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
Chain footprint
15 facilities
Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars
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
RN hours / resident day
0.40
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.55
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.54
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.96
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.81
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
8,278
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.70
Baseline 19.77% · Performance 19.71% · Measure score 3.70 · Achievement 3.70 · Improvement 0
Healthcare-associated infections
4.63
Baseline 6.86% · Performance 6.45% · Measure score 4.63 · Achievement 4.63 · Improvement 1.69
Total nurse turnover
1.52
Baseline 60.47% · Performance 57.45% · Measure score 1.52 · Achievement 1.52 · Improvement 0.35
Adjusted total nurse staffing
1.06
Baseline 3.58 hours · Performance 3.38 hours · Measure score 1.06 · Achievement 1.06 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.86% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 14.29% · Lower 95% interval 7.8% |
| Discharge to community | 46.26% |
50.57%
4.3 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 38.67% · Lower 95% interval 36.5% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 72.73% |
95.27%
22.5 pts worse
|
Numerator 64 · Denominator 88 |
| Falls with major injury | 1.14% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 88 |
| Discharge self-care score | 45.95% |
53.69%
7.7 pts worse
|
Numerator 17 · Denominator 37 |
| Discharge mobility score | 43.24% |
50.94%
7.7 pts worse
|
Numerator 16 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 88 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.45% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 4.44% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 9.78% |
8.2%
1.6 pts better
|
Numerator 9 · Denominator 92 |
| Staff flu vaccination coverage | 32.61% |
42%
9.4 pts worse
|
Numerator 30 · Denominator 92 |
| Discharge function score | 43.24% |
56.45%
13.2 pts worse
|
Numerator 16 · Denominator 37 |
| Transfer of health information to provider | 90.63% |
95.95%
5.3 pts worse
|
Numerator 29 · Denominator 32 |
| Transfer of health information to patient | 97.44% |
96.28%
1.2 pts better
|
Numerator 38 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 67.74% |
25.2%
42.5 pts better
|
Numerator 42 · Denominator 62 |
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 · Adjusted 0.8 · Observed 1.3 · Expected 3.1 · 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 1.8 · Expected 2.2 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 87.5% · Q3 100.0% · Q4 100.0% · 4Q avg 97.3% |
| 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 | 2.7% |
1.6%
1.1 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 3.4% · Q4 3.6% · 4Q avg 2.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 9.5% · Q3 18.2% · Q4 7.4% · 4Q avg 8.2% |
| 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 · Q1 22.7% · Q2 17.4% · Q3 22.2% · Q4 22.7% · 4Q avg 21.3% |
| 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 · Q1 16.0% · Q2 13.0% · Q3 14.3% · Q4 12.5% · 4Q avg 14.0% |
| 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 · 4Q avg 5.2% · 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 | 11.2% |
11.0%
0.2 pts worse
|
16.3%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 13.6% · Q3 4.0% · Q4 0.0% · 4Q avg 4.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 11.0% · Q2 17.5% · Q3 15.7% · Q4 12.7% · 4Q avg 14.1% |
| 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 · Q1 11.2% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 3.8% · Used in QM five-star |
| 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 · Q1 99.1% · Q2 95.3% · Q3 95.0% · Q4 100.0% · 4Q avg 97.2% |
| 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 · Adjusted 12.6% · Observed 12.6% · Expected 11.2% · Used in QM five-star |
| 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 · Q1 3.6% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| 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 · 4Q avg 97.7% |
| 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 · Adjusted 17.7% · Observed 18.4% · Expected 24.8% · Used in QM five-star |
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
Nearby options
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Lemon Grove, CA
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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