Cycle 1
Health 2025-11-17 · Fire 2025-11-17
6 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lemon Grove, CA
Bella Vista Health Center
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
7922 Palm Street, Lemon Grove, CA
(619) 644-1000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2011-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.27
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.81
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.86
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.34
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.88
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,760
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9958
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 19.12% · Performance 16.44% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
3.68
Baseline 9.73% · Performance 7.75% · Measure score 3.68 · Achievement 0 · Improvement 3.68
Total nurse turnover
3.45
Baseline 51.67% · Performance 49.59% · Measure score 3.45 · Achievement 3.45 · Improvement 0.28
Adjusted total nurse staffing
0
Baseline 3.96 hours · Performance 3.19 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.94% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 344 · Observed rate 11.63% · Lower 95% interval 8.91% |
| Discharge to community | 61.6% |
50.57%
11 pts better
|
Better than the National Rate · Eligible stays 342 · Observed rate 57.02% · Lower 95% interval 56.8% |
| Medicare spending per beneficiary | 1.56 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 82.71% |
95.27%
12.6 pts worse
|
Numerator 220 · Denominator 266 |
| Falls with major injury | 0.75% |
0.77%
About the same
|
Numerator 2 · Denominator 266 |
| Discharge self-care score | 48.21% |
53.69%
5.5 pts worse
|
Numerator 94 · Denominator 195 |
| Discharge mobility score | 44.1% |
50.94%
6.8 pts worse
|
Numerator 86 · Denominator 195 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 266 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.75% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 239 · Observed rate 7.53% · Lower 95% interval 5.22% |
| Staff COVID-19 vaccination coverage | 25.5% |
8.2%
17.3 pts better
|
Numerator 51 · Denominator 200 |
| Staff flu vaccination coverage | 35.12% |
42%
6.9 pts worse
|
Numerator 72 · Denominator 205 |
| Discharge function score | 52.82% |
56.45%
3.6 pts worse
|
Numerator 103 · Denominator 195 |
| Transfer of health information to provider | 97.78% |
95.95%
1.8 pts better
|
Numerator 88 · Denominator 90 |
| Transfer of health information to patient | 97.14% |
96.28%
0.9 pts better
|
Numerator 136 · Denominator 140 |
| Resident COVID-19 vaccinations up to date | 10.88% |
25.2%
14.3 pts worse
|
Numerator 16 · Denominator 147 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.3
0.2 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 3.5 · Expected 3.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.7 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
1.6%
0.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 30.6% |
6.8%
23.8 pts worse
|
11.4%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 19.4% · Q3 26.9% · Q4 46.9% · 4Q avg 30.6% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
4.1%
4 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 16.1% · Q3 0.0% · Q4 3.2% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
13.7%
4.1 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.4% · Q3 7.1% · Q4 11.8% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.7% |
14.2%
11.5 pts better
|
16.7%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 33.0% |
11.0%
22 pts worse
|
16.3%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.6% |
10.7%
17.9 pts worse
|
14.9%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 25.8% · Q3 40.7% · Q4 23.3% · 4Q avg 28.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
1.0%
2.1 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.9% · Q3 3.3% · Q4 2.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.2%
0.4 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 3.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.7% |
10.9%
2.8 pts worse
|
19.8%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 19.2% · Q3 9.1% · Q4 13.5% · 4Q avg 13.7% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
4.7%
3.1 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.2% · Q3 0.0% · Q4 2.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
11.2%
2.9 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.7% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 3.3% · Q3 3.8% · Q4 1.3% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.7% |
93.2%
6.5 pts better
|
79.7%
20 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
23.2%
5.7 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 16.7% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-26 · Fire 2024-07-26
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-01-27 · Fire 2022-01-27
13 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-17
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-11-26
F · Potential for more than minimal harm
2025-11-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-11-26
C · Minimal harm
2025-11-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-26
F · Potential for more than minimal harm
2024-07-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-26
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-26
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2024-08-19
E · Potential for more than minimal harm
2022-01-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-02-17
D · Potential for more than minimal harm
2022-01-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-02-17
D · Potential for more than minimal harm
2022-01-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-17
D · Potential for more than minimal harm
2022-01-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-02-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-17
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2026-01-02
E · Potential for more than minimal harm
2025-11-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-02
E · Potential for more than minimal harm
2025-11-17
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-11-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-11-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-11-17
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2026-01-02
D · Potential for more than minimal harm
2024-07-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-26
F761 · Pharmacy Service Deficiencies
Health
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 2024-08-09
D · Potential for more than minimal harm
2024-02-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-08
F · Potential for more than minimal harm
2022-01-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-02-24
F · Potential for more than minimal harm
2022-01-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-24
E · Potential for more than minimal harm
2022-01-27
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-02-24
E · Potential for more than minimal harm
2022-01-27
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F761 · Pharmacy Service Deficiencies
Health
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 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-02-24
Penalties and ownership
What sits behind the stars
Ownership
Bari, Mohammed
General Partnership Interest · Individual
Floyd, Susan
Corporate Director · Individual
Floyd, Susan
W-2 Managing Employee · Individual
Hassel, Evelyn
W-2 Managing Employee · Individual
Ishaque, Saleem
General Partnership Interest · Individual
Nearby options
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5-star overall rating with 4-star inspections with 11 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
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3-star overall rating with 2-star inspections with $7,443 in total fines with 24 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Amaya Springs Health Care Center
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4-star overall rating with 4-star inspections with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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