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
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing
LPN hours / resident day
1.79
Licensed practical nurse staffing
Aide hours / resident day
2.87
Nurse aide staffing
Weekend hours
4.67
Weekend nurse staffing
RN turnover
23%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
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 |
| 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 |
| 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 | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 8.8% |
11.0%
2.2 pts better
|
16.3%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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