Lemon Grove Care and Rehabilitation Center
8351 Broadway · Lemon Grove, CA · 91945 · 6194630294
158 certified beds For profit - Corporation Chain: The Ensign Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.95 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.47 | 0.55–0.75 |
| Weekend hours / resident-day | 3.68 | ≈ weekday level |
| Nursing turnover / year | 44% | median 45% |
| Fines (3-yr window) | 1 · $7,443 |
Inspection citations (60 in the current record)
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Potential for harm · D December 18, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected January 17, 2026 · Resident Rights
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Potential for harm · D December 18, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected January 17, 2026 · Resident Rights
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Potential for harm · D December 18, 2025
Respond appropriately to all alleged violations.
Corrected January 17, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 18, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected January 17, 2026 · Resident Rights
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Potential for harm · D December 18, 2025
Ensure each resident receives an accurate assessment.
Corrected January 17, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 18, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected January 17, 2026 · Resident Assessment and Care Planning
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Potential for harm · E December 18, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 17, 2026 · Quality of Life and Care
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Potential for harm · D December 18, 2025
Provide activities to meet all resident's needs.
Corrected January 17, 2026 · Quality of Life and Care
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Potential for harm · E December 18, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 17, 2026 · Quality of Life and Care
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Potential for harm · D December 18, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 17, 2026 · Quality of Life and Care
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Potential for harm · D December 18, 2025
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.
Corrected January 17, 2026 · Quality of Life and Care
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Potential for harm · D December 18, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected January 17, 2026 · Quality of Life and Care
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Potential for harm · D December 18, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected January 17, 2026 · Pharmacy Service
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Potential for harm · E December 18, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected January 17, 2026 · Pharmacy Service
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Potential for harm · E December 18, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected January 17, 2026 · Pharmacy Service
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Potential for harm · D December 18, 2025
Ensure 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.
Corrected January 17, 2026 · Pharmacy Service
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Potential for harm · D December 18, 2025
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected January 17, 2026 · Nutrition and Dietary
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Potential for harm · F December 18, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected January 17, 2026 · Administration
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Potential for harm · F December 18, 2025
Provide and implement an infection prevention and control program.
Corrected January 17, 2026 · Infection Control
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Potential for harm · E December 18, 2025
Implement a program that monitors antibiotic use.
Corrected January 17, 2026 · Infection Control
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Potential for harm · D December 18, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected January 17, 2026 · Infection Control
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Potential for harm · D December 18, 2025
Educate 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.
Corrected January 17, 2026 · Infection Control
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Potential for harm · E December 18, 2025
Keep all essential equipment working safely.
Corrected January 17, 2026 · Environmental
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No harm found · B December 18, 2025
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Corrected January 17, 2026 · Environmental
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Potential for harm · D December 27, 2024 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected January 8, 2025 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 12, 2023 | Fine | $7,443 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055182 · certified since January 1, 1967. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.