8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cherry Valley, CA
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
9246 Avenida Miravilla, Cherry Valley, CA
(951) 845-3194
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
59
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1991-11-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.28
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.50
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.34
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.32
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.25
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
2,616
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.73
Composite VBP score used to determine payment impact.
Payment multiplier
1.0025
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.77
Performance 18.76% · Measure score 5.77 · Achievement 5.77 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.04
Performance 6.93% · Measure score 3.04 · Achievement 3.04 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
7.57
Baseline 40.00% · Performance 32.76% · Measure score 7.57 · Achievement 7.57 · Improvement 4.28
Adjusted total nurse staffing
3.11
Baseline 4.92 hours · Performance 3.96 hours · Measure score 3.11 · Achievement 3.11 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.49% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 8.57% · Lower 95% interval 6.87% |
| Discharge to community | 46.79% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 40.74% · Lower 95% interval 35.59% |
| Medicare spending per beneficiary | 1.41 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 72 · Denominator 72 |
| Falls with major injury | 1.39% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 72 |
| Discharge self-care score | 35.71% |
53.69%
18 pts worse
|
Numerator 20 · Denominator 56 |
| Discharge mobility score | 42.86% |
50.94%
8.1 pts worse
|
Numerator 24 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 1.39% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 72 · Adjusted rate 1.06% |
| Healthcare-associated infections requiring hospitalization | 6.92% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 5% · Lower 95% interval 3.33% |
| Staff COVID-19 vaccination coverage | 19.67% |
8.2%
11.5 pts better
|
Numerator 12 · Denominator 61 |
| Staff flu vaccination coverage | 34.81% |
42%
7.2 pts worse
|
Numerator 47 · Denominator 135 |
| Discharge function score | 39.29% |
56.45%
17.2 pts worse
|
Numerator 22 · Denominator 56 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 39 · Denominator 39 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 54.76% |
25.2%
29.6 pts better
|
Numerator 23 · Denominator 42 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.3
0.3 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · 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 | 1.3% |
1.6%
0.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.7% |
6.8%
5.9 pts worse
|
11.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 17.9% · Q3 10.3% · Q4 5.7% · 4Q avg 12.7% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
4.1%
1.5 pts worse
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 6.1% · Q3 5.3% · Q4 5.7% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
13.7%
4.3 pts worse
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 13.9% · Q3 15.4% · Q4 22.2% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.0% |
14.2%
4.2 pts better
|
16.7%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.5% · Q3 8.3% · Q4 7.4% · 4Q avg 10.0% · 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 | 3.6% |
11.0%
7.4 pts better
|
16.3%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
10.7%
3.6 pts worse
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 22.6% · Q3 12.5% · Q4 6.2% · 4Q avg 14.3% · 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 | 13.6% |
10.9%
2.7 pts worse
|
19.8%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 8.9% · Q3 16.0% · Q4 9.0% · 4Q avg 13.6% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.7%
1.6 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.3% · Q3 0.0% · Q4 6.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
94.0%
1.3 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 94.2% · Q3 95.1% · Q4 96.3% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
11.2%
2.6 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 11.7% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.3% |
93.2%
1.9 pts worse
|
79.7%
11.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
23.2%
1 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 20.0% · Expected 21.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Nutrition and Dietary (5 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-11
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 2025-06-01
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-30
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-01
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-06-15
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-06-10
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-06-10
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-06-10
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-06-10
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-06-10
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-06-10
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-06-10
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-06-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-10
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-10
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-10
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-11-30
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-11-30
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-30
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-30
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-30
Inspection history
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-08-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-09
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-09
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-09
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-06-09
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-09
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-09
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-09
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-12-20
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-26
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 2024-08-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-16
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-04-16
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-16
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-04-16
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-04-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-16
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-04-16
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-04-16
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-04-16
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 2024-04-16
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-12
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-07
Health
Dispose of garbage and refuse properly.
Corrected 2022-12-07
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-07
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-12-07
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-12-07
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-12-07
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-12-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-07
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-07
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 2022-12-07
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-12-07
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-07
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-12-07
Penalties and ownership
Payment Denial · denial start 2024-04-05 · 11 days
11 day denial
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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4-star overall rating with 3-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Banning, CA
1-star overall rating with 2-star inspections with 20 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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