Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Yucaipa Hills Post Acute during CMS and state inspections, most recent first.
A resident at high risk for falls and fully dependent on staff for mobility fell from bed while being changed by a contracted CNA, resulting in a head injury. The CNA did not seek assistance from another staff member, despite the resident's severe cognitive impairment and need for two-person assistance. The facility's fall prevention policy was not adequately followed, leading to the incident.
A resident with dementia and a history of falls eloped from a locked memory care unit due to inadequate supervision. The resident, who required close monitoring, was found unassisted in a field by a surveyor. Staff interviews revealed a lack of coordination during breaks, leading to insufficient supervision. The facility's policy on elopement was not effectively implemented, as the exit door was not alarmed, and staff coverage was inadequate.
A facility failed to complete and submit MDS assessments for several residents within the required timeframes, resulting in inadequate monitoring of residents' conditions. The delays were attributed to staffing challenges, as the MDS nurse position was vacant or on leave, and the facility lacked a specific policy for timely MDS completion.
A facility failed to accurately complete a POLST form for a resident with serious medical conditions, resulting in conflicting information about medical interventions. The resident's POLST indicated a desire for CPR, but the section for medical interventions incorrectly selected selective treatment instead of full treatment. The DON confirmed the error, and the SSD, who completed the form, acknowledged the mistake. The facility's policy requires regular reviews of POLST forms, which was not adhered to, leading to this deficiency.
The facility failed to follow care plans for two residents, one with smoking restrictions and another with diabetes management needs. A resident with cognitive impairment and on oxygen therapy was found with smoking materials, contrary to their care plan. Another resident's blood sugar was checked after starting a meal, against the care plan's requirement for pre-meal checks. These oversights indicate non-compliance with established care protocols.
A facility failed to monitor and document the use of a low air loss mattress for a resident with a stage 4 pressure ulcer, as per the physician's order. The resident, with Alzheimer's and epilepsy, was on a mattress meant for tissue load management, requiring checks every shift. However, documentation was missing for several dates, indicating non-compliance. The Treatment Nurse and LVN acknowledged the importance of monitoring, while the DON suggested it might be a documentation error. The care plan emphasized the need for treatment monitoring, but the facility's policy was not adhered to.
A facility failed to document a gradual dose reduction (GDR) for a resident's Trazadone medication from 100 mg to 50 mg, despite a recommendation from the NP. The resident, diagnosed with major depressive disorder and bipolar disorder, was stable and agreed to the GDR. However, the resident continued receiving the 100 mg dose, and the DON did not document the resident's refusal of the GDR or the communication with the NP, contrary to the facility's documentation policy.
A facility failed to follow its policy for labeling and dating food items when a bottle of coffee creamer was found open and unlabeled in the kitchen. The Dietary Services Supervisor confirmed the oversight, acknowledging that the creamer should have been labeled and stored according to the facility's policy. A review of the facility's policy indicated that all food items must be labeled and dated, highlighting a deviation from these procedures.
The facility failed to provide the required 80 square feet per resident in two rooms, with measurements showing 72.7 and 71.3 square feet per resident. Despite this, residents did not express concerns, and no safety hazards were noted.
A resident reported that staff would take her call light away, making it inaccessible, which was corroborated by her roommate. Despite the facility's policy requiring immediate reporting of such allegations, the Administrator was not informed until a surveyor's intervention. Interviews with CNAs revealed awareness of similar incidents, but they were not properly reported, leading to a delay in addressing the alleged abuse.
A resident exposed to COVID-19 was observed participating in group activities without a mask, contrary to their care plan and facility policy. The resident, sharing a room with a COVID-19 positive individual, was supposed to follow droplet precautions, including mask-wearing and avoiding communal activities. The DON confirmed the care plan was not adhered to, risking virus transmission.
The facility failed to ensure a safe environment by not providing accessible call lights for two residents. One resident with dementia and a history of falls had her call light hanging from a light fixture, while another resident with multiple health issues had her call light on the floor behind a nightstand. Staff acknowledged that the call lights should have been within reach but were not.
Failure to Prevent Avoidable Accident Resulting in Resident Injury
Penalty
Summary
The facility failed to prevent an avoidable accident involving a resident who was at high risk for falls and fully dependent on staff for mobility while in bed. The incident occurred when a contracted Certified Nursing Assistant (CNA) was changing the resident's brief and turned the resident away from her, causing the resident to fall from the bed. This resulted in the resident sustaining a head injury, including a bleeding laceration to the right eyebrow and a subarachnoid hemorrhage. The Director of Nursing confirmed that the CNA should have had assistance from another staff member due to the resident's condition, which included contractures and severe cognitive impairment. The resident's medical history included cerebral palsy, Parkinson's disease, disorders of bone density and structure, and epilepsy. The resident's Minimum Data Set assessment indicated severe cognitive impairment and a dependency on staff for rolling in bed, requiring the assistance of two or more helpers. The resident was identified as high-risk for falls, with a fall risk assessment score of 14. The facility's policy on fall prevention required investigation of falls and actions to reduce further incidents, but the failure to follow proper procedures led to the resident's injury.
Resident Elopement Due to Inadequate Supervision in Memory Care Unit
Penalty
Summary
An immediate jeopardy situation was identified in a nursing home facility when a resident with dementia and a history of falls eloped from a locked memory care unit. The resident, who had severe cognitive impairment and required supervision for mobility, was found unassisted in a field adjacent to the facility by a surveyor. The facility staff were unaware of the resident's absence until informed by the surveyor, indicating a lapse in supervision and monitoring. The resident's clinical records showed a history of cognitive deficits, unsteadiness, and impaired safety awareness, necessitating close supervision. Despite these needs, the facility failed to provide adequate supervision, as evidenced by the resident's ability to leave the secure unit and exit the building. Interviews with staff revealed that there was a lack of coordination and communication regarding staff coverage during breaks, leading to insufficient supervision in the memory care unit at the time of the incident. The facility's policy on elopement and unsafe wandering was not effectively implemented, as the exit door used by the resident was not alarmed, and staff were not adequately stationed to monitor residents. The staffing schedule did not clearly assign responsibilities for supervising each hallway during staff breaks, contributing to the oversight that allowed the resident to elope. This deficiency in supervision posed a significant risk to the resident's safety and well-being.
Removal Plan
- Resident 27 was assessed by the Director of Nursing and a physician. Body assessment was done with no apparent injury. The attending physician ordered Complete Blood Count, Complete Metabolic Panel, and Urinalysis with culture and sensitivity.
- Resident 27 was placed on change of condition monitoring and 1:1 supervision with closed visual check. No change was noted related to incident.
- The Facility Administrator installed a functional audio alarm system on all exit doors in the lower unit.
- All exterior doors in the lower/Memory care unit will be checked every 15 minutes by a designated staff along with the installation of alarm system.
- Director of Nursing and designees evaluated 80 residents' elopement and wandering risk to identify any residents that were at high risk for elopement and wandering. No other residents were affected.
- Director of Nursing and designees ensured that identification of all 80 residents was in place such as wrist bands and/or photo on the electronic medical record. All residents had a wrist band and/or photos were uploaded.
- Facility staff received an in-service and training from the Director of Staff Development regarding Policy and Procedure Incident/Accident with emphasis on Elopement/Wandering Incidents. In-services will be given to all staff before the beginning of their next shift.
- Director of Staff Development initiated in-service with the Licensed Nurses and Certified Nursing Assistants about coverage during breaks and lunch. The licensed nurse is responsible for creating the daily shift assignment form including the scheduled break and lunch time to ensure that the floor has adequate staff and supervision provided to the residents. In an event that a staff is running late for the scheduled break and lunch, it is the staff's responsibility to notify the Charge Nurse or Registered Nurse supervisor so that, if necessary, the Licensed Nurse can make the adjustment to ensure adequate supervision is provided to the residents. In-services will be given to all licensed nurses and certified nursing assistants before the beginning of their next shift.
- Director of Staff Development and/or Charge Nurse will ensure that daily shift assignment is completed and scheduled breaks and lunch time is covered.
- Administrator initiated the in-service regarding the policy, monitoring, and maintenance alarm system in all exterior doors in the lower unit.
- All Exterior doors in the lower unit will be checked every 15 minutes.
- Maintenance Supervisor will test the alarms weekly and will be maintained according to manufacturer guideline.
- A log of maintenance and testing will be kept by the Maintenance Supervisor.
Delayed MDS Assessments Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for thirteen residents were conducted and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required federal submission timeframes. This deficiency was identified through interviews and record reviews, revealing that the assessments were completed significantly past the Assessment Reference Date (ARD) for each resident. The delay in completing these assessments resulted in inadequate monitoring of the residents' progress or decline and a lack of resident-specific information submitted to CMS for payment and quality measure monitoring. The report details specific instances of late MDS assessments for each of the thirteen residents, highlighting the extent of the delays. For example, Resident 54's quarterly MDS assessment was completed 33 days past the ARD, while Resident 27's assessment was completed 52 days past the ARD. These delays were consistent across all residents reviewed, with the Resource MDS Nurse (RMN) and the Director of Nursing (DON) acknowledging the late submissions but unable to provide reasons for the delays. Interviews with facility staff, including the RMN and DON, revealed that the facility was experiencing staffing challenges, particularly with the MDS nurse position. The previous MDS nurse had left the company, and the current MDS nurse was on leave, contributing to the delays in completing the assessments. Additionally, the facility did not have a specific policy and procedure regarding the completion of MDS assessments, relying instead on the guidelines from the Resident Assessment Instrument (RAI) manual. This lack of structured protocol may have further contributed to the oversight in timely submissions.
Inaccurate Completion of POLST Form
Penalty
Summary
The facility failed to ensure that a Physician Orders for Life Sustaining Treatment (POLST) form for one resident was accurately completed, resulting in conflicting information regarding medical interventions. The resident, who had been admitted with conditions including hemiplegia, heart failure, chronic respiratory failure, and COPD, had a POLST form that indicated a desire for resuscitation/CPR in Section A. However, Section B of the form, which should have indicated full treatment to align with the CPR choice, instead had selective treatment checked. This discrepancy was identified during a review of the resident's records. The Director of Nursing (DON) confirmed the inconsistency in the POLST form and acknowledged that it needed clarification. The Social Services Director (SSD), who completed the POLST, admitted to the error and stated that the form was revised by a physician after the mistake was identified. The facility's policy requires that POLST forms be reviewed quarterly and upon admission to ensure accuracy and completeness, but this process was not followed, leading to the deficiency.
Failure to Follow Care Plans for Smoking and Diabetes Management
Penalty
Summary
The facility failed to ensure that Resident 14 received care and services as specified in their care plan. Resident 14, who has a history of hemiplegia, hemiparesis, falls, and heart failure, was found to be keeping their own smoking materials, including cigarettes and lighters, despite having moderate cognitive impairment and being on oxygen therapy. The care plan for Resident 14 clearly stated that smoking materials should be kept by staff and that the resident should be supervised while smoking. However, during an interview and observation, it was discovered that Resident 14 had access to these materials, which contradicted the facility's policy and posed a potential fire hazard. The facility also failed to adhere to the care plan for Resident 11, who has diabetes. Resident 11's care plan required that their blood sugar be checked before meals to ensure proper insulin administration. However, during an observation, it was noted that Resident 11's blood sugar was checked after they had already started eating breakfast. This oversight was acknowledged by the DON, who confirmed that the blood sugar should have been checked prior to the meal, as per the physician's orders and the facility's policy. These deficiencies highlight the facility's failure to follow established care plans and policies, which are crucial for ensuring the safety and well-being of residents. The lack of adherence to these plans not only compromised the care of Residents 14 and 11 but also posed potential risks to their health and safety.
Failure to Monitor Low Air Loss Mattress for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to monitor and document the use of a low air loss mattress for a resident with a stage 4 pressure ulcer, as per the physician's order. The resident, who was admitted with Alzheimer's Disease and epilepsy, was observed on a low air loss mattress, which was intended for tissue load management. The physician's order required the mattress to be checked for placement and settings every shift. However, there were multiple instances of missing documentation indicating that the mattress was not monitored as required. The Treatment Nurse acknowledged gaps in documentation on several dates and shifts, suggesting that the monitoring of the low air loss mattress was not completed. The Licensed Vocational Nurse (LVN) confirmed the importance of repositioning the resident and monitoring the mattress settings due to the resident's pressure ulcer. The Director of Nursing suggested that the issue might be a documentation error. The care plan for the resident highlighted the risk for skin breakdown and the need for treatments to be administered and monitored for effectiveness, but the facility's policy on pressure ulcer management was not followed as required.
Failure to Document Gradual Dose Reduction for Trazadone
Penalty
Summary
The facility failed to document a gradual dose reduction (GDR) for a resident when a recommended decrease in Trazadone from 100 mg to 50 mg was not executed and documented. The resident, who was admitted with diagnoses including major depressive disorder and bipolar disorder, was found to be stable by the Nurse Practitioner (NP) on October 7, 2024, and a GDR was recommended. However, the resident continued to receive the 100 mg dose as per the physician's orders, and there was no documented evidence of the dose reduction in the resident's records. The Director of Nurses (DON) confirmed that the resident was still taking Trazadone 100 mg and acknowledged that the resident had refused the dose reduction, preferring to continue with the current dose. The DON admitted to failing to document the resident's refusal and the communication with the NP, which was a discrepancy in the facility's documentation practices. The facility's policy and procedure on nursing documentation required documentation of treatment refusals, which was not followed in this case.
Improper Labeling and Storage of Food Item
Penalty
Summary
The facility failed to adhere to its policy and procedure for labeling and dating food items, as evidenced by an observation during a kitchen tour. A bottle of [brand name] coffee creamer was found open and partially used on a table at room temperature without an open date. This oversight was confirmed by the Dietary Services Supervisor (DSS 1), who acknowledged that the creamer should have been labeled and stored according to the facility's policy. A review of the facility's policy titled 'Labeling and dating of foods' dated 2023, indicated that all food items in storage areas must be labeled and dated. The procedure specifies that newly opened food items should be closed, labeled with an open date, and used by the date following storage guidelines. The lack of labeling and proper storage of the creamer represents a deviation from these established procedures.
Room Size Deficiency in Resident Rooms
Penalty
Summary
The facility failed to ensure that two of its resident rooms met the required space standards, with each resident needing at least 80 square feet in shared rooms. Specifically, rooms were found to be below this requirement, with one room measuring 72.7 square feet per resident and another measuring 71.3 square feet per resident. This deficiency was identified during an environmental tour conducted with the Maintenance Director, where the measurements of the rooms were taken and confirmed to be insufficient. Despite the deficiency in room size, observations and interviews with the residents occupying these rooms revealed that they did not express any concerns or issues regarding the space. The residents were observed to be resting comfortably, and there were no reported problems with the accessibility of beds, bedside tables, or wheelchairs. Additionally, the rooms were not crowded, and no safety hazards were noted during the survey.
Failure to Report Alleged Abuse of Resident Call Light
Penalty
Summary
The facility failed to ensure that staff reported an allegation of abuse involving a resident's call light being taken away, as required by the facility's policy and federal regulations. This deficiency was identified during a surveyor's interview with Resident 36, who reported that staff would sometimes take her call light away, making it inaccessible. Resident 46, her roommate, corroborated this claim, stating she had witnessed staff taking the call light away from Resident 36. Despite these allegations, the facility's Administrator, who is also the abuse prevention coordinator, was not informed of these incidents until the surveyor brought it to his attention. Further interviews revealed that Certified Nursing Assistant 6 was aware of the incident and had informed a supervisor, though she could not recall who. Certified Nursing Assistant 7 also mentioned hearing about similar incidents from other residents but did not report them to anyone. The facility's policy on abuse investigation and reporting mandates that all allegations of abuse be reported immediately to various authorities, including the state licensing agency and law enforcement, within specified timeframes. However, this protocol was not followed, resulting in a delay in reporting and investigating the alleged abuse, potentially placing residents at risk.
Failure to Implement COVID-19 Precautions for Exposed Resident
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically in managing the spread of COVID-19. Resident 1, who was exposed to COVID-19 through a roommate, Resident 5, was placed on transmission-based droplet precautions. Despite this, Resident 1 was observed participating in group activities with eleven other residents in a common area without wearing a mask. The Infection Preventionist Nurse confirmed that Resident 1 was not following the care plan, which included wearing a mask and avoiding communal activities to prevent the spread of the virus. The Director of Nursing acknowledged that Resident 1's care plan, which emphasized mask-wearing, social distancing, and avoiding group activities, was not followed. The facility's policy on infection prevention and control, which aligns with CDC recommendations, was not effectively implemented, as evidenced by Resident 1's participation in communal activities despite being on isolation precautions due to COVID-19 exposure.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure a safe environment for two residents by not providing accessible call lights. Resident 1, who has dementia, unsteadiness on feet, and a history of repeated falls, was found with her call light hanging from a light fixture on the wall, making it inaccessible. During an observation and interview, Resident 1 stated she did not know where the call light was and needed to use the restroom. The Director of Staff Development (DSD) and a Certified Nurse Assistant (CNA) acknowledged that the call light should have been within reach but was not. Similarly, Resident 3, who has dementia, peripheral vascular disease, and respiratory failure, was found with her call light on the floor behind a nightstand, making it inaccessible. During an observation, Resident 3 was lying in bed with her eyes closed. The DSD and CNA acknowledged that the call light should have been within reach but was not. The facility's policy, which mandates that call lights be accessible to residents, was not followed, as confirmed by the Administrator during a review of the policy and procedure.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Yucaipa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside Post Acute | 0.2 mi | — | 2 | 0 |
| Cedar Mountain Post Acute | 2.1 mi | — | 17 | 0 |
| Oak Glen Post Acute | 4.8 mi | — | 0 | 0 |
| University Post Acute | 5.7 mi | — | 9 | 0 |
| Highland Springs Care Center | 5.8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.