1: 17 P.M., an interview and record review was conducted with the Director of Staff Development (DSD), Director of Nursing in training (DONIT), and the Director of Nursing (DON). The DSD stated she started working on April 224 with DSD role and doing Infection Preventionist (IP) role on 12/11/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident equipment in a safe, functional manner for 57 of 159 residents, located in the secured unit, (specialized, secured area for residents with dementia or mental illness, who are prone to wandering), when:1. Handrails in the hallway, ( Station 3), had peeling paint, and;2. A bed remote control had exposed wires. These failures had the potential for peeling paint to be ingested by confused residents and the wires from the bed's remote control to pierce the skin of a resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity for two of six residents (Resident 4 and Resident 177) when:1. Resident 177 had an uncovered urinary collection bag (when urine drains from the bladder into a clear plastic drainage bag); and,2 . A staff member stood over Resident 4, while assisting with a meal. These failures had the potential for Residents 4 and 177 to feel exposed and undignified.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a Licensed Nurse (LN 1) notified the physician immediately, when a resident who was on anticoagulant therapy (medicines that help prevent blood clots) experienced episodes of vomiting large amount of coffee ground vomit (coffee ground vomit indicates upper gastrointestinal bleeding), for one of three sampled residents (Resident 1) reviewed for closed record. This deficient practice resulted in a delay in the resident receiving treatment to address Resident 1's significant change in condition and placed Resident 1's health at risk. Cross Reference F 684.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a thorough investigation was conducted for an allegation of abuse for one of one resident (Resident 162), when Resident 162 reported a male staff (RNA- restorative nursing assistant 1) inappropriately touched her. This failure had the potential to negatively affect Resident 162's psychosocial wellbeing and the potential to expose all residents in the facility to abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a written notice of transfer and its bed hold policy to a resident and his Responsible Party (RP) at the time of his hospital transfer for one of three residents (18) reviewed for closed record. As a result, Resident 18 and his RP were not fully informed of Resident 18's bed hold rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and code two of six residents (130 and 9) for Restorative Nursing Services (RNA-a specially training certified nursing assistant who provides range of motion exercises with residents, in order to maintain mobility and flexibility) on their Minimum Data Set (MDS-a mandated reporting assessment tool) used to inform Centers for Medicare and Medicaid Services (CMS), of residents' current status reviewed for MDS accuracy. This failure resulted in CMS not being informed of Resident 130's and Resident 9's current health status and services being provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASSAR 2-a federally mandated process that ensures individuals with serious mental illness (SMI), intellectual disabilities (ID), developmental disabilities (DD), are not inappropriately admitted to Medicaid-certified nursing facilities (NFs) if they can be served in a more integrated, community-based setting) was completed in a timely manner for one of three residents (Resident 129) reviewed for PASSAR.The failure had the potential for Resident 129 to be improperly placed or to miss out on additional services offered for PASSAR II residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized therapeutic and or social activities that promote the residents' highest physical, mental, and psychosocial well-being, according to their plan of care for one of three reviewed residents (Resident 23). This deficient practice placed Resident 23 at risk for decreased emotional well-being, social isolation, and reduced quality of life due to the lack of meaningful engagement. Cross Reference F 677.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete post fall assessments for one of one resident (Resident 57) reviewed for accidents according to the facility's policy and procedure. This failure had the potential for not identifying the root cause of Resident 57's falls and maintain Resident 57's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (Resident 5) was positioned properly while tube feeding (TF-nutrition in liquid form through a tube) was ongoing per the resident's plan of care for one of two residents reviewed for TF. As a result, Resident 5 was at risk for aspiration (back up of fluid from the stomach to the lungs) and other TF complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess respiratory status during a nebulizer treatment (liquid medication delivered as a fine mist inhaled into the lungs through a mouthpiece or mask) for two of two residents (Resident 178 and Resident 8) reviewed for respiratory care. This failure had the potential for residents to receive inappropriate care and treatment to address their respiratory problems.

Inspectors wroteBased on interview and record review, the facility failed to address and implement the Consulting Pharmacist's (CP) recommendation during a monthly Medication Regimen Review (MRR) regarding a psychotropic medication (a medication that affects brain function), for one of five residents (Resident 99), for Medication Review. In addition, the CP did not identify monitoring of untoward side effects of anticoagulant (AC, blood thinner medication) for one of two residents (Resident 5) reviewed for AC (Cross Reference F 757). This failure had the potential for Resident 99 not to be monitored appropriately by staff for exhibiting specific behaviors. In addition, Resident 5 was not monitored for untoward side effects of AC for five months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications had proper storage and labeling when:1. Two tablets were found loose and unlabeled inside a medication drawer,2. Expired medications were stored inside the medication refrigerator These failures had the potential for medications to be incorrectly administered and decrease medication potency (medication strength) that could compromise the therapeutic effectiveness of stored medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff carried out the tasks of the food and nutrition services department in accordance with the standard of practice for the following kitchen competencies: 1. [NAME] (CK) 1 did not demonstrate how to conduct spoon tilt tests (food must hold its shape on a spoon and when tilted, it should fall off with little residue) of pureed food. 2. CK 2 did not know how to calibrate food thermometers. These failures had the potential to expose all residents who consumed food from the kitchen to contract a food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to obtain written consents and educational proof that residents and their responsible persons (RPs-a person assign to make medical decisions on behalf of the resident) were informed of the risk and benefits for receiving or declining pneumococcal (an immunization protecting against streptococcus pneumoniae bacteria, which causes severe infections) and influenza vaccines (prevents the seasonal flu, a contagious respiratory illness) for two of five residents (Resident 14 and 121), reviewed for vaccinations. As a result, Residents 4 and 121, along with their RPs were not informed of the risks and benefits, if the vaccine was received or declined.1. Resident 121 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought). [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain written consents and educational proof that residents and their responsible persons (RPs-a person assign to make medical decisions on behalf of the resident) were informed of the risks and benefits for receiving or declining the SARS-COV-2 vaccine (prevents severe COVID-19 illness, a highly contagious respiratory virus), for two of five residents (Resident 14 and 121), reviewed for vaccinations. As a result, Residents 4 and 121, along with their RPs were not informed of the risks and benefits, or if the vaccine was received or declined.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement for the accommodation of no more than four residents per resident room. This affected two of 65 resident rooms (room [ROOM NUMBER] and 112). rooms [ROOM NUMBERS] were occupied by five residents in each room. This failure had the potential for residents to feel crowded.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the required resident assessment for 1 resident reviewed for accuracy of assessments. This failure had the potential for not identifing Resident 1's needs.

Inspectors wroteBased on interview and record review, the facility failed to implement their admission policy when one of three residents (Resident 1) was admitted to the facility without sufficient information to determine if appropriate care and services could be provided to the resident. As a result of this deficient practice, the facility sent Resident 1 back to the hospital which had the potential to cause the resident distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) was permitted to remain in the facility when the resident was discharged to the hospital without a valid clinical reason. This deficient practice had to potential to cause Resident 1 to experience psychosocial and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to update the care plan with resident-specific interventions for one of one resident reviewed for falls (Resident 1). This failure had the potential for Resident 1 to sustain further falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation in the clinical record was accurate for one of two residents (Resident 1) when: 1. Licensed nurses (LN) documented Lithium (a mood stabilizing medication) as having been administered to the Resident 1 when the medication was unavailable. 2. Resident 1 ' s documented behavior monitoring did not reflect accurate observations of the resident ' s behavior. As a result, Resident 1 ' s clinical record did not accurately reflect the care and treatment that was provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement resident-centered care plans related to: 1. Resident 47 was not assessed for activities. 2. Resident 42 was not assessed for triggers related to Post-Traumatic Stress Disorder (PTSD- a condition in which a person has difficulty recovering after witnessing or experiencing a terrifying event). 3. The central port (a line used for dialysis access) was not identified or did not provide direction of care for Resident 32. 4. In addition, turning and repositioning was not implemented for Resident 43. As a result, there was not a consistent approach by staff to address residents' care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were safely stored when: 1. The medication refrigerator temperature log was incomplete. 2. A food product was found stored in a medication cart. 3. A discontinued medication was not discarded from a medication cart. 4. A medication cart was not locked and unsecured. 5. A medication was left unattended at a resident's bedside. As a result, refrigerator medications could have been ineffective if not stored at the correct temperature, food could cause cross contamination to medications, discontinued medication could have been accidentally been administered, and unauthorized residents, visitors and staff could have access to medications, which could be harmful.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 106) was assisted with a meal in a dignified manner. This failure had the potential for Resident 106 to experience a diminished self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy was provided to one of 29 residents (Resident 32) during personal care. As a result, there was the potential for Resident 32 to feel embarrassed and distressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activities of interest for one of one residents (47) reviewed for activities. This failure had the potential to not maintain or improve Resident 47's physical, mental and psychosocial well-being and independence.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident with a past trauma received trauma informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents (42 ) reviewed for trauma informed care. As a result, there was the potential for the resident to not have a sense of emotional and physical safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four licensed nurses (LN) 10 was competent (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to perform medication administration. As result, the medications LN 10 administered to Resident 43 did not consistently adhere to the physician's order, were incompletely given, had hold parameters that were not verified, medications were left unattended, acceptable infection control standards were not implemented, and documentation in the medication administration record (MAR) was inaccurate. These deficiencies had the potential to effect resident safety and the efficacy of treatment. Cross reference F759, F761, F842, and F880.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 8.33 percent. Three (3) medication errors were observed, a total of 36 opportunities, during the medication administration process for two (2) of five randomly observed residents (Residents 10 and 43). As a result, the facility could not ensure medications were correctly administered to all residents. Cross reference F726.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 122) received food and drink that was palatable, appetizing, and attractive, when the resident was served nectar thick beverages (liquids that had a thickener added to make the consistency like nectar) and some pureed food items (food blended to a pudding-like texture) without a physician's order or clear indication. As a result, Resident 122 stated she did not want to eat the food which put the resident at risk for unintended weight loss and malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure documentation of medication administration was accurate in one of five residents' (Resident 43) medication administration record (MAR). This failure had the potential to not accurately reflect the treatments provided to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents' (Resident 43) medication administration followed acceptable infection control practices when licensed nurse (LN) 10 attempted to administer a medication that had been disposed of in the trash can. This deficient practice had the potential to expose Resident 43 to infection via the resident's g-tube (a tube surgically placed through the abdominal wall for medication administration and liquid feeding). Cross reference F726.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Residents were free from physical and verbal abuse when Resident 3, who had a history of hitting others and wandering, wandered around the facility, entered other resident rooms, and start altercations while unsupervised. On five separate occasions (12/26/22, 1/26/23, 2/17/23, 3/13/23, and 9/12/23) Resident 3 entered other residents ' rooms/personal space wherein she yelled and cussed at, pulled hair, slapped, and hit other residents. 2. After Resident 3 had repeatedly verbally and physically abused other residents, the facility failed to implement close supervision of the resident when wandering to prevent further incidents from occurring. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure its abuse policies were implemented when certified nursing assistant (CNA) 4 did not report Resident 1 ' s allegation of physical abuse. In addition, the facility did not report the allegation of abuse within 24 hours to the California Department of Public Health (CDPH, state survey agency that regulates nursing homes) and law enforcement entity as was mandated by law. As a result of this deficient practice, investigation into the allegation of abuse was delayed and placed residents at risk for further abuse. Cross reference F600.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident ' s (Resident 3) written care plan for wandering behavior was implemented when incidents of wandering and what diversional activity was attempted were not consistently documented. As a result, the facility could not track Resident 3 ' s incidents of wandering and what diversional activity may or may not have been effective. Cross reference F600 and F609.

Inspectors wroteBased on interview and record review, the facility failed to revise/update Resident 3 ' s written care plan to provide close supervision when the resident was wandering around the facility after Resident 3 had incidents of entering other residents ' rooms that resulted in resident-to-resident altercations. As a result of this deficiency, Resident 3 continued to wander into other residents ' rooms and those residents experienced abuse or were at risk for experiencing abuse. Cross reference F600.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide catheter (tube inserted into the bladder) care for four of four residents (19, 61, 123 and 126). This failure had the potential to increase the risk of infection for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to support one of 29 resident's (81) choice for medical treatment. As a result, Resident 81 was given medication without her consent.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge for one of three sampled residents (146). As a result, Resident 146 was discharged to a homeless shelter where her medical and daily needs could not be met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive care plan was developed related to suprapubic catheter (tubing inserted to the bladder through a small hole in the belly to drain urine) care for one of four residents (61) reviewed for catheter care. As a result, Resident 61 was at risk for developing an infection.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide adequate monitoring for one of 29 resident's (81) medical condition. This created the potential for Resident 81 to have higher amounts of drugs in her system and increase the likelihood of side-effects related to her medication orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Licensed Nurse (LN) followed the physician's order and the facility's policy and procedure prior to administration of medication through a tube feeding (tube surgically inserted into stomach to provide medications and nutrition) for one of one residents (85). This failure had the potential for Resident 85 to not receive the full dose of medications administered.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 6.25 %. Two medications errors were observed out of 32 opportunities, during the medication administration process for two of 5 randomly observed residents (Resident 62, 69, 84, 85 and 86). As a result, the facility could not ensure medications were correctly administered to all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and discard potentially hazardous food. As a result, all residents were at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement for the accommodation of no more than four residents per resident room. This affected two of 65 resident rooms (room [ROOM NUMBER] and 112). rooms [ROOM NUMBERS] were occupied by five resident beds in each room.