Lemon Grove Care And Rehabilitation Center

F-F726.

Findings:

A review of Resident 43's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses to include hemiplegia and hemiparesis (paralysis and weakness) affecting right side following

a stroke, hypertension, dementia (memory loss), and gastrostomy (opening into the abdominal wall for insertion of a feeding tube [g-tube]).

A review of Resident 43's physician orders dated 4/11/24, indicated, Enhanced Barrier Precautions: [interventions used to control transmission of microorganisms resistant to antibiotics] PPE [personal protection equipment such as gowns and gloves] required for high resident contact care activities. Indication: Implanted feeding device [g-tube].

On 8/14/24 at 9:03 A.M., a medication administration was observed with LN 10. LN 10 began to dispense Resident 43's medications.

At 9:12 A.M., LN 10 donned PPE and entered Resident 43's room to administer the medications. LN 10 checked the placement of Resident 43's g-tube. While at the resident's bedside, LN 10 poured cold water into the clear plastic medication cups with powdered (crushed) tablet/s. The powdered tablet/s in the medication cups did not fully dissolve in the cold water and adhered to the bottom and/or sides of the medication cups. LN 10 administered the medications to the resident. LN 10 threw away one medication cup with a heavy amount of chalky, white substance into the resident's bedside trash can. The medication cup laid on its side in the trash can on top of the used PPE. LN 10 stated he was finished administering Resident 43's medications and disconnected and closed the resident's g-tube.

LN 10 retrieved the medication cup that was thrown in the trash can with heavy, white substance and observed it. LN 10 acknowledged that nearly a full dose of medication had remained in the medication cup. LN 10 then stated he would try to administer it again to Resident 43. LN 10 began to reassemble his supplies and to access the resident's g-tube. LN 10 was requested by this surveyor to stop the administration and to not give the resident the medication that had been in the trash can. LN 10 then stated he would not want to be given a medication that had been in the trash can if he were the resident. LN 10 stated it was an infection control concern. LN 10 stated he would go get another dose of medication to give to the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 055182 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055182 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 8/14/24 at 10:05 A.M., an interview was conducted with the director of nursing (DON). The observed medication administration with LN 10 was discussed. The DON was informed that LN 10 had been stopped Level of Harm - Minimal harm or from giving medication that had been put in the trash can. The DON stated it was unacceptable to administer potential for actual harm medication that had been in the trash can.

Residents Affected - Few On 8/14/24 at 4 P.M., an interview was conducted with the infection prevention nurse (IPN). The observed medication administration with LN 10 was discussed. The IPN stated attempting to administer a medication that had been in the trash can was not following acceptable infection control practices. The IPN stated no one should ever give a resident a medication that had been in the trash can. The IPN stated Resident 43 also had a g-tube and infection could be spread through the resident's g-tube.

A review of the facility's undated policy titled Administering Medications, indicated, Medications shall be administered in a safe and timely manner

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 055182

F-F880.

Findings:

A review of Resident 43's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses to include hemiplegia and hemiparesis (paralysis and weakness) affecting right side following

a stroke, hypertension, dementia (memory loss), and gastrostomy (opening into the abdominal wall for insertion of a feeding tube [g-tube]).

On 8/14/24 at 9:03 A.M., a medication administration was observed with LN 10 while at the LN's medication cart located outside of Resident 43's room. LN 10 stated he needed to go find a disinfecting wipe and proceeded to walk down the hallway and out of sight. LN 10 left the medication cart unlocked and unattended. LN 10 returned to the medication cart at 9:05 A.M., and acknowledged the medication cart was unlocked. LN 10 stated he should have locked the medication cart before he left.

LN 10 began to dispense Resident 43's medications into individual, unlabeled medication cups (30 milliliters/ml size) as followed:

1. Amlodipine 2.5 milligrams (mg- a unit of measurement) (controls blood pressure [LN 10 crushed the tablet into a powder])

2. Apixaban 5 mg (anticoagulant [LN 10 crushed the tablet into a powder])

3. Lactulose 25 ml (promotes bowel movement)

4. Keppra 5 ml (controls seizures)

5. Polyethylene glycol 17 grams (promotes bowel movement [LN 10 mixed it with approximately 4 ounces of water])

6. Multivitamins 5 ml

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 25 055182 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055182 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 7. Vitamin D 50 mcg (LN 10 crushed the tablets into a powder).

Level of Harm - Minimal harm or At 9:12 A.M., LN 10 donned personal protective equipment (PPE, gown and gloves) and entered Resident potential for actual harm 43's room to administer the medications. LN 10 checked the placement of Resident 43's g-tube. While at the resident's bedside, LN 10 poured cold water into the clear plastic medication cups with powered (crushed) Residents Affected - Few tablet/s. The powdered tablet/s in the medication cups did not fully dissolve in the cold water and adhered to

the bottom and/or sides of the medication cups. LN 10 administered the medications to the resident. LN 10 threw away one medication cup with a heavy amount of chalky, white substance into the resident's bedside trash can. The medication cup laid on its side in the trash can on top of the used PPE. LN 10 administered

the remaining medications and did not flush the medication cups with water to ensure all the residual medication had been administered. All medication cups had visible residue in them. LN 10 stated he was finished administering Resident 43's medications and disconnected and closed the resident's g-tube.

LN 10 retrieved the medication cup that was thrown in the trash can with heavy, white substance and observed it. LN 10 acknowledged that nearly a full dose of medication had remained in the medication cup. LN 10 then stated he would try to administer it again to Resident 43. LN 10 began to reassemble his supplies and to access the resident's g-tube. LN 10 was requested by this surveyor to stop the administration and to not give the resident the medication that had been in the trash can. LN 10 then stated he would not want to be given a medication that had been in the trash can if he were the resident. LN 10 stated it was an infection control concern. LN 10 stated he would go get another dose of medication to give to the resident. LN 10 stated the medication was Amlodipine. LN 10 was asked how he had determined the medication was Amlodipine when there were two medications that had also been crushed into a white powder and placed in unlabeled medication cups. LN 10 stated he knew it was Amlodipine due to the way he had arranged the medication cups.

LN 10 went back to the medication cart in the hallway and redispensed Amlodipine 2.5 mg and returned to Resident 43's bedside at 9:30 A.M. The medication mostly dissolved when the cold water was added to the medication cup and became a cloudy mixture. LN 10 observed the mixture in the medication cup and then stated it did not look the same as the chalky, white substance in the previously discarded medication cup. LN 10 then stated the chalky, white substance had been Vitamin D. LN 10 left the cup with the Amlodipine mixture at Resident 43's bedside and returned to the medication cart in the hallway. Resident 43's privacy curtain was drawn and the resident along with the Amlodipine could not be seen by LN 10. LN 10 redispensed Vitamin D 50 mcg and returned to the bedside.

At 9:35 A.M., LN 10 administered the Vitamin D to Resident 43. LN 10 was asked if the Amlodipine in the medication cup should have been left unattended at the resident's bedside. LN 10 stated he should not have done that. LN 10 stated the other two residents in Resident 43's room were cognitively impaired and one of them could get out of bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 25 055182 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055182 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 On 8/14/24 at 9:52 A.M., a joint interview and record review was conducted with LN 10. Resident 43's clinical

record was reviewed. Resident 43's physician order for Amlodipine 2.5 mg indicated a hold parameter if the Level of Harm - Minimal harm or resident's systolic blood pressure was less than 110 mm/Hg (millimeters of mercury, how blood pressure was potential for actual harm measured) and/or the resident's heart rate was less than 60 beats per minute. LN 10 was asked how he had verified Resident 43's systolic blood pressure and heart rate when dispensing and administering the Residents Affected - Few resident's Amlodipine. LN 10 stated the certified nursing assistants took the residents' vital signs earlier and wrote them down on a piece of paper and gave it to the charge nurse. LN 10 stated the charge nurse then imputed all the resident's vitals signs into the electronic medical record (EMR). LN 10 navigated the EMR to

the vitals record. Resident 43 had a recorded blood pressure of 154/87 mm/Hg and heart rate of 98 beats per minute. This data had an electronic timestamp: 8/14/24 at 9:13 A.M. LN 10 was asked how he knew it was safe to administer Resident 43's Amlodipine when the resident's blood pressure and heart rate were not entered until 9:13 A.M. LN 10 was informed he was already in the process of administering the resident's medications before 9:13 A.M. LN 10 did not provide an answer.

LN 10 stated he did not recall receiving any training related to administering medications via g-tube. LN 10 stated he did not recall being evaluated for competency in administering medications via g-tube.

On 8/14/24 at 10:05 A.M., an interview was conducted with the director of nursing (DON). The observed medication administration with LN 10 was discussed. The DON stated the medication cart should have been locked when unattended by the LN. The DON stated medications should not have been left unattended at any resident's bedside. The DON was informed that LN 10 had been stopped from giving medication that had been put in the trash can. The DON stated it was unacceptable to administer medication that had been

in the trash can. The DON stated LN 10 should have verified the hold parameter for Amlodipine and Resident 43's vital signs before dispensing and administering the medication. The DON stated LN 10 did not administer Resident 43's medications in a competent manner.

On 8/14/24 at 11 A.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated she sometimes conducted LN competency evaluations. LN 10's observed medication administration was discussed with the DSD. The DSD stated since LN 10 did not label

the medication cups and there was more than one medication crushed into white powder form, he should have stopped and called the physician and informed them of the error. The DSD stated it was not safe to attempt to readminister the unknown medication. The DSD stated it there was the possibility Resident 43 would receive a double dose of medication which could effect the resident negatively. The DSD stated LN 10's medication administration had not been competently done.

A review of LN 10's [facility name] Orientation and Annual Skills Checklist Licensed Nurses, dated 3/14/24, indicated, .g. Medication Administration via feeding tube It had an evaluator's initial next to it and a check mark. The DSD stated the initials on LN 10's Orientation and Annual Skills Checklist Licensed Nurses belonged to the DON.

On 8/14/24, Resident 43's physician's orders were reviewed, and the resident was ordered to receive 30 ml of Lactulose. Resident 43's medication administration record (MAR) indicated a lactobacillus capsule had been documented as given to the resident during the medication administration observation. This had not been observed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 25 055182 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055182 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 On 8/14/24 at 2:40 P. M., an interview was conducted with LN 10. LN 10 stated Resident 43's Lactulose should have been 30 ml and not 25 ml. LN 10 stated he did not administer Lactobacillus to Resident 43 and Level of Harm - Minimal harm or had charted in error. LN 10 then stated it had been discussed in the morning meeting that the order for potential for actual harm Resident 43's Lactobacillus was going to be discontinued. LN 10 acknowledged the order was still active and that he should have administered the Lactobacillus to Resident 43. Residents Affected - Few

A review of the facility's policy titled Nursing Staff Competency, revised 2/2019, indicated, .The competency

in skills and techniques necessary to care for residents' needs include but not limited to . G. Medication management .I. Infection Control

A review of the facility's undated policy titled Administering Medications, indicated, Medications shall be administered in a safe and timely manner, and as prescribed .6. The following information must be checked/verified for each resident prior to administering medications .b. Vital signs, if necessary . 14. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse

A review of the facility's policy titled Medication Administration- Enteral, dated 1/2024, indicated, It is the policy of this facility to accurately prepare, administer, and document medications . 5. Dilute crushed meds with water

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 25 055182 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055182 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 39111 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the medication error rate was Residents Affected - Few 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