Cycle 1
Health 2025-07-18 · Fire 2025-07-18
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Yucaipa, CA
Creekside Post Acute
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
35253 Avenue H, Yucaipa, CA
(909) 795-2476
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.88
Registered nurse staffing
LPN hours / resident day
2.78
Licensed practical nurse staffing
Aide hours / resident day
2.97
Nurse aide staffing
Weekend hours
5.94
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
98.5%
3.4 pts worse
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
98.2%
1.8 pts worse
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
1.6%
1.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
6.8%
4.4 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.9% |
4.1%
0.8 pts worse
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
13.7%
12.2 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 7.9% |
14.2%
6.3 pts better
|
16.7%
8.8 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 need for help with daily activities has increased | 2.4% |
10.7%
8.3 pts better
|
14.9%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.0%
0.9 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.2%
0.7 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.3% |
10.9%
7.4 pts worse
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 10.0% |
4.7%
5.3 pts worse
|
5.1%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.3% |
94.0%
15.7 pts worse
|
81.7%
3.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
11.2%
0.1 pts worse
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.5%
1.2 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.9% |
93.2%
44.3 pts worse
|
79.7%
30.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.3% |
23.2%
7.1 pts worse
|
23.9%
6.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-07 · Fire 2024-06-07
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2022-03-17 · Fire 2022-03-17
12 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-08-07
F · Potential for more than minimal harm
2025-07-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-08-07
F · Potential for more than minimal harm
2025-07-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-07
F · Potential for more than minimal harm
2025-07-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-07-18
K233 · Egress Deficiencies
Fire Safety
Install resident room doors of proper design and width.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-07-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-07-18
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 2025-08-11
D · Potential for more than minimal harm
2024-06-07
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-06-07
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-06-07
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-06-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-06-07
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-06-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-06-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-06-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-26
F · Potential for more than minimal harm
2022-03-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
K373 · Smoke Deficiencies
Fire Safety
Have enough space near smoke barriers to protect residents.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-03-17
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 2022-06-02
D · Potential for more than minimal harm
2022-03-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-28
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 2026-02-06
D · Potential for more than minimal harm
2026-01-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-06
F · Potential for more than minimal harm
2025-07-18
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-07-18
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 2025-08-08
E · Potential for more than minimal harm
2025-07-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-07-18
F761 · Pharmacy Service Deficiencies
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 2025-08-08
D · Potential for more than minimal harm
2025-07-18
F578 · Resident Rights Deficiencies
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 2025-08-08
D · Potential for more than minimal harm
2025-07-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-18
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 2025-08-08
D · Potential for more than minimal harm
2025-07-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-18
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 2025-08-08
D · Potential for more than minimal harm
2025-07-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-08
E · Potential for more than minimal harm
2024-06-07
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-07
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 2024-06-28
D · Potential for more than minimal harm
2024-06-07
F761 · Pharmacy Service Deficiencies
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 2024-06-28
D · Potential for more than minimal harm
2024-06-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-03-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-21
D · Potential for more than minimal harm
2023-08-31
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-08
F · Potential for more than minimal harm
2022-03-17
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 2022-05-10
F · Potential for more than minimal harm
2022-03-17
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-05-10
E · Potential for more than minimal harm
2022-03-17
F803 · Nutrition and Dietary Deficiencies
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 2022-05-10
E · Potential for more than minimal harm
2022-03-17
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-05-10
E · Potential for more than minimal harm
2022-03-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-10
E · Potential for more than minimal harm
2022-03-17
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-05-10
D · Potential for more than minimal harm
2022-03-17
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2022-05-10
D · Potential for more than minimal harm
2022-03-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-05-10
D · Potential for more than minimal harm
2022-03-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-05-10
D · Potential for more than minimal harm
2022-03-17
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 2022-05-10
D · Potential for more than minimal harm
2022-03-17
F761 · Pharmacy Service Deficiencies
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 2022-05-10
Penalties and ownership
What sits behind the stars
Ownership
Rockwell Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Carrozza, Evangeline
Operational/Managerial Control · Individual
Carrozza, Evangeline
Corporate Officer · Individual
Peterson, Tanner
W-2 Managing Employee · Individual
Rockwell Healthcare LLC
Operational/Managerial Control · Organization
Villanueva, Ricky
W-2 Managing Employee · Individual
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#2
Cedar Mountain Post Acute
Yucaipa, CA
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Oak Glen Post Acute
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3-star overall rating with 3-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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