Cycle 1
Health 2024-10-03 · Fire 2024-10-03
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Upland, CA
Villa Mesa Care Center
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
867 E. 11th St, Upland, CA
(909) 985-1981
Overall
4 / 5
CMS overall stars
Health inspections
5 / 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
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1972-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.35
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.84
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.56
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
0.00
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
71%
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
11,037
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.29
Baseline 23.55% · Performance 22.38% · Measure score 1.29 · Achievement 0 · Improvement 1.29
Healthcare-associated infections
1.13
Baseline 6.41% · Performance 7.50% · Measure score 1.13 · Achievement 1.13 · Improvement 0
Total nurse turnover
2.47
Baseline 57.14% · Performance 53.57% · Measure score 2.47 · Achievement 2.47 · Improvement 0.61
Adjusted total nurse staffing
2.4
Baseline 3.25 hours · Performance 3.76 hours · Measure score 2.4 · Achievement 2.4 · Improvement 1.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.88% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 10.07% · Lower 95% interval 7.47% |
| Discharge to community | 44.9% |
50.57%
5.7 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 37.11% · Lower 95% interval 35.58% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 200 · Denominator 208 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 208 |
| Discharge self-care score | 40.2% |
53.69%
13.5 pts worse
|
Numerator 41 · Denominator 102 |
| Discharge mobility score | 31.37% |
50.94%
19.6 pts worse
|
Numerator 32 · Denominator 102 |
| Pressure ulcers or injuries, new or worsened | 0.48% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 208 · Adjusted rate 0.4% |
| Healthcare-associated infections requiring hospitalization | 7.5% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 110 · Observed rate 8.18% · Lower 95% interval 4.49% |
| Staff COVID-19 vaccination coverage | 25.93% |
8.2%
17.7 pts better
|
Numerator 56 · Denominator 216 |
| Staff flu vaccination coverage | 33.73% |
42%
8.3 pts worse
|
Numerator 84 · Denominator 249 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 34 · Denominator 102 |
| Transfer of health information to provider | 92.94% |
95.95%
3 pts worse
|
Numerator 79 · Denominator 85 |
| Transfer of health information to patient | 74.47% |
96.28%
21.8 pts worse
|
Numerator 35 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 21.43% |
25.2%
3.8 pts worse
|
Numerator 21 · Denominator 98 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.3
0.8 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 4.1 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.9 · Expected 1.9 · 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 | 98.8% |
98.2%
0.6 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
1.6%
About the same
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 3.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.4% |
6.8%
13.6 pts worse
|
11.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 12.1% · Q3 31.4% · Q4 28.8% · 4Q avg 20.4% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
4.1%
1.1 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.5% · Q3 1.6% · Q4 3.8% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.0% |
13.7%
19.3 pts worse
|
19.6%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 33.8% · Q3 33.3% · Q4 34.5% · 4Q avg 33.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
14.2%
1.5 pts better
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 15.6% · Q3 12.0% · Q4 8.5% · 4Q avg 12.7% · 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 | 17.7% |
11.0%
6.7 pts worse
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
10.7%
0.3 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 11.3% · Q3 15.4% · Q4 2.7% · 4Q avg 10.4% · 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 1.2% · 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 | 5.5% |
10.9%
5.4 pts better
|
19.8%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.7% · Q3 8.3% · Q4 1.4% · 4Q avg 5.5% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.7%
1.2 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.7% · Q3 7.0% · Q4 4.8% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
94.0%
3.5 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.6% · Q3 94.8% · Q4 97.6% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
11.2%
4.7 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 7.6% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.5%
1.4 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.7% · Q3 3.6% · Q4 4.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
93.2%
0.6 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
23.2%
0.6 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 25.0% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-19 · Fire 2021-11-19
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2019-10-31 · Fire 2019-10-31
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-10-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-25
E · Potential for more than minimal harm
2023-03-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-04-24
D · Potential for more than minimal harm
2021-11-19
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-11-19
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-11-19
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-11-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-11-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-11-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-11-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-11-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-11-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-11-19
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-01-24
D · Potential for more than minimal harm
2019-10-31
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-10-31
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-10-31
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-10-31
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-10-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-10-31
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-10-31
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-10-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-10-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-12-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-13
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 2025-01-10
D · Potential for more than minimal harm
2024-10-28
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 2024-11-14
E · Potential for more than minimal harm
2024-10-03
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-24
D · Potential for more than minimal harm
2023-10-19
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 2023-11-13
D · Potential for more than minimal harm
2023-06-22
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 2023-07-03
D · Potential for more than minimal harm
2023-06-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-03
E · Potential for more than minimal harm
2023-03-28
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-04-11
D · Potential for more than minimal harm
2023-03-15
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 2023-03-27
E · Potential for more than minimal harm
2021-11-19
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 2022-01-12
E · Potential for more than minimal harm
2021-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-11-19
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 2022-01-12
D · Potential for more than minimal harm
2021-11-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-11-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-11-19
F726 · Nursing and Physician Services Deficiencies
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 2022-01-12
D · Potential for more than minimal harm
2021-11-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-11-19
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 2022-01-12
E · Potential for more than minimal harm
2019-10-31
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2019-11-20
E · Potential for more than minimal harm
2019-10-31
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 2019-11-20
E · Potential for more than minimal harm
2019-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-31
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 2019-11-20
D · Potential for more than minimal harm
2019-10-31
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 2019-11-20
Penalties and ownership
What sits behind the stars
Ownership
Mahan, Marylynn
5% Or Greater Direct Ownership Interest · Individual
Weinberger, Philip
5% Or Greater Direct Ownership Interest · Individual
Weiss, Hadassah
5% Or Greater Direct Ownership Interest · Individual
Weiss, Martin
5% Or Greater Direct Ownership Interest · Individual
Gharibian, Patric
Operational/Managerial Control · Individual
Gharibian, Patric
Corporate Officer · Individual
Grant, Daniel
Operational/Managerial Control · Individual
Mahan, Marylynn
Corporate Director · Individual
Mahan, Marylynn
Corporate Officer · Individual
Renew Health Consulting Services LLC
Operational/Managerial Control · Organization
Rizvi, Abid
Operational/Managerial Control · Individual
Sharma, Vatsala
Operational/Managerial Control · Individual
Weinberger, Philip
Corporate Director · Individual
Weinberger, Philip
Corporate Officer · Individual
Weiss, Hadassah
Corporate Director · Individual
Weiss, Martin
Corporate Director · Individual
Weiss, Martin
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Upland Rehabilitation and Care Center
Upland, CA
5-star overall rating with 4-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Heritage Park Nursing Center
Upland, CA
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Ontario Grove Healthcare & Wellness Centre, LP
Ontario, CA
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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