Starfile / California

LEMON GROVE CARE AND REHABILITATION CENTER

8351 BROADWAY, LEMON GROVE, CA 91945 · CCN 055182

Inspection history vs California & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$7,443

Number of fines

1

Number of penalties

1

Payment denials

0

Chain

Chain

THE ENSIGN GROUP

Facilities in chain

329

Chain avg overall

3.20 / 5

Inspection citations (71)1 actual harm

1. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2025-12-18 · Health · corrected 2026-01-17

   Potential for more than minimal harm

2. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-12-18 · Health · corrected 2026-01-17

   Potential for more than minimal harm

3. DF0610Respond appropriately to all alleged violations.2025-12-18 · Health · corrected 2026-01-17

   Potential for more than minimal harm

4. DF0628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.2025-12-18 · Health · corrected 2026-01-17

   Potential for more than minimal harm

5. DF0641Ensure each resident receives an accurate assessment.2025-12-18 · Health · corrected 2026-01-17

   Potential for more than minimal harm

6. DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2025-12-18 · Health · corrected 2026-01-17

   Potential for more than minimal harm

7. EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-12-18 · Health · corrected 2026-01-17

   Potential for more than minimal harm

8. DF0679Provide activities to meet all resident's needs.2025-12-18 · Health · corrected 2026-01-17

   Potential for more than minimal harm

9. EF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-12-18 · Health · corrected 2026-01-17

   Potential for more than minimal harm

10. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

11. DF0693Ensure 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.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

12. DF0695Provide safe and appropriate respiratory care for a resident when needed.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

13. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

14. EF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

15. EF0759Ensure medication error rates are not 5 percent or greater.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

16. DF0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

17. DF0802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

18. FF0865Have a plan that describes the process for conducting QAPI and QAA activities.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

19. FF0880Provide and implement an infection prevention and control program.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

20. EF0881Implement a program that monitors antibiotic use.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

21. DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

22. DF0887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

23. EF0908Keep all essential equipment working safely.2025-12-18 · Health · corrected 2026-01-17

    Potential for more than minimal harm

24. BF0911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.2025-12-18 · Health · corrected 2026-01-17

    Potential for minimal harm

25. DF0641Ensure each resident receives an accurate assessment.2024-12-27 · Health · corrected 2025-01-08

    Potential for more than minimal harm

26. DF0620Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.2024-12-12 · Health · corrected 2024-12-22

    Potential for more than minimal harm

27. DF0622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.2024-12-12 · Health · corrected 2024-12-22

    Potential for more than minimal harm

28. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-10-17 · Health · corrected 2024-11-05

    Potential for more than minimal harm

29. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-09-05 · Health · corrected 2024-09-25

    Potential for more than minimal harm

30. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-08-15 · Health · corrected 2024-09-05

    Potential for more than minimal harm

31. DF0583Keep residents' personal and medical records private and confidential.2024-08-15 · Health · corrected 2024-09-05

    Potential for more than minimal harm

32. EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-08-15 · Health · corrected 2024-09-05

    Potential for more than minimal harm

33. DF0679Provide activities to meet all resident's needs.2024-08-15 · Health · corrected 2024-09-05

    Potential for more than minimal harm

34. DF0699Provide care or services that was trauma informed and/or culturally competent.2024-08-15 · Health · corrected 2024-09-05

    Potential for more than minimal harm

35. DF0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.2024-08-15 · Health · corrected 2024-09-05

    Potential for more than minimal harm

36. DF0759Ensure medication error rates are not 5 percent or greater.2024-08-15 · Health · corrected 2024-09-05

    Potential for more than minimal harm

37. EF0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.2024-08-15 · Health · corrected 2024-09-05

    Potential for more than minimal harm

38. DF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2024-08-15 · Health · corrected 2024-09-05

    Potential for more than minimal harm

39. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-08-15 · Health · corrected 2024-09-05

    Potential for more than minimal harm

40. DF0880Provide and implement an infection prevention and control program.2024-08-15 · Health · corrected 2024-09-05

    Potential for more than minimal harm

41. EF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2024-02-08 · Health · corrected 2024-03-05

    Potential for more than minimal harm

42. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-02-08 · Health · corrected 2024-03-05

    Potential for more than minimal harm

43. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-02-08 · Health · corrected 2024-03-05

    Potential for more than minimal harm

44. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-02-08 · Health · corrected 2024-03-05

    Potential for more than minimal harm

45. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2023-08-17 · Health · corrected 2023-09-12

    Potential for more than minimal harm

46. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-07-12 · Health · corrected 2023-09-25

    Potential for more than minimal harm

47. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-07-12 · Health · corrected 2023-09-25

    Actual harm

48. DF0740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.2023-07-12 · Health · corrected 2023-09-06

    Potential for more than minimal harm

49. DF0836Ensure 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.2023-07-12 · Health · corrected 2023-09-25

    Potential for more than minimal harm

50. DF0850Hire a qualified full-time social worker in a facility with more than 120 beds.2023-07-12 · Health · corrected 2023-09-06

    Potential for more than minimal harm

51. DF0881Implement a program that monitors antibiotic use.2023-07-12 · Health · corrected 2023-09-06

    Potential for more than minimal harm

52. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2023-05-31 · Health · corrected 2023-07-10

    Potential for more than minimal harm

53. DF0758Implement 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.2023-05-31 · Health · corrected 2023-07-10

    Potential for more than minimal harm

54. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2023-05-31 · Health · corrected 2023-07-10

    Potential for more than minimal harm

55. DF0626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.2023-04-27 · Health · corrected 2023-05-25

    Potential for more than minimal harm

56. DF0641Ensure each resident receives an accurate assessment.2023-04-27 · Health · corrected 2023-05-25

    Potential for more than minimal harm

57. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2023-04-27 · Health · corrected 2023-05-25

    Potential for more than minimal harm

58. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-04-27 · Health · corrected 2023-05-25

    Potential for more than minimal harm

59. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-03-10 · Health · corrected 2023-05-10

    Potential for more than minimal harm

60. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-03-10 · Health · corrected 2023-05-10

    Potential for more than minimal harm

61. EF0741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.2023-03-10 · Health · corrected 2023-05-10

    Potential for more than minimal harm

62. EF0838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.2023-03-10 · Health · corrected 2023-05-10

    Potential for more than minimal harm

63. DF0561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.2022-03-17 · Health · corrected 2022-05-11

    Potential for more than minimal harm

64. DF0624Prepare residents for a safe transfer or discharge from the nursing home.2022-03-17 · Health · corrected 2022-05-11

    Potential for more than minimal harm

65. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2022-03-17 · Health · corrected 2022-05-11

    Potential for more than minimal harm

66. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2022-03-17 · Health · corrected 2022-05-11

    Potential for more than minimal harm

67. EF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2022-03-17 · Health · corrected 2022-05-11

    Potential for more than minimal harm

68. DF0693Ensure 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.2022-03-17 · Health · corrected 2022-05-11

    Potential for more than minimal harm

69. DF0759Ensure medication error rates are not 5 percent or greater.2022-03-17 · Health · corrected 2022-05-11

    Potential for more than minimal harm

70. DF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-03-17 · Health · corrected 2022-05-11

    Potential for more than minimal harm

71. DF0911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.2022-03-17 · Health · corrected 2022-05-11

    Potential for more than minimal harm

Ownership

Other facilities in LEMON GROVE

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.