Yucaipa, CA

Cedar Mountain Post Acute

3-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

11970 4th St, Yucaipa, CA

(909) 790-2273

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

99

Certified beds

Average residents

93

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Madison Creek Partners

Operator or chain grouping

Approved since

1992-01-22

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

12 facilities

Chain averages 3 overall / 3 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

Hours and turnover

RN hours / resident day

0.48

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.52

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

4.56

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

2.00

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

4.24

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.38

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.34

CMS adjusted RN staffing hours

Adjusted total hours

3.22

CMS adjusted total nurse staffing hours

Case-mix index

1.93

Higher values indicate more complex resident acuity

RN turnover

46%

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

12,305

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

12.94

Composite VBP score used to determine payment impact.

Payment multiplier

0.9812

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.51

Performance 21.19% · Measure score 0.51 · Achievement 0.51 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

0

Baseline 7.04% · Performance 8.37% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

3.03

Performance 51.30% · Measure score 3.03 · Achievement 3.03 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

1.64

Baseline 2.47 hours · Performance 3.18 hours · Measure score 1.64 · Achievement 0 · Improvement 1.64

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 10.67%
10.72%
0.1 pts better
No Different than the National Rate · Eligible stays 51 · Observed rate 13.73% · Lower 95% interval 6.78%
Discharge to community 47.47%
50.57%
3.1 pts worse
No Different than the National Rate · Eligible stays 43 · Observed rate 34.88% · Lower 95% interval 32.68%
Medicare spending per beneficiary 1.28
1.02
0.3 pts worse
Drug regimen review with follow-up 97.92%
95.27%
2.7 pts better
Numerator 47 · Denominator 48
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 48
Discharge self-care score 20%
53.69%
33.7 pts worse
Numerator 4 · Denominator 20
Discharge mobility score 20%
50.94%
30.9 pts worse
Numerator 4 · Denominator 20
Pressure ulcers or injuries, new or worsened 0%
2.29%
2.3 pts better
Numerator 0 · Denominator 48 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization 8.37%
7.12%
1.2 pts worse
No Different than the National Rate · Eligible stays 43 · Observed rate 16.28% · Lower 95% interval 4.75%
Staff COVID-19 vaccination coverage 10.11%
8.2%
1.9 pts better
Numerator 18 · Denominator 178
Staff flu vaccination coverage 41.13%
42%
0.9 pts worse
Numerator 102 · Denominator 248
Discharge function score 25%
56.45%
31.5 pts worse
Numerator 5 · Denominator 20
Transfer of health information to provider 79.17%
95.95%
16.8 pts worse
Numerator 19 · Denominator 24
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date Not Available
25.2%
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 3.3
2.3
1 pts worse
1.9
1.4 pts worse
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 5.2 · Expected 3.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 2.0
1.6
0.4 pts worse
1.8
0.2 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.4 · 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 0.3%
1.6%
1.3 pts better
3.3%
3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 5.8%
6.8%
1 pts better
11.4%
5.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 6.6% · Q3 1.5% · Q4 0.0% · 4Q avg 5.8%
Percentage of long-stay residents who lose too much weight 7.0%
4.1%
2.9 pts worse
5.4%
1.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 5.4% · Q3 6.8% · Q4 7.8% · 4Q avg 7.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 29.2%
13.7%
15.5 pts worse
19.6%
9.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 29.3% · Q3 29.9% · Q4 29.1% · 4Q avg 29.2%
Percentage of long-stay residents who received an antipsychotic medication 18.6%
14.2%
4.4 pts worse
16.7%
1.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 10.0% · Q3 22.5% · Q4 20.5% · 4Q avg 18.6% · 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 10.3%
11.0%
0.7 pts better
16.3%
6 pts better
Long Stay · 2024Q4-2025Q3 · Q4 8.8% · 4Q avg 10.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 11.0%
10.7%
0.3 pts worse
14.9%
3.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 18.0% · Q3 11.1% · Q4 3.8% · 4Q avg 11.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.3%
1.0%
0.7 pts better
1.0%
0.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 9.6%
10.9%
1.3 pts better
19.8%
10.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 10.5% · Q3 5.1% · Q4 0.0% · 4Q avg 9.6%
Percentage of long-stay residents with pressure ulcers 10.2%
4.7%
5.5 pts worse
5.1%
5.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 9.1% · Q3 8.8% · Q4 10.6% · 4Q avg 10.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 97.9%
94.0%
3.9 pts better
81.7%
16.2 pts better
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 97.4% · Q3 99.1% · Q4 100.0% · 4Q avg 97.9%
Percentage of short-stay residents who had an outpatient emergency department visit 11.0%
11.2%
0.2 pts better
12.0%
1 pts better
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 11.1% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.5%
1.5%
About the same
1.6%
0.1 pts better
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.4% · Q3 0.0% · Q4 1.7% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 97.5%
93.2%
4.3 pts better
79.7%
17.8 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 19.3%
23.2%
3.9 pts better
23.9%
4.6 pts better
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 22.2% · Expected 27.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-11-25 · Fire 2025-11-25

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-03-16 · Fire 2023-03-16

12 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

17 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 3 Health 2019-12-06 · Fire 2019-12-06

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

13 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-11-25

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2025-10-22

F · Potential for more than minimal harm 2025-11-25

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-10-22

D · Potential for more than minimal harm 2025-11-25

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2025-10-22

D · Potential for more than minimal harm 2025-11-25

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2025-10-22

D · Potential for more than minimal harm 2025-11-25

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-10-22

E · Potential for more than minimal harm 2023-03-16

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-03-16

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-03-16

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-03-16

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-16

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-16

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-16

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-16

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-16

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-16

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-16

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2023-04-20

D · Potential for more than minimal harm 2023-03-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-04-20

C · Minimal harm 2023-03-16

E23 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for medical documentation.

Corrected 2023-04-20

C · Minimal harm 2023-03-16

E32 · Emergency Preparedness Deficiencies

Fire Safety

Provide primary/alternate means for communication.

Corrected 2023-04-20

C · Minimal harm 2023-03-16

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-04-20

C · Minimal harm 2023-03-16

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2023-04-20

C · Minimal harm 2023-03-16

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-04-20

D · Potential for more than minimal harm 2019-12-06

E18 · Emergency Preparedness Deficiencies

Fire Safety

Establish procedures for tracking staff and patients during an emergency.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2020-01-21

D · Potential for more than minimal harm 2019-12-06

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2020-01-21

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-16

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2026-02-08

D · Potential for more than minimal harm 2025-11-25

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-12-04

D · Potential for more than minimal harm 2025-11-25

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 2025-12-04

D · Potential for more than minimal harm 2025-11-25

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 2025-12-04

D · Potential for more than minimal harm 2025-11-25

F790 · Quality of Life and Care Deficiencies

Health

Provide routine and 24-hour emergency dental care for each resident.

Corrected 2025-12-04

D · Potential for more than minimal harm 2025-11-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-12-04

D · Potential for more than minimal harm 2023-10-09

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-10-27

D · Potential for more than minimal harm 2023-07-08

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 2023-08-03

E · Potential for more than minimal harm 2023-03-16

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 2023-04-13

D · Potential for more than minimal harm 2023-03-16

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-04-13

D · Potential for more than minimal harm 2023-03-16

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2023-04-13

D · Potential for more than minimal harm 2023-03-16

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2023-04-13

D · Potential for more than minimal harm 2023-03-16

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2023-04-13

D · Potential for more than minimal harm 2023-03-16

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-04-13

D · Potential for more than minimal harm 2023-03-16

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 2023-04-13

D · Potential for more than minimal harm 2023-03-16

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-04-13

D · Potential for more than minimal harm 2023-03-16

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 2023-04-13

D · Potential for more than minimal harm 2023-03-16

F758 · Pharmacy Service Deficiencies

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 2023-04-13

D · Potential for more than minimal harm 2023-03-16

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2023-04-13

D · Potential for more than minimal harm 2023-03-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-04-13

F · Potential for more than minimal harm 2019-12-06

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 2020-02-06

D · Potential for more than minimal harm 2019-12-06

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2020-02-06

D · Potential for more than minimal harm 2019-12-06

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 2020-02-06

Penalties and ownership

What sits behind the stars

Ownership

Christensen, Covey

5% Or Greater Indirect Ownership Interest · Individual

100% 12 facilities 2015-04-05
Cedar Operations LLC

5% Or Greater Direct Ownership Interest · Organization

0% 1 facilities 2015-04-05
Christensen, Covey

Operational/Managerial Control · Individual

0% 12 facilities 2015-04-05
Christensen, Covey

Corporate Officer · Individual

0% 12 facilities 2015-04-05
Madison Creek Partners LLC

5% Or Greater Direct Ownership Interest · Organization

0% 10 facilities 2015-04-05

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