Upland Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Upland Rehabilitation and Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 6, 2022

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary practices were maintained in the kitchen when: 1. Three (3) of three (3) ice machines had a black unknown substance in the ice chute (area between where ice is formed and where it enters the ice bin) which put 133 residents, who used or ingested ice from this machine, at risk for foodborne illness (illness acquired from ingesting contaminated food). 2. Three (3) sinks in the kitchen and one of three (3) ice machines (ice machine 1) did not have an air gap (which had the potential for back flow from the sewer to enter the ice machine and the sinks). […]

• No harm, potential for more than minimal, patternF812May 9, 2025

  Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food safety when employees' food was found inside 1 of 3 residents' refrigerators (Station 1 RR). This failure had the potential to expose 50 highly susceptible residents from Station 1, who were on an oral diet, to cross-contaminated (the transfer of harmful substances or disease- causing microorganisms) food. Findings: During a review of the facility's Station 1 Daily Census, dated May 4, 2025, the census indicated there were 56 residents in Station 1. During a review of the Station 1 Dietary Order Tally Report, (undated), the Dietary Order Tally Report indicated there were six residents who were not receiving an oral diet. […]

• No harm, potential for more than minimal, isolatedF676Sep 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure activities of daily living services were provided for one of three residents (Resident 1) in accordance with facility policy when, Resident 1 was not provided with a restorative nursing assistance (RNA) exercise for walking. This failure had the potential to cause a decline in a clinically compromised resident (Resident 1) health and ability to walk. Findings: During a review of Resident 1' admission Record (general demographics) on September 8, 2025, the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, type 2 diabetes (a condition in which the body have more sugar in the blood), hypertension (a condition in with a high blood pressure) and… […]

• No harm, potential for more than minimal, isolatedF550May 9, 2025

  Based on observation, interview, and record review, the facility failed to treat one of three sampled residents (Resident 398) with dignity when Certified Nurse Assistant 3 (CNA 3) was standing over the resident while assisting during lunch. This deficient practice had the potential to negatively impact the self-esteem and self-worth of Resident 398. Findings: During a review of Resident 398's Admission Record (AR), the AR indicated Resident 398 was admitted on [DATE], with diagnoses that included unstable angina (a type of chest pain or discomfort caused by reduced blood flow to the heart muscle), atherosclerosis (a condition where plaque builds up inside the arteries, causing them to narrow and potentially harden), hypertension (high blood pressure), and diabetes (a disorder… […]

• No harm, potential for more than minimal, isolatedF578May 9, 2025

  Based on interview and record review, the facility failed to honor the right to formulate an Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) for five of 37 sampled residents (Residents 50, 147, 153, 175, and 497) when: 1. The Advance Directives Checklist forms did not indicate whether Residents 50, 147, and 153 were provided an opportunity to formulate an Advance Directive. 2. Resident 175's Advance Directives Checklist form was not followed up to ensure their responsible party was given the opportunity to complete an Advance Directive on behalf of the resident. 3. […]