7 health deficiencies
Top issue: Infection Control (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Spring Valley, CA
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
8625 Lamar Street, Spring Valley, CA
(619) 461-3222
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
50
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacific Healthcare Holdings
Operator or chain grouping
Approved since
1974-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.40
Registered nurse staffing
LPN hours / resident day
1.55
Licensed practical nurse staffing
Aide hours / resident day
2.58
Nurse aide staffing
Weekend hours
3.96
Weekend nurse staffing
RN turnover
83%
Annual RN turnover
Total nurse turnover
53%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
2.3
1.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
98.5%
1.2 pts worse
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
1.6%
1.1 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 8.2% |
6.8%
1.4 pts worse
|
11.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 21.3% |
4.1%
17.2 pts worse
|
5.4%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
13.7%
0.3 pts worse
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
14.2%
9 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.2% |
11.0%
0.2 pts worse
|
16.3%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
10.7%
6.4 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.1% |
10.9%
3.2 pts worse
|
19.8%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.7%
0.9 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
94.0%
3.2 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
11.2%
1.4 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
93.2%
4.5 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.7% |
23.2%
5.5 pts better
|
23.9%
6.2 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Infection Control (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Resident Rights (4 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-30
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-09-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-30
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 2024-09-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-30
Fire Safety
Use approved construction type or materials.
Corrected 2024-09-30
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-30
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-30
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-09-30
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-09-30
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-03-11
Fire Safety
Install proper backup exit lighting.
Corrected 2022-03-11
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-03-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-11
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-04-14
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-04-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-14
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2020-04-14
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-04-14
Fire Safety
Install proper backup exit lighting.
Corrected 2020-04-14
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-04-14
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-04-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-04-14
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2020-04-14
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-04-14
Inspection history
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-15
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-01
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-13
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-10-13
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-13
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-13
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-10-13
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-06-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-26
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-13
Health
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 2022-03-18
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2022-03-18
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-03-18
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-03-18
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-03-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-03-18
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-03-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-03-18
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-18
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-03-18
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 2022-03-18
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-18
Health
Put firmly secured handrails on each side of hallways.
Corrected 2022-03-18
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-04-06
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2020-04-06
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2020-04-06
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-06
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2020-04-06
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-04-06
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-04-06
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 2020-04-06
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
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5-star overall rating with 5-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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