Upland Hills Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Upland Hills Nursing and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF757Jan 27, 2026

  Based on interview and record review the facility failed to ensure that each resident's drug regimen must be free from unnecessary drugs for 1 or 2 residents (R28). R28 has a history of a Gastrointestinal bleed (GI bleed; bleeding that occurs in the digestive tract) and R28 did not receive adequate monitoring for bleeding while taking an anticoagulant (blood thinner) medication. A Certified Nursing Assistant (CNA) notified RN G (Registered Nurse) of R28 possibly having blood in her stool. RN G did not assess R28 when it was first reported and initiate continued monitoring for bleeding for R28. R28 continued to decline and was sent to the emergency department (ED) where she received 2 units of blood due to a GI bleed and anemia. […]

• Actual harm, isolatedF689Jul 10, 2024

  Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 4 residents reviewed for accidents (R1 and R4.) R1 experienced a fall with major injury on 2/9/24 and again on 6/25/24. The facility noted R1's impulsivity, lack of using her call light and bell, and frequent attempts to self-transfer and did not put measures in place to ensure she was supervised. On 6/25/24, R1 was left alone in the dayroom while other staff tended to other residents and R1 got up, walked to her room, and fell , fracturing her hip. R4 had multiple falls due to self-transferring which resulted in a left wrist fracture. […]

• Actual harm, isolatedF689Jan 5, 2021

  Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R1). CNA C did not follow R1's care plan which resulted in a fall with multiple fractures. Findings include: R1 was admitted to the facility on [DATE]. According to R1's care plan, initiated 9/19/19, she is to be transferred by EZ stand with 1 staff. On 10/21/20, R1 experienced a fall while being transferred. The facility recorded the following nursing notes: *1:25 PM: Resident was being transferred to bathroom by CNA C (Certified Nursing Assistant). CNA C was transferring resident via 1 assist with gait belt, stand pivot in the bathroom - attempting to put resident on toilet. […]

• No harm, potential for more than minimal, widespreadF812Sep 18, 2024

  Based on observation, interview and record review, the facility did not ensure the preparation of food in a clean and sanitary environment with the potential to affect all residents in the facility. Surveyor observed a food item in dry storage with open and expiration dates and wwas beyond the labeled discard date. Surveyor observed a frozen food item uncovered in freezer. Surveyor reviewed facility's documentation and found staff did not document the water temperature or the sanitizing solution. Surveyor observed staff touching fresh cantaloupe with contaminated gloves. […]

• No harm, potential for more than minimal, widespreadF812Jul 26, 2023

  Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 34 residents. Ice and water were observed in food items. Food items were not dated to reflect open and/or use by date. Findings include: Example 1 On 7/25/23 at 8:18 AM, Surveyor observed frozen chunks of ice falling from the air handler in the facility's main kitchen freezer. Chunks of ice were observed hanging from the air handler and sitting on top of the food items, which consisted of pre-made leftovers inside plastic containers and an open box of cranberries with 2 individual packs, one sealed and one opened but tied. Chunks of ice were observed directly inside the box of cranberries. […]