6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Yucaipa, CA
4-star overall rating with 4-star inspections with $31,899 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
13542 2nd St., Yucaipa, CA
(909) 795-2421
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
82
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1972-11-06
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
RN hours / resident day
0.32
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
9,956
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1
Baseline 17.67% · Performance 20.97% · Measure score 1 · Achievement 1 · Improvement 0
Healthcare-associated infections
3.13
Baseline 7.75% · Performance 6.90% · Measure score 3.13 · Achievement 3.13 · Improvement 2.58
Total nurse turnover
2.43
Baseline 73.68% · Performance 59.38% · Measure score 2.43 · Achievement 1.05 · Improvement 2.43
Adjusted total nurse staffing
2.21
Baseline 3.20 hours · Performance 3.71 hours · Measure score 2.21 · Achievement 2.21 · Improvement 1.46
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.51% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 13.16% · Lower 95% interval 8.11% |
| Discharge to community | 39.56% |
50.57%
11 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 28.57% · Lower 95% interval 27.57% |
| Medicare spending per beneficiary | 1.56 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 67 · Denominator 67 |
| Falls with major injury | 1.49% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 67 |
| Discharge self-care score | 20.45% |
53.69%
33.2 pts worse
|
Numerator 9 · Denominator 44 |
| Discharge mobility score | 34.09% |
50.94%
16.8 pts worse
|
Numerator 15 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 1.49% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 67 · Adjusted rate 1.02% |
| Healthcare-associated infections requiring hospitalization | 6.9% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 6.67% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 8.2% |
8.2%
About the same
|
Numerator 10 · Denominator 122 |
| Staff flu vaccination coverage | 27.14% |
42%
14.9 pts worse
|
Numerator 38 · Denominator 140 |
| Discharge function score | 18.18% |
56.45%
38.3 pts worse
|
Numerator 8 · Denominator 44 |
| Transfer of health information to provider | 93.33% |
95.95%
2.6 pts worse
|
Numerator 28 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 43.33% |
25.2%
18.1 pts better
|
Numerator 13 · Denominator 30 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.3
0.4 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.5 · 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 | 97.5% |
98.2%
0.7 pts worse
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
1.6%
4.6 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 9.5% · Q3 4.2% · Q4 1.4% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
6.8%
6.4 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
4.1%
1.8 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.4% · Q3 9.8% · Q4 3.0% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.3% |
13.7%
6.4 pts better
|
19.6%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 6.8% · Q3 11.6% · Q4 5.7% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
14.2%
4.7 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 8.0% · Q3 3.8% · Q4 6.1% · 4Q avg 9.5% · 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 | 13.8% |
11.0%
2.8 pts worse
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 20.6% · Q3 9.7% · Q4 16.5% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
10.7%
6.7 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 17.9% · Q3 17.7% · Q4 24.2% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
1.0%
0.8 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.0% · Q3 2.5% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
10.9%
14 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 19.1% · Q3 22.8% · Q4 30.0% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.7%
0.7 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 6.9% · Q3 4.3% · Q4 8.0% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
94.0%
3.1 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 97.4% · Q3 100.0% · Q4 100.0% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.5% |
11.2%
14.3 pts worse
|
12.0%
13.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 27.3% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 4.2% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.5% |
93.2%
20.7 pts worse
|
79.7%
7.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
23.2%
0.2 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 25.8% · Expected 26.3% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-02
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-02
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-02
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-10
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-10
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-11-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-10
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-10
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-11-10
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-10
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-16
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-16
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-16
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-03-16
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-03-16
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2023-03-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-16
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-03-16
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-03-16
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-03-16
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-16
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-03-16
Inspection history
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 2026-02-09
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-02-09
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-02-09
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-09
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-09
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2026-02-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-26
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-11-26
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 2024-11-26
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-26
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-26
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-26
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-11-26
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-03
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-04-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-17
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-08-22
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-10
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-08-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-07
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 2023-03-20
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-03-20
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-03-20
Health
Assess the resident when there is a significant change in condition
Corrected 2023-03-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-20
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-20
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-20
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-20
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-03-20
Penalties and ownership
Fine · fine $22,932
Fine
Payment Denial · denial start 2024-11-15 · 11 days
11 day denial
Fine · fine $8,967
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Organization
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