Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Lemon Grove Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with hearing loss was inaccurately assessed as having adequate hearing in the facility's MDS assessments. Despite being deaf and preferring written communication, the assessments indicated no difficulty in normal conversation. Staff interviews revealed discrepancies in the assessment process, with the Case Manager and MDS Coordinator Nurse acknowledging errors in coding.
A resident on parole with an ankle monitor was admitted to a facility without sufficient information to determine if appropriate care could be provided. The facility lacked specific admission criteria and did not screen for parole status, leading to the resident being sent back to the hospital without a medical need. The DON acknowledged the lack of information and screening criteria in the admission process.
A resident on parole with an ankle monitor was improperly discharged from an LTC facility to a hospital without a valid clinical reason. The resident was admitted, given a room, and provided dinner, but was sent back to the hospital the next day after an administrative staff member questioned their parole status. Interviews with staff revealed the facility admitted the resident without proper screening and later decided they were uncomfortable providing care, despite no documentation of danger or medical need for hospital evaluation.
A resident with early onset Alzheimer's and muscle weakness experienced a fall in the shower while assisted by one CNA, despite requiring two staff members for ADLs. The facility failed to update the care plan with interventions to prevent further falls, as identified by the DON.
A resident's clinical records were inaccurately documented, showing administration of Lithium when it was unavailable and misrepresenting behavior monitoring related to Risperidone. Nurses recorded the medication as given despite pharmacy errors and misinterpreted the resident's actions, leading to incorrect behavior documentation.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in care. A resident was not assessed for activities, resulting in boredom, while another with PTSD had a care plan lacking trigger identification. A resident requiring dialysis had an inaccurate care plan referencing a non-existent fistula, and a resident at risk for skin breakdown was not repositioned as required. Staff were unaware of critical care needs, and the facility lacked necessary policies.
The facility failed to ensure safe medication storage and handling, with issues including incomplete temperature logs, food in a medication cart, a discontinued medication not removed, an unlocked medication cart, and a medication left unattended at a resident's bedside. These actions violated facility policies and posed risks to resident safety.
A resident was fed in a manner lacking dignity, as a speech therapist stood above her while feeding, contrary to the facility's policy of maintaining eye-level contact. The therapist, in her clinical fellowship, was unaware of this practice, and no training documentation was found.
A resident with Alzheimer's disease was left exposed in a brief and socks, visible from the hallway, due to a CNA not drawing the curtain or closing the door during personal care. Both the CNA and LN acknowledged the lack of privacy, and the DON confirmed that privacy should have been maintained.
A facility failed to provide activities of interest for a resident with a thoracic vertebra fracture, leading to potential impacts on her well-being. The resident expressed dissatisfaction with the activities, and an activity/interest assessment was not completed as required. The facility's policy to plan activities according to residents' preferences was not followed.
A resident with PTSD did not receive trauma-informed care due to the facility's failure to identify and manage the resident's triggers. Staff interviews revealed a lack of awareness regarding the resident's specific triggers, leading to an inadequate care plan. The facility's policy requires trauma-informed care, but the necessary steps to explore and address the resident's needs were not taken.
A licensed nurse in a LTC facility failed to competently administer medications to a resident, leaving the medication cart unlocked and unattended, and using unlabeled cups for crushed medications. The nurse did not verify vital signs before administering Amlodipine, leading to potential safety risks. The Director of Nursing and Director of Staff Development acknowledged the nurse's incompetence in medication administration.
A facility's medication error rate was 8.33%, exceeding the acceptable limit. An LPN made errors during medication administration for two residents, including incorrect dosages and incomplete administration. The LPN acknowledged not following physician's orders, and the DON confirmed the expectation for adherence to prescribed orders.
A resident was served pureed food and nectar thick beverages without a physician's order, despite being on a mechanical soft diet with thin liquids. The resident expressed dissatisfaction with the meals, and facility staff confirmed the inconsistency. The facility's policy lacked guidance on food texture and beverage consistency.
A resident's medication administration record inaccurately documented the administration of a Lactobacillus capsule, which was not given. LN 10 admitted to the error, acknowledging the active order for the capsule despite discussions of its discontinuation. The DON emphasized the expectation for accurate documentation.
A resident with a g-tube was at risk of infection when an LN attempted to administer medication that had been discarded in the trash. The LN initially failed to dissolve the medication properly, discarded it, and then retrieved it from the trash to administer. A surveyor intervened, and the DON and IPN confirmed the breach of infection control practices.
Inaccurate Resident Hearing Assessment
Penalty
Summary
The facility failed to accurately code the required resident assessment for a resident, which had the potential to not identify the resident's needs. The resident was admitted with health conditions requiring assistance with personal care and unspecified hearing loss. During an unannounced visit, it was found that the resident was deaf and preferred written communication, which she responded to verbally. However, the facility's MDS assessments inaccurately indicated that the resident's hearing was adequate, showing no difficulty in normal conversation or social interaction. Interviews with facility staff revealed discrepancies in the assessment process. The Case Manager acknowledged that the MDS assessments were expected to be completed in person, but a mistake was made in the coding of the resident's hearing ability. The MDS Coordinator Nurse confirmed signing off on the assessments but could not recall why the resident's hearing was coded as adequate. The Social Worker responsible for the most recent assessment was unavailable for comment, leaving the error unexplained.
Failure to Implement Admission Policy for Resident with Parole Status
Penalty
Summary
The facility failed to implement its admission policy when a resident was admitted without sufficient information to determine if appropriate care and services could be provided. The resident, who was on parole and wore an ankle monitor, was admitted to the facility and later sent back to the hospital without a medical need for hospital treatment. The facility's admissions coordinator stated that the facility did not have specific admission criteria and did not screen for parole status or criminal background, although they had previously admitted residents with similar backgrounds. The director of nursing acknowledged that the facility did not have sufficient information about the resident's parole status and that the hospital did not disclose this information. The facility's admission process lacked criteria to screen for residents with criminal history or those on parole, which led to the resident being admitted without proper screening. The facility's policy indicated that admission decisions should be based on the ability to meet the medical and psychosocial needs of the resident, but this was not followed in this case.
Improper Discharge of Resident Without Valid Clinical Reason
Penalty
Summary
The facility failed to ensure that a resident was permitted to remain in the facility when they were discharged to the hospital without a valid clinical reason. The resident, who was on parole and wearing an ankle monitor, was admitted to the facility, given a room and bed, and provided dinner. The next morning, an administrative staff member questioned the resident about their parole status and ankle monitor, subsequently informing the resident that they could not stay at the facility and would have to return to the hospital. The resident was then transported back to the hospital, despite not having a medical need that required hospital treatment. Interviews with facility staff, including the admissions coordinator, licensed nurse, and director of nursing, revealed that the facility had admitted the resident without properly screening them and later decided they were not comfortable providing care. The facility's policy states that a resident should not be transferred or discharged unless it is necessary for their welfare, their health has improved, or the safety and health of others in the facility are endangered. However, there was no documentation indicating that the resident posed a danger to themselves or others, nor was there a medical situation necessitating hospital evaluation.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan with resident-specific interventions for a resident who was reviewed for falls. The resident, who was admitted with diagnoses including muscle weakness, cognitive communication deficit, and early onset Alzheimer's disease, was dependent on staff for showering. The Minimum Data Set (MDS) indicated that the resident required the assistance of one staff member for activities of daily living (ADLs) prior to a fall incident. However, after the fall, it was determined that the resident required two staff members for assistance. The deficiency was identified when the resident reported a fall in the shower while sitting in a shower chair, with only one Certified Nursing Assistant (CNA) present. The Director of Nursing (DON) identified the root cause of the fall as a sudden movement by the resident and stated that interventions to prevent further falls included providing bed baths instead of showers and educating the resident and staff. Despite these findings, the resident's care plan was not updated with the necessary interventions to address the root cause of the fall, as required by the facility's Falls Prevention policy.
Inaccurate Documentation of Medication and Behavior Monitoring
Penalty
Summary
The facility failed to ensure accurate documentation in the clinical record for a resident who was prescribed Lithium, a mood stabilizing medication. The resident's medication administration record (MAR) inaccurately indicated that Lithium was administered on multiple occasions when the medication was not available due to a pharmacy error. The pharmacy had not dispensed the medication because they believed the resident was allergic to it. Despite this, licensed nurses documented that the medication was given, which was later acknowledged as an error by the nurses involved. Additionally, the facility failed to accurately document the resident's behavior monitoring associated with the administration of Risperidone, an antipsychotic medication. The MAR inaccurately recorded episodes of the resident striking out toward others, which was not observed by the nurses. Instead, the resident was seen swinging his amputated arm in a manner that was misinterpreted as aggressive behavior. The nurses admitted to documenting these actions inaccurately, which did not reflect the true nature of the resident's behavior. The director of nursing acknowledged the inaccuracies in the documentation and confirmed that the Lithium was not dispensed until a later date. The facility's policy on charting and documentation did not provide guidance on ensuring the accuracy of documentation, contributing to the deficiencies observed in the resident's clinical records.
Deficiencies in Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for several residents, leading to deficiencies in care. Resident 47, who was admitted with a fracture of the thoracic vertebra, was not assessed for activities, resulting in a lack of engagement and boredom. The Activity Director admitted that an activity/interest assessment was not completed within the required timeframe, and the care plan did not address the resident's preferences for activities. This oversight was acknowledged by the facility's consultant, who noted the need for a more thorough assessment. Resident 42, diagnosed with Post-Traumatic Stress Disorder (PTSD), had a care plan that failed to identify specific triggers for re-traumatization. Interviews with various staff members, including the Assistant Director of Nursing and a Certified Nursing Assistant, revealed that none were aware of the resident's triggers, which were crucial for providing appropriate care. The facility's consultant recognized the inadequacy of the care plan, noting that the resident's triggers should have been explored more thoroughly. Resident 32, who required dialysis, had a care plan that inaccurately referenced an arteriovenous fistula, despite the resident having a permacath for dialysis access. Licensed nurses were incorrectly documenting care related to a fistula, which the resident did not have. The Director of Nursing confirmed the inaccuracies in the care plan, emphasizing the importance of having resident-specific and accurate care plans to prevent miscommunication and errors. Additionally, Resident 43, who was at risk for skin breakdown, was not turned and repositioned every two hours as required by their care plan, with staff failing to implement this critical intervention. The facility lacked a policy on turning and repositioning, further contributing to the deficiency.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and handling of medications, as evidenced by several observations and interviews. The medication refrigerator temperature log was found to be incomplete, with missing entries for two consecutive days. This lack of documentation raised concerns about whether medications were stored at the correct temperature, potentially affecting their efficacy. Additionally, a food product was discovered in a medication cart, which could lead to cross-contamination with medications. The facility's policy on medication storage emphasizes the importance of maintaining clean and clutter-free storage areas, which was not adhered to in this instance. Further deficiencies were noted when a discontinued medication was not removed from a medication cart, posing a risk of accidental administration. A medication cart was also left unlocked and unattended by a licensed nurse, which could allow unauthorized access to medications. The facility's policy requires medication carts to be locked when out of sight, a protocol that was not followed in this case. These lapses in medication management highlight a failure to adhere to the facility's policies and procedures, potentially compromising resident safety. In another incident, a medication was left unattended at a resident's bedside, which is against the facility's policy of keeping medications secure. The licensed nurse involved acknowledged the mistake, noting that other cognitively impaired residents in the room could have accessed the medication. The Director of Nursing confirmed that medications should not be left unattended at any resident's bedside, underscoring the importance of maintaining control over medication administration to prevent potential harm.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was assisted with a meal in a dignified manner. Resident 106, who was readmitted with a diagnosis including epilepsy, was observed being fed by a staff member in a manner that did not maintain eye-level contact. The staff member, identified as Speech Therapist 1 (ST 1), was standing approximately two feet above the resident's head while feeding her a pureed diet. ST 1 was conducting a swallowing skills assessment and admitted to not being informed about the importance of feeding residents at eye level. Interviews with other staff members, including Licensed Nurse 31 (LN 31) and Physical Therapy Assistant 1 (PTA 1), confirmed that maintaining eye-level contact while feeding is a standard practice to promote resident dignity. It was revealed that ST 1 was in her clinical fellowship and there was no documented evidence of her receiving training on proper feeding techniques. The Director of Nursing (DON) also emphasized the expectation for staff to maintain eye level during meal assistance, aligning with the facility's policy on dignity and privacy.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy for a resident during personal care, as observed by surveyors. The resident, who was admitted with Alzheimer's disease and was severely cognitively impaired, was left visible from the hallway while wearing only a brief and socks on the lower half of his body. This occurred when a certified nursing assistant (CNA) left the room carrying a bag of soiled items without drawing the curtain or closing the door, leaving the resident exposed to passers-by. Interviews with the licensed nurse (LN) and the CNA involved confirmed that privacy should have been provided by drawing the curtain and closing the door. Both staff members acknowledged that the resident was unable to verbalize his feelings due to confusion, and they expressed that the situation was undignified. The director of nursing (DON) also confirmed that privacy should have been maintained during the resident's personal care, in accordance with the facility's policy on dignity and privacy.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide activities of interest for a resident, identified as Resident 47, which had the potential to impact her physical, mental, and psychosocial well-being and independence. Resident 47 was admitted with a diagnosis of a fracture of the thoracic vertebra. During an observation and interview, Resident 47 expressed boredom and dissatisfaction with the activities offered, describing them as suitable for young children. The Activity Director admitted that an activity/interest assessment was not completed within the required five days after admission. The resident's activities care plan indicated minimal involvement in activities and a stated wish not to participate, which was not adequately addressed. The facility's policy requires activities to be planned according to residents' preferences, needs, and abilities, but this was not followed in Resident 47's case.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), as required by professional standards of practice. The resident, identified as Resident 42, was admitted with a diagnosis of PTSD, which necessitates careful management to prevent re-traumatization. However, the facility did not identify the resident's triggers, which are crucial for providing appropriate care. Interviews with various staff members, including the Assistant Director of Nursing, a certified nursing assistant, a registered nurse, and the Director of Staff Development, revealed that none of them were aware of the resident's specific triggers. This lack of knowledge indicates a failure to implement a comprehensive care plan tailored to the resident's needs. The facility's policy on Behavioral Health Services emphasizes the importance of providing trauma-informed care to prevent re-traumatization. Despite this policy, the care plan for Resident 42 was found to be inadequate, as acknowledged by the facility's consultant and administrator. The consultant noted that the facility should have explored the resident's diagnosis and potential triggers more thoroughly, especially since the resident and their family were unable to provide this information. This oversight resulted in the potential for the resident to lack a sense of emotional and physical safety, as the facility did not take necessary steps to identify and mitigate possible triggers.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a licensed nurse (LN 10) was competent in medication administration, which led to several deficiencies during the administration of medications to Resident 43. LN 10 left the medication cart unlocked and unattended, which is against the facility's policy. During the medication administration, LN 10 crushed several medications into powder and placed them in unlabeled cups, leading to confusion about which medication was which. LN 10 attempted to administer a medication that had been discarded in the trash, which was stopped by the surveyor due to infection control concerns. Resident 43, who had a history of hemiplegia, hemiparesis, hypertension, dementia, and a gastrostomy, was at risk due to LN 10's actions. LN 10 did not verify the resident's vital signs before administering Amlodipine, which had specific hold parameters based on blood pressure and heart rate. The vital signs were recorded after the medication administration had begun, indicating a lack of adherence to the physician's order. Additionally, LN 10 did not fully dissolve the medications in water, resulting in incomplete administration, and inaccurately documented the administration of Lactobacillus, which was not given. The Director of Nursing (DON) and the Director of Staff Development (DSD) acknowledged that LN 10's medication administration was not competently done. The DON confirmed that the medication cart should have been locked and that medications should not have been left unattended. The DSD noted that LN 10 should have contacted the physician after the error with the unlabeled medication cups. LN 10 admitted to not recalling any training or competency evaluation related to administering medications via a g-tube, highlighting a gap in the facility's competency evaluation process.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed rate of 8.33 percent. During the medication administration process, three errors were noted out of 36 opportunities. Specifically, LN 10 was observed administering medications to two residents, where errors were made in the dosage and administration of medications. For Resident 43, LN 10 dispensed medications into unlabeled cups and attempted to dissolve crushed tablets in cold water, which did not fully dissolve, resulting in a significant portion of the medication being discarded. LN 10 acknowledged that nearly a full dose of Vitamin D remained in the cup, indicating a failure to administer the complete prescribed dose. Additionally, LN 10 administered an incorrect dosage of Lactulose to Resident 43, providing 25 ml instead of the prescribed 30 ml. For Resident 10, LN 10 used a facility supply of Calcium with Vitamin D that contained 200 IU more than the physician's order. These actions were contrary to the physician's orders, as confirmed by LN 10 during an interview. The Director of Nursing stated that it was expected for medications to be administered as prescribed, highlighting a deviation from the facility's policy on administering medications safely and timely.
Inappropriate Dietary Consistency for Resident
Penalty
Summary
The facility failed to provide Resident 122 with food and drink that were palatable, appetizing, and appropriate for her dietary needs. Despite the resident's admission record indicating a mechanical soft-ground texture diet with thin liquids, she was served pureed food items and nectar thick beverages without a physician's order or clear indication. This inconsistency led to the resident expressing dissatisfaction with the meals, describing them as resembling cat food and bland, and resulted in her altering the consistency of her drinks by adding water from her bedside pitcher. Observations and interviews revealed that the resident had no diagnosis of dysphagia or swallowing issues, and the registered dietitian and speech therapist confirmed that the resident should have been on a mechanical soft diet. The facility's policy did not provide guidance on food palatability, texture, or beverage consistency, contributing to the oversight. The director of nursing acknowledged the error, stating that the resident's diet texture and fluid consistency should have been clearly understood and adhered to.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for one of its residents, identified as Resident 43. During an observation of medication administration, LN 10 was seen dispensing medications into individual, unlabeled cups and administering them through the resident's g-tube. The medications included Amlodipine, Apixaban, Lactulose, Keppra, Polyethylene glycol, Multivitamins, and Vitamin D. However, the administration of a Lactobacillus capsule, which was ordered by the physician, was not observed. Despite this, the medication administration record (MAR) inaccurately indicated that the Lactobacillus capsule had been given. Upon review, it was confirmed that LN 10 did not administer the Lactobacillus capsule and had erroneously documented it as administered. LN 10 acknowledged the mistake, noting that there had been a discussion about discontinuing the Lactobacillus order, but the order was still active at the time of administration. The Director of Nursing stated that it was expected for the clinical record to accurately reflect the care and treatment provided, which was not the case in this instance.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for one resident, identified as Resident 43. The resident, who had a g-tube for medication administration and feeding, was at risk of infection due to the actions of LN 10. During a medication administration observation, LN 10 attempted to administer a medication that had been disposed of in the trash can. Initially, LN 10 prepared the medication by dissolving crushed tablets in cold water, which did not fully dissolve, leaving a significant amount of medication in the cup. After discarding the cup in the trash, LN 10 retrieved it and considered administering the remaining medication to the resident. The incident was observed by a surveyor who intervened, preventing LN 10 from administering the medication from the trash. LN 10 acknowledged the infection control concern and decided to obtain a new dose of medication. Interviews with the DON and the IPN confirmed that the practice of administering medication from the trash can was unacceptable and not in line with infection control standards. The facility's policy on administering medications emphasized the importance of safe and timely administration, which was not adhered to in this instance.
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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) |
|---|---|---|---|---|
| Amaya Springs Health Care Center | 0.8 mi | — | 0 | 0 |
| Bella Vista Health Center | 1.1 mi | — | 11 | 0 |
| La Mesa Healthcare Center | 1.2 mi | — | 1 | 0 |
| Brighton Place Spring Valley | 1.2 mi | — | 2 | 0 |
| Community Care Center | 1.6 mi | — | 0 | 0 |
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