8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Victorville, CA
1-star overall rating with 1-star inspections with $82,963 in total fines with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
14973 Hesperia Road, Victorville, CA
(760) 245-6477
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
126
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1971-02-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 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
0.35
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.41
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.97
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.73
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.18
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.26
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
0.36
CMS adjusted RN staffing hours
Adjusted total hours
4.79
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
11,265
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.82
Baseline 22.30% · Performance 21.08% · Measure score 1.82 · Achievement 0.77 · Improvement 1.82
Healthcare-associated infections
0
Baseline 8.10% · Performance 10.43% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.42
Baseline 3.83 hours · Performance 4.05 hours · Measure score 3.42 · Achievement 3.42 · Improvement 0.65
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.36% |
10.72%
2.4 pts better
|
No Different than the National Rate · Eligible stays 170 · Observed rate 6.47% · Lower 95% interval 5.56% |
| Discharge to community | 42.94% |
50.57%
7.6 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 36.79% · Lower 95% interval 35.43% |
| Medicare spending per beneficiary | 1.42 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98.85% |
95.27%
3.6 pts better
|
Numerator 259 · Denominator 262 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 262 |
| Discharge self-care score | 24.77% |
53.69%
28.9 pts worse
|
Numerator 27 · Denominator 109 |
| Discharge mobility score | 18.35% |
50.94%
32.6 pts worse
|
Numerator 20 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 2.29% |
2.29%
About the same
|
Numerator 6 · Denominator 262 · Adjusted rate 1.72% |
| Healthcare-associated infections requiring hospitalization | 10.43% |
7.12%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 157 · Observed rate 15.29% · Lower 95% interval 7.09% |
| Staff COVID-19 vaccination coverage | 3.5% |
8.2%
4.7 pts worse
|
Numerator 7 · Denominator 200 |
| Staff flu vaccination coverage | 51% |
42%
9 pts better
|
Numerator 102 · Denominator 200 |
| Discharge function score | 18.35% |
56.45%
38.1 pts worse
|
Numerator 20 · Denominator 109 |
| Transfer of health information to provider | 98.43% |
95.95%
2.5 pts better
|
Numerator 125 · Denominator 127 |
| Transfer of health information to patient | 95.74% |
96.28%
0.5 pts worse
|
Numerator 45 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 32.58% |
25.2%
7.4 pts better
|
Numerator 43 · Denominator 132 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.8 |
2.3
1.5 pts worse
|
1.9
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 6.2 · Expected 3.2 · 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 2.1 · Expected 2.3 · 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 | 82.4% |
98.2%
15.8 pts worse
|
95.5%
13.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.4% |
| 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 1.3% · Q2 1.3% · Q3 1.2% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 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 who lose too much weight | 2.6% |
4.1%
1.5 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.8% · Q3 1.8% · Q4 1.5% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.0% |
13.7%
20.3 pts worse
|
19.6%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 31.5% · Q3 31.6% · Q4 34.7% · 4Q avg 34.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
14.2%
3 pts worse
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 16.7% · Q3 20.3% · Q4 16.7% · 4Q avg 17.2% · 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 | 21.1% |
11.0%
10.1 pts worse
|
16.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 9.7% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.7% |
10.7%
8 pts worse
|
14.9%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 19.4% · Q3 12.3% · Q4 22.1% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.4% |
1.0%
4.4 pts worse
|
1.0%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.0% · Q3 4.0% · Q4 3.5% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 13.5% |
1.2%
12.3 pts worse
|
1.7%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 7.1% · Q3 13.6% · Q4 12.5% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.4% |
10.9%
5.5 pts worse
|
19.8%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 19.2% · Q3 13.6% · Q4 20.8% · 4Q avg 16.4% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
4.7%
3.9 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 10.3% · Q3 10.3% · Q4 8.4% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
94.0%
5.9 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
11.2%
1.7 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 10.1% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
1.5%
2.6 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.1% · Q3 4.8% · Q4 3.2% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.4% |
93.2%
1.8 pts worse
|
79.7%
11.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
23.2%
2.1 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 28.5% · Expected 26.9% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Nutrition and Dietary (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-23
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-12-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-23
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-12-23
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-23
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-23
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-12-23
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-12-23
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-03-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-25
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-03-25
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-03-25
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-03-25
Fire Safety
Use approved construction type or materials.
Corrected 2022-03-25
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-03-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-25
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-03-25
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-03-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-25
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-03-25
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-25
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-07-10
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-07-10
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-07-10
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-07-10
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-07-10
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2019-07-10
Fire Safety
Use approved construction type or materials.
Corrected 2019-07-10
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-07-10
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-07-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-10
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-07-10
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-07-10
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-07-10
Inspection history
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-10-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-07
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-13
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-13
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-13
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-13
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-12-13
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-13
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-25
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-11
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-09-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-05
Health
Dispose of garbage and refuse properly.
Corrected 2022-04-05
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-05
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-04-05
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-04-05
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-05
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2022-04-05
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-04-05
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 2022-04-05
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2022-04-05
Health
Keep all essential equipment working safely.
Corrected 2022-04-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-05-22
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 2019-05-22
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2019-05-22
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 2019-05-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-05-22
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 2019-05-22
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-05-22
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-05-22
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 2019-05-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-22
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-05-22
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-05-22
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-22
Penalties and ownership
Fine · fine $15,920
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $10,586
Fine
Fine · fine $2,823
Fine
Fine · fine $2,470
Fine
Fine · fine $707
Fine
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
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