Lemon Grove Care And Rehabilitation Center
LEMON GROVE CARE AND REHABILITATION CENTER in LEMON GROVE, CA — inspection on August 15, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F726.
Findings:
A review of Resident 43's Admission Record indicated the resident was admitted to the facility on [DATE] 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.
055182
Form Approved OMB
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
F-F880.
Findings:
A review of Resident 43's Admission Record indicated the resident was admitted to the facility on [DATE] 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
055182
Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.