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
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing
LPN hours / resident day
1.08
Licensed practical nurse staffing
Aide hours / resident day
2.42
Nurse aide staffing
Weekend hours
3.56
Weekend nurse staffing
RN turnover
71%
Annual RN turnover
Total nurse turnover
53%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 ability to walk independently worsened | 17.7% |
11.0%
6.7 pts worse
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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