6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Yucaipa, CA
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
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
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
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
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
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
| 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
| 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
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-10-22
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-22
Fire Safety
Use approved construction type or materials.
Corrected 2025-10-22
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
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-22
Fire Safety
Use approved construction type or materials.
Corrected 2023-04-20
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-04-20
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-20
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-20
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-20
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
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-20
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
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-20
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-04-20
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-04-20
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-04-20
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-04-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-20
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2020-01-21
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-01-21
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2020-01-21
Fire Safety
Use approved construction type or materials.
Corrected 2020-01-21
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-01-21
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-21
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-01-21
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-21
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-01-21
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
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-21
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-01-21
Inspection history
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2026-02-08
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-04
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-04
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-12-04
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-04
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-03
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
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-13
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-04-13
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-04-13
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-04-13
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-13
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-13
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
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
Health
Provide or obtain dental services for each resident.
Corrected 2023-04-13
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-13
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
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
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
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Direct Ownership Interest · Organization
Nearby options
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