Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bella Vista Health Center during CMS and state inspections, most recent first.
A resident with fibromyalgia had an order for oxycodone 10 mg, one tablet every six hours PRN for pain. An LN documented administering one tablet on the MAR, but the controlled medication count sheet showed that two 10 mg tablets were signed out and, according to the DON, were given because the LN did not realize the order had changed and did not re-read the current order before administration. This failed to follow the facility’s medication administration policy requiring adherence to physician orders and placed the resident at increased risk of medication side effects.
The facility did not fit test 161 out of 162 staff members for N95 masks during a COVID-19 outbreak, despite CDC guidance requiring fit testing as part of a comprehensive respiratory protection program. The Director of Staff Development, who also served as the Infection Preventionist, was the only staff member fit tested. The Director of Nursing and the Administrator mistakenly believed fit testing was only recommended, not required.
A facility failed to ensure a PASRR Level I accurately reflected a resident's diagnosed mental disorder. The resident, admitted with major depressive disorder, had a PASRR screening that did not indicate this diagnosis, resulting in a negative screening and no Level II evaluation. Facility staff, including MR Staff, DON, and the Administrator, acknowledged the need for accurate PASRR reviews and updates.
Expired medications and biologicals were found in the facility's storage areas, including a Nozin Nasal Sanitizer and Tucks medicated pads, both expired in March 2024. RN and DON confirmed these items should have been discarded during routine checks, highlighting a deficiency in medication management.
Failure to Administer Oxycodone as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer medication as ordered for one of four sampled residents. The resident was admitted with diagnoses including fibromyalgia and had a physician’s order on the April 2026 MAR for oxycodone 10 mg, one tablet every six hours as needed for pain. On 4/4/26 at 12:24 p.m., LN 2 documented on the MAR that one tablet of oxycodone 10 mg was administered, but the facility’s controlled Medication Count sheet shows that LN 2 signed out two tablets of oxycodone 10 mg for this resident at the same time. In a subsequent telephone interview, LN 2 could not recall why two tablets were signed out, and the DON later stated that LN 2 had given two tablets instead of one because he did not realize the order had changed and that LN 2 should have read the current order before administering the medication. The facility’s Medication Administration & Documentation Policy requires that medications be administered according to physician orders, facility protocols, and professional standards of practice, which was not followed in this instance, and as a result the resident was at increased risk of medication side effects. The survey findings are based on interview and record review, including the admission record, MAR, controlled medication count sheet, and staff interviews with LN 2 and the DON, which together confirmed that the resident received more oxycodone than ordered on the date in question.
Failure to Fit Test Staff for N95 Masks During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that 161 out of 162 staff members with direct exposure to COVID-19 positive residents were fit tested for N95 masks during a COVID-19 outbreak. According to the CDC's Infection Control Guidance, healthcare personnel entering the room of a patient with suspected or confirmed SARS-CoV-2 infection should use a NIOSH-approved particulate respirator with N95 filters or higher, along with other protective equipment. The guidance also specifies that respirators should be used within a comprehensive respiratory protection program, which includes fit testing as per OSHA's standards. Interviews with facility staff, including the Director of Staff Development (DSD) who also served as the Infection Preventionist (IP), revealed that although arrangements were made for fit testing, it had not been completed for the majority of the staff. The DSD was the only staff member who had been fit tested at the time of the survey. Both the Director of Nursing (DON) and the Administrator believed that fit testing was recommended but not required, which contributed to the delay in completing the fit testing for the staff.
Inaccurate PASRR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a Level I Preadmission Screening and Resident Review (PASRR) accurately reflected the presence of a diagnosed mental disorder for a resident. The facility's policy required that all applicants be screened for mental illness and/or intellectual disability before admission. However, the PASRR Level I Screening for a resident admitted on 06/04/2024 did not reflect their diagnosis of major depressive disorder, which was documented in their medical history and care plan. The screening incorrectly indicated that the resident did not have a serious diagnosed mental disorder, resulting in a negative screening and no requirement for a Level II evaluation. Interviews with facility staff revealed that the Medical Records (MR) Staff was responsible for reviewing PASRRs completed by hospitals to ensure accuracy. The MR Staff acknowledged that if a resident had a mental illness, it needed to be reflected on their PASRR, and she was responsible for submitting a corrected PASRR if necessary. The Director of Nursing (DON) and the Administrator both indicated that facility staff should review PASRRs for accuracy and update them as needed, with the Administrator expecting PASRRs to be complete and accurate.
Expired Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure the removal of expired medications and biologicals from its storage areas, as observed during a survey. In the medication storage room at Station 1, a Nozin Nasal Sanitizer with an expiration date of March 2024 was found. Additionally, in the central supply closet, two boxes of Tucks medicated pads, also expired in March 2024, were discovered. During interviews, RN #3 acknowledged that the expired Nozin Nasal Sanitizer should not have been in the medication storage room. The Director of Nursing (DON) confirmed that routine checks for expired medications should occur weekly and that the expired items should have been discarded. The Administrator also stated that expired medications should be removed and disposed of, confirming the deficiency in the facility's medication management practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lemon Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Mesa Healthcare Center | 1 mi | — | 1 | 0 |
| Lemon Grove Care And Rehabilitation Center | 1.1 mi | — | 27 | 0 |
| Amaya Springs Health Care Center | 1.2 mi | — | 0 | 0 |
| Brighton Place Spring Valley | 2.1 mi | — | 2 | 0 |
| Community Care Center | 2.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.