Health inspection·August 17, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure for one of three residents (Resident 1) that: Residents Affected - Few 1. Certified nursing assistants (CNA) completed the required documentation of Resident 1's bowel movements each shift, and 2. Licensed nurses (LNs) followed up on the accuracy and completeness of CNA documentation for Resident 1's bowel movements to determine if bowel protocol (systematic interventions to prevent/address constipation) needed to be initiated. As a result, there was the potential for documentation that was incomplete and not followed up on to affect the residents' health and well-being. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility 6/16/23. A review of CNA documentation titled Documentation Survey Report v2, for Resident 1's July 2023 bowel movements indicated, CNAs were required to document each shift (AM shift 7 A.M. to 3 P.M., PM shift 3 P.M. to 11 P.M., and Night shift 11 P.M. to 7 A.M.). The CNA documentation were incomplete with blank entries on: 7/2, 7/8, 7/9, 7/10, 7/14, 7/15, 7/16, 7/19 and 7/20/23. The CNA documentation further indicated, Resident 1 did not have bowel movements for seven days (7/10 through 7/16/23). Resident 1's clinical record was reviewed. There was no documentation the LN responded to and followed up on the CNA's incomplete bowel movement documentation. There was no documentation the LN assessed if Resident 1 had required bowel protocol. There was no documentation bowel protocol had been initiated for Resident 1. On 8/15/23 at 8:50 A.M., a joint interview and record review was conducted with CNA 2. CNA 2 stated CNAs were required to document the residents' bowel activity every shift. CNA 2 reviewed Resident 1's Documentation Survey Report v2, dated July 2023, and stated the documentation that were left blank meant the CNA did not do their documentation. On 8/15/23 at 8:58 A.M., a joint interview and record review was conducted with CNA 3. CNA 3 stated documentation of the residents' activities of daily living (ADLs, self-care activities such as toileting) was mandatory and had to be completed every shift by the CNA assigned to each resident. CNA 3 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055182 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055182 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 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)