Deficiency Records for Lemon Grove Care and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Lemon Grove Care and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-12 | 2023-09-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-12 | 2023-09-25 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-07-12 | 2023-09-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-17 | 2023-09-12 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-07-12 | 2023-09-06 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-07-12 | 2023-09-06 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-07-12 | 2023-09-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-31 | 2023-07-10 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-31 | 2023-07-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-31 | 2023-07-10 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-04-27 | 2023-05-25 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-27 | 2023-05-25 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-27 | 2023-05-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-27 | 2023-05-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-10 | 2023-05-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-10 | 2023-05-10 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-03-10 | 2023-05-10 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-03-10 | 2023-05-10 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-02-09 | 2023-02-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-09 | 2023-02-21 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-01 | 2023-02-21 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-03 | 2022-11-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-12 | 2022-10-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-17 | 2022-05-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-17 | 2022-05-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-17 | 2022-05-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-17 | 2022-05-11 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-03-17 | 2022-05-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-17 | 2022-05-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-17 | 2022-05-11 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-03-17 | 2022-05-11 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-03-17 | 2022-05-11 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-18 | 2022-04-15 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-03-22 | 2022-04-07 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-03-22 | 2022-04-07 | N |
| Use approved construction type or materials. | Fire Safety | 2022-03-22 | 2022-04-07 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-03-22 | 2022-04-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-22 | 2022-04-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-22 | 2022-04-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-11 | 2021-10-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-11 | 2021-10-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-11 | 2021-06-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-19 | 2021-05-19 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-09-05 | 2019-10-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-05 | 2019-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-05 | 2019-10-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-09-05 | 2019-10-07 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-08-19 | 2019-09-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-19 | 2019-09-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-19 | 2019-09-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-19 | 2019-09-20 | N |
| Provide appropriate foot care. | Health | 2019-08-19 | 2019-09-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-19 | 2019-09-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-19 | 2019-09-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-19 | 2019-09-20 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-08-19 | 2019-09-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-19 | 2019-09-20 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-08-19 | 2019-09-20 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-08-19 | 2019-09-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-19 | 2019-09-20 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-08-19 | 2019-09-20 | N |
| Keep all essential equipment working safely. | Health | 2019-08-19 | 2019-09-20 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-08-19 | 2019-09-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-10-16 | 2018-11-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-16 | 2018-11-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-16 | 2018-11-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-08-02 | 2018-09-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-08-02 | 2018-09-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-02 | 2018-09-02 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-08-02 | 2018-09-02 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-08-02 | 2018-09-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-02 | 2018-09-02 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2018-08-02 | Not Fixed | N |
