Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Bella Vista Health Center during CMS and state inspections, most recent first.
A resident with fibromyalgia had an order for oxycodone 10 mg, one tablet every six hours PRN for pain. An LN documented administering one tablet on the MAR, but the controlled medication count sheet showed that two 10 mg tablets were signed out and, according to the DON, were given because the LN did not realize the order had changed and did not re-read the current order before administration. This failed to follow the facility’s medication administration policy requiring adherence to physician orders and placed the resident at increased risk of medication side effects.
Dietary staff were not competent in the cooling process for TCS foods. During a kitchen tour, boiled eggs were found on the stove and a DA said leftovers were used for egg salad sandwiches, but there was no cool down log for the eggs. Tuna salad sandwiches made from canned tuna were also observed, and the DA stated the facility only had cool down logs for macaroni salad. The FSD and RDC acknowledged that the tuna and boiled eggs should have had proper cooling and logs, and that staff should have been trained on the process.
Food Contamination, Cooling, and Dishwashing Deficiencies: Surveyors observed fruit flies in the kitchen, an open trash can next to an open thickener container, a staff food cart stored in the kitchen, expired cream cheese in the walk-in, and wet stacked dishes and mugs with residue. They also found hard-boiled eggs and tuna sandwiches without proper cooling logs or cooling process, and cooked chicken was plated without a temperature check before being served.
Unsafe storage and labeling of resident food was identified in the dining hall refrigerator. A CNA found the refrigerator warm, with temperatures logged above the acceptable range and a broken thermometer, while resident food was left unlabeled or beyond the 72-hour limit. Staff food was also stored in the resident refrigerator, contrary to facility policy.
PASARR Level II follow-up was not completed for two residents with positive Level I PASARR screenings for SMI. One resident had schizophrenia, major depressive disorder, and bipolar disorder, and the other had schizophrenia disorder, unspecified. The MRD stated she was responsible for tracking PASARRs and should have followed up once the residents stayed beyond the initial short-stay determination, and the DON stated the follow-up should have occurred when they became permanent residents.
Controlled medication documentation did not reconcile for a resident receiving morphine sulfate 15 mg PRN for pain. The CDR showed multiple removals of the opioid, but the MAR did not document those administrations. An LN and the DON reviewed the records and confirmed the CDR and MAR did not match, with the facility policy requiring immediate documentation after administration in both the narcotic log and MAR.
A resident waited over 11 months for a denture evaluation after requesting a new denture, and the SSD confirmed the delay was due to waiting for a dentist through a newly approved dental program because insurance did not cover dentures. The CN and DON acknowledged the request should have been addressed sooner, and the DON stated the process should not have taken almost a year.
The facility did not fit test 161 out of 162 staff members for N95 masks during a COVID-19 outbreak, despite CDC guidance requiring fit testing as part of a comprehensive respiratory protection program. The Director of Staff Development, who also served as the Infection Preventionist, was the only staff member fit tested. The Director of Nursing and the Administrator mistakenly believed fit testing was only recommended, not required.
A facility failed to ensure a PASRR Level I accurately reflected a resident's diagnosed mental disorder. The resident, admitted with major depressive disorder, had a PASRR screening that did not indicate this diagnosis, resulting in a negative screening and no Level II evaluation. Facility staff, including MR Staff, DON, and the Administrator, acknowledged the need for accurate PASRR reviews and updates.
Expired medications and biologicals were found in the facility's storage areas, including a Nozin Nasal Sanitizer and Tucks medicated pads, both expired in March 2024. RN and DON confirmed these items should have been discarded during routine checks, highlighting a deficiency in medication management.
Failure to Administer Oxycodone as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer medication as ordered for one of four sampled residents. The resident was admitted with diagnoses including fibromyalgia and had a physician’s order on the April 2026 MAR for oxycodone 10 mg, one tablet every six hours as needed for pain. On 4/4/26 at 12:24 p.m., LN 2 documented on the MAR that one tablet of oxycodone 10 mg was administered, but the facility’s controlled Medication Count sheet shows that LN 2 signed out two tablets of oxycodone 10 mg for this resident at the same time. In a subsequent telephone interview, LN 2 could not recall why two tablets were signed out, and the DON later stated that LN 2 had given two tablets instead of one because he did not realize the order had changed and that LN 2 should have read the current order before administering the medication. The facility’s Medication Administration & Documentation Policy requires that medications be administered according to physician orders, facility protocols, and professional standards of practice, which was not followed in this instance, and as a result the resident was at increased risk of medication side effects. The survey findings are based on interview and record review, including the admission record, MAR, controlled medication count sheet, and staff interviews with LN 2 and the DON, which together confirmed that the resident received more oxycodone than ordered on the date in question.
Dietary Staff Not Competent in Food Cooling Process
Penalty
Summary
The facility failed to ensure dietary staff were competent in the ambient temperature food cool down process and the cooked food cool down process for Time/Temperature Control for Safety foods. During an initial kitchen tour, hard-boiled eggs were observed in a pot on the stove, and a Dietary Aide stated some of the eggs had been served to a resident for breakfast while the leftovers were cooled down to make egg salad sandwiches. When asked about the cool down process and logs for the boiled eggs, the Dietary Aide reviewed a binder containing a cool down log for macaroni salad and stated there was no cool down log for the boiled eggs. During the same tour, large canned tunas were observed in dry storage at 75.5 degrees F, and tuna salad sandwiches made the prior day were observed in the reach-in refrigerator. When asked about the cool down process and log for the ambient temperature prepared food, the Dietary Aide stated the facility only had entries for macaroni salad and did not have cool down logs for the ambient temperature prepared food. In interviews, the FSD and Administrator acknowledged that the canned tuna and boiled eggs should have been cooled down properly and that cool down logs should have been kept, and the FSD stated staff should have been trained on that. The Registered Dietitian Consultant also stated she was not aware the facility did not have ambient temperature prepared tuna salad and boiled egg cool down logs, but there should have been a cool down process and logs kept for those food items.
Food Contamination, Cooling, and Dishwashing Deficiencies
Penalty
Summary
The facility failed to ensure food was protected from contamination and stored in accordance with dietary sanitation practices. During a kitchen tour, fruit flies were observed flying around onions, potatoes, and bananas stored under a prep table. An open trash can was placed next to an open food thickener container under the same table, and a staff food cart containing food, seasonings, condiments, and cooking equipment was stored in the kitchen. In the walk-in refrigerator, cream cheese labeled with a Use By Date of 9/24/25 was found, and the dietary aide stated it should have been discarded. The facility also failed to properly cool and store prepared foods. Hard-boiled eggs were observed in a pot on the stove, and the dietary aide stated some had been served to a resident for breakfast and the leftovers were used to make egg salad sandwiches. Tuna sandwiches made the prior day were observed in the reach-in refrigerator, but the dietary aide stated there was no cool down process or cool down log for tuna sandwiches or boiled eggs. Canned tuna was also observed in dry storage, and the dry storage room temperature was 75.5 degrees F. The registered dietitian consultant stated ambient-temperature prepared tuna and egg items should have had a cool down process and logs kept. Dishwashing and tray line practices were also not followed as observed. About one hundred pitchers and several food storage containers were stacked while still wet, and two measuring cups had residue on them. Two trays of dry black coffee mugs were observed with residue inside, including one mug with red residue at the rim resembling lipstick. During lunch tray line, cooked chicken was plated from a metal container without checking its temperature before serving. The food service director stated the chicken temperature should have been checked before plating, and the registered dietitian consultant stated all food should be checked for core temperatures before plating.
Unsafe Storage and Labeling of Resident Food
Penalty
Summary
The facility failed to ensure safe storage of resident food brought from outside the facility. During an observation of the resident refrigerator in the dining hall, a CNA stated that the refrigerator stored resident food brought from outside the facility and that kitchen staff checked the refrigerator and temperature log. The temperature log showed temperatures greater than 41 degrees F on most days in September 2025, and when the CNA checked the refrigerator, the temperature was 50 degrees F. The CNA also stated the temperature was warm. The refrigerator contained resident food items that were not properly labeled or had been kept beyond the allowed timeframe, including a ketchup bottle with a handwritten date and shift notation, a clear container of lemon wedges dated without a resident name, and a white container with a hard-boiled egg dated 9/23/25 with a resident name. The CNA stated the ketchup bottle was a staff food item and should not have been stored in the resident refrigerator. The FSD stated dietary aides were expected to check refrigerator temperatures daily, that the temperatures should have been between 36 and 41 degrees F, and that the broken thermometer meant the temperatures entered on the log were wrong. The FSD also stated resident food should have been clearly labeled with the resident's name and the date received, food not consumed within 72 hours should be discarded, and no staff food should have been kept in the resident refrigerator.
PASARR Level II Follow-Up Not Completed for Two Residents
Penalty
Summary
The facility failed to ensure PASARR Level II follow-up was completed for two residents who had Level I PASARR screenings positive for Serious Mental Illness. Resident 26 was admitted with diagnoses of schizophrenia, major depressive disorder, and bipolar disorder, and the Level I PASARR screening dated 6/5/25 identified the resident as positive for SMI. The determination report stated the individual had a condition expected to require less than fifteen days of care in a nursing facility and that no further evaluation was required at that time. Resident 49 was admitted with a diagnosis of schizophrenia disorder, unspecified, and the Level I PASARR screening dated 7/22/25 also identified the resident as positive for SMI. The determination report for Resident 49 likewise stated the individual had a condition expected to require less than fifteen days of care in a nursing facility and that no further evaluation was required at that time. During interview and record review, the MRD stated she was responsible for reviewing, tracking, and submitting PASARR Level I screenings and following up on residents' PASARRs in the facility. She reviewed both residents' Level I screenings and determination reports and stated she should have followed up on PASARR screening for PASARR Level II after the residents stayed longer than fifteen days in the facility. The DON stated it was important to follow up on the PASARR screenings for patient safety and care and stated the MRD should have followed up on Resident 26 and Resident 49 when they became permanent residents so they would have been evaluated for PASARR Level II screening. The facility policy stated that no individual with known or suspected SMI, ID, or related condition would be admitted without the required Level I screening and, if indicated, a Level II evaluation.
Controlled Medication Documentation Did Not Reconcile
Penalty
Summary
The facility failed to provide pharmaceutical services according to acceptable standards of practice when the documentation on Resident 14’s Controlled Drug Record and Medication Administration Record did not reconcile for morphine sulfate 15 mg tablets. Resident 14 was admitted on 2/8/25 with a diagnosis of surgical aftercare following surgery on the skin and subcutaneous tissue, and had an order dated 8/27/25 for morphine sulfate 15 mg orally every four hours as needed for moderate to severe pain. During interview and record review on 9/29/25, the LN reviewed September 2025 records and found multiple instances in which Resident 14’s morphine 15 mg tablet was documented as removed from storage on the CDR but was not documented on the MAR. This occurred on 9/9/25 at 3 P.M., 9/14/25 at 2 P.M., 9/18/25 at 6:30 A.M., 9/19/25 at 5:30 A.M., 9/24/25 at 7 A.M., 9/24/25 at 1 P.M., and 9/27/25 at 3 P.M. The LN stated the CDR and MAR did not match and should have, and that documentation on both records should occur at the same time the medication was given. On 10/01/25, the DON reviewed the records and stated controlled medications should be tracked for residents’ comfort, pain management, and to avoid potential drug diversion; the facility policy also stated to document medication immediately after administration and record each administration in the narcotic log and MAR.
Delayed Dental Services for Resident Waiting for Denture
Penalty
Summary
The facility failed to provide outside dental resources and services in a timely manner for one resident, Resident 6. The resident was admitted to the facility on [DATE], and during an interview on 9/28/25, stated she was waiting for her teeth. Record review showed that Resident 6 requested a denture, but the facility did not obtain a dental evaluation for a new denture for over 11 months. The Social Services Director reviewed the resident’s dental progress notes and stated the resident was waiting for a denture evaluation by a dentist from the newly approved dental program because the resident’s insurance did not cover dentures. During later interviews, the Charge Nurse confirmed that Resident 6 had requested a denture the prior year, and the Social Services Director acknowledged that it had been a year since the request and that the delay in care could have affected the resident’s ability to fit a denture in her mouth. The Director of Nursing stated the denture request should have been addressed using all available resources and that the resident should have been evaluated and had a new denture made within a few months of the request, rather than almost a year. The facility policy titled Ancillary referral indicated residents should maintain or improve their highest practicable physical well-being.
Failure to Fit Test Staff for N95 Masks During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that 161 out of 162 staff members with direct exposure to COVID-19 positive residents were fit tested for N95 masks during a COVID-19 outbreak. According to the CDC's Infection Control Guidance, healthcare personnel entering the room of a patient with suspected or confirmed SARS-CoV-2 infection should use a NIOSH-approved particulate respirator with N95 filters or higher, along with other protective equipment. The guidance also specifies that respirators should be used within a comprehensive respiratory protection program, which includes fit testing as per OSHA's standards. Interviews with facility staff, including the Director of Staff Development (DSD) who also served as the Infection Preventionist (IP), revealed that although arrangements were made for fit testing, it had not been completed for the majority of the staff. The DSD was the only staff member who had been fit tested at the time of the survey. Both the Director of Nursing (DON) and the Administrator believed that fit testing was recommended but not required, which contributed to the delay in completing the fit testing for the staff.
Inaccurate PASRR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a Level I Preadmission Screening and Resident Review (PASRR) accurately reflected the presence of a diagnosed mental disorder for a resident. The facility's policy required that all applicants be screened for mental illness and/or intellectual disability before admission. However, the PASRR Level I Screening for a resident admitted on 06/04/2024 did not reflect their diagnosis of major depressive disorder, which was documented in their medical history and care plan. The screening incorrectly indicated that the resident did not have a serious diagnosed mental disorder, resulting in a negative screening and no requirement for a Level II evaluation. Interviews with facility staff revealed that the Medical Records (MR) Staff was responsible for reviewing PASRRs completed by hospitals to ensure accuracy. The MR Staff acknowledged that if a resident had a mental illness, it needed to be reflected on their PASRR, and she was responsible for submitting a corrected PASRR if necessary. The Director of Nursing (DON) and the Administrator both indicated that facility staff should review PASRRs for accuracy and update them as needed, with the Administrator expecting PASRRs to be complete and accurate.
Expired Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure the removal of expired medications and biologicals from its storage areas, as observed during a survey. In the medication storage room at Station 1, a Nozin Nasal Sanitizer with an expiration date of March 2024 was found. Additionally, in the central supply closet, two boxes of Tucks medicated pads, also expired in March 2024, were discovered. During interviews, RN #3 acknowledged that the expired Nozin Nasal Sanitizer should not have been in the medication storage room. The Director of Nursing (DON) confirmed that routine checks for expired medications should occur weekly and that the expired items should have been discarded. The Administrator also stated that expired medications should be removed and disposed of, confirming the deficiency in the facility's medication management practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 473 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| La Mesa Healthcare Center | 1 mi | ★★★★★ | 2 | 0 |
| Lemon Grove Care And Rehabilitation Center | 1.1 mi | ★★★★★ | 27 | 0 |
| Amaya Springs Health Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Brighton Place Spring Valley | 2.1 mi | ★★★★★ | 4 | 0 |
| Community Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bella Vista Health Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.