The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited July 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
LEMON GROVE CARE AND REHABILITATION CENTER
LEMON GROVE, CA · Medicare-certified · 158 beds
In good standing
For-profitChain member
3 of 5 overall
LEMON GROVE CARE AND REHABILITATION CENTER has a 3-star overall rating. It has a 2-star health inspection rating, 4-star staffing, and 5-star quality measures, with reported nurse staffing below the federal benchmark (3.95 vs 4.1 hours per resident per day); there were no fines in the last 24 months.
Facility ratings
Health inspections
Staffing
3.9535 hrs/resident/day
Quality measures
Last inspection: December 18, 2025Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.9535.
Staffing detail
- Registered nurses
- 0.47
- Licensed practical nurses
- 1.07
- Nurse aides
- 2.41
- Weekend nursing
- 3.68
Hours per resident per day.
Total staff turnover: 44%
Registered nurse turnover: 40%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
11.1%7.1%Improving
Residents with a fall causing major injury
1.7%0%Improving
Residents with pressure ulcers (bedsores)
1%1.7%Worsening
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
3.7%1.8%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
5%5.7%Worsening
Residents whose ability to walk got worse
7.6%10.3%Worsening
Long-stay residents on antianxiety or sleep medication
20.4%30.4%Worsening
Short-stay residents newly given an antipsychotic
0%0.7%Worsening
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
20%11.9%Improving
Residents with depressive symptoms
49.6%32.4%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—98.5%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—99.5%—
Short-stay residents given the pneumonia vaccine
100%100%No change
What the inspectors found
The home failed to have a plan for how it would carry out quality improvement and oversight activities. Cited December 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 865 — 42 CFR §483.75 — S/S: F
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited December 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: F
The nursing home failed to provide needed care and help with daily activities for residents who could not do them on their own. Cited December 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 677 — 42 CFR §483.24(a)(2) — S/S: E
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited December 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 24 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $7,443 in total fines.
- $7,443
Federal fine
Jul 12, 2023
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of THE ENSIGN GROUP · 338 homes · 3.2 stars avg
- Occupancy
- 149.5 residents on an average day (95% of 158 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 59 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.