Cycle 1
Health 2025-05-09 · Fire 2025-05-09
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Upland, CA
Upland Rehabilitation and Care Center
5-star overall rating with 4-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1221 E Arrow Hwy, Upland, CA
(909) 985-1903
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
206
Certified beds
Average residents
184
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 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
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.79
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.87
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.10
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.23
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.67
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
4.27
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,104
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.72
Composite VBP score used to determine payment impact.
Payment multiplier
1.0061
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 18.37% · Performance 16.70% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
2.13
Baseline 7.09% · Performance 7.20% · Measure score 2.13 · Achievement 2.13 · Improvement 0
Total nurse turnover
5.98
Baseline 35.44% · Performance 39.24% · Measure score 5.98 · Achievement 5.98 · Improvement 0
Adjusted total nurse staffing
2.58
Baseline 3.55 hours · Performance 3.81 hours · Measure score 2.58 · Achievement 2.58 · Improvement 0.68
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.57% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 240 · Observed rate 11.25% · Lower 95% interval 8.14% |
| Discharge to community | 55.68% |
50.57%
5.1 pts better
|
No Different than the National Rate · Eligible stays 237 · Observed rate 46.41% · Lower 95% interval 47.2% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.46% |
95.27%
4.2 pts better
|
Numerator 185 · Denominator 186 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 186 |
| Discharge self-care score | 57.3% |
53.69%
3.6 pts better
|
Numerator 51 · Denominator 89 |
| Discharge mobility score | 43.82% |
50.94%
7.1 pts worse
|
Numerator 39 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 1.61% |
2.29%
0.7 pts better
|
Numerator 3 · Denominator 186 · Adjusted rate 1.17% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 160 · Observed rate 8.75% · Lower 95% interval 5.14% |
| Staff COVID-19 vaccination coverage | 3.54% |
8.2%
4.7 pts worse
|
Numerator 13 · Denominator 367 |
| Staff flu vaccination coverage | 58.01% |
42%
16 pts better
|
Numerator 257 · Denominator 443 |
| Discharge function score | 52.81% |
56.45%
3.6 pts worse
|
Numerator 47 · Denominator 89 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 54 · Denominator 54 |
| Transfer of health information to patient | 98.96% |
96.28%
2.7 pts better
|
Numerator 95 · Denominator 96 |
| Resident COVID-19 vaccinations up to date | 12.09% |
25.2%
13.1 pts worse
|
Numerator 11 · Denominator 91 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.3
0.6 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.8 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 2.0 · 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 | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
1.6%
0.8 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
6.8%
6.1 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.9% · Q4 0.9% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
4.1%
1 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.0% · Q3 3.9% · Q4 4.1% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
13.7%
2.6 pts worse
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 17.0% · Q3 14.8% · Q4 13.7% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
14.2%
8.3 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.0% · Q3 5.7% · Q4 5.7% · 4Q avg 5.9% · 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 | 8.8% |
11.0%
2.2 pts better
|
16.3%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 5.9% · Q3 8.9% · Q4 9.1% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
10.7%
6.9 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.5% · Q3 1.2% · Q4 4.8% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.0%
1.3 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.5% · Q3 2.5% · Q4 1.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.2%
0.5 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 3.1% · Q4 2.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.2% |
10.9%
4.7 pts better
|
19.8%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 7.7% · Q3 4.7% · Q4 2.8% · 4Q avg 6.2% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.7%
0.2 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.6% · Q3 5.3% · Q4 4.2% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
94.0%
5 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 99.7% · Q3 99.8% · Q4 98.9% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
11.2%
3.8 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 8.9% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 1.9% · Q4 0.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.2% |
93.2%
5 pts better
|
79.7%
18.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
23.2%
0.7 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 30.4% · Expected 32.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-06 · Fire 2022-05-06
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-08-09 · Fire 2019-08-09
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-09
F · Potential for more than minimal harm
2025-05-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-09
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-06-09
F · Potential for more than minimal harm
2022-05-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-14
E · Potential for more than minimal harm
2022-05-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-07-14
E · Potential for more than minimal harm
2022-05-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-05-06
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-07-14
D · Potential for more than minimal harm
2019-08-09
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-09-19
D · Potential for more than minimal harm
2019-08-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-09-19
D · Potential for more than minimal harm
2019-08-09
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2019-09-19
D · Potential for more than minimal harm
2019-08-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-09-19
D · Potential for more than minimal harm
2019-08-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-09-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-22
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-10-04
E · Potential for more than minimal harm
2025-05-09
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 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F578 · Resident Rights Deficiencies
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 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-09
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 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-09
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 2025-06-06
D · Potential for more than minimal harm
2025-05-09
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 2025-06-06
D · Potential for more than minimal harm
2025-05-09
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 2025-06-06
D · Potential for more than minimal harm
2025-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
D · Potential for more than minimal harm
2024-10-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-20
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-07-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-23
D · Potential for more than minimal harm
2024-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-16
D · Potential for more than minimal harm
2023-08-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-29
F · Potential for more than minimal harm
2022-05-06
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 2022-05-31
D · Potential for more than minimal harm
2022-05-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-05-06
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 2022-05-31
D · Potential for more than minimal harm
2022-05-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-05-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-05-06
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-05-31
F · Potential for more than minimal harm
2019-08-09
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 2019-08-29
D · Potential for more than minimal harm
2019-08-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2019-08-29
D · Potential for more than minimal harm
2019-08-09
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 2019-08-29
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare Central LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Jergensen, Jeremy
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Mcmillan, Kip
Operational/Managerial Control · Individual
Sato, Ami
Corporate Officer · Individual
Takhar, Daljinder
Operational/Managerial Control · Individual
Willits, Adam
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Villa Mesa Care Center
Upland, CA
4-star overall rating with 5-star inspections with 1 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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