Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Upland Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with muscle weakness and mobility issues was not provided with restorative nursing assistance for ambulation after completing physical therapy, despite care plan requirements and recommendations from rehab staff. Staff interviews confirmed that only upper body RNA was performed, and the resident was not assisted with walking, contrary to facility policy.
Surveyors identified that the facility did not maintain required fire sprinkler system records and had an illegible Auxiliary Drain information sign. The Maintenance Director could not provide documentation of the annual sprinkler inspection, and the only available record was from a previous five-year inspection. This deficiency affected all staff and residents in the facility.
Surveyors observed several cigarette butts on the ground in the designated smoking area, and the Maintenance Director was unaware of their presence or duration. This failure to maintain the smoking area in accordance with regulations affected all residents in the facility.
A penetration in the wall beneath a restroom sink in one room created a seven-inch opening, compromising the fire barrier and potentially allowing smoke and gases to pass between areas. The Maintenance Director was unaware of how long the issue had existed, and this deficiency affected 32 residents in one smoke compartment.
A corridor kitchen door equipped with a self-closing device was found not to latch when tested during a facility tour, as confirmed by the Maintenance Director. This deficiency impacted 32 residents in one smoke compartment and resulted in noncompliance with NFPA 101 standards for self-closing doors.
A box of sponge cakes belonging to a housekeeper was found stored in a refrigerator designated for residents' food only, despite clear signage and facility policy prohibiting employee food storage in that area. Staff interviews confirmed the food's ownership and revealed lapses in daily monitoring, resulting in a failure to follow food safety standards and facility policy.
A resident requiring one-on-one meal assistance, with multiple medical conditions, was assisted by a CNA who stood over them during feeding, contrary to both the resident's preference and facility policy. Leadership and facility documents confirmed that staff are expected to be seated at eye level to promote dignity and safe feeding, but this procedure was not followed.
The facility did not consistently provide or document opportunities for residents or their representatives to formulate Advance Directives. In several cases, forms were incomplete, missing, or not followed up, affecting residents with both impaired and intact decision-making capacity. Staff interviews confirmed that required processes for offering and recording Advance Directive information were not reliably implemented.
A resident with chronic respiratory failure received PRN clonazepam for anxiety, and the order was extended beyond the initial period without documented rationale from the prescriber in the medical record. The DON confirmed that this extension lacked the required documentation, which did not comply with facility policy on psychoactive drug monitoring.
A resident admitted for orthopedic aftercare following a left below-the-knee amputation was discharged without the required advance notification to the State LTC Ombudsman. The facility's policy and federal regulations require that the Ombudsman be notified at least 30 days before discharge, but staff confirmed the notification was sent after the resident had already left. Both the DON and Administrator acknowledged the failure to meet the notification timeframe.
Three residents did not have appropriate individualized care plans developed or implemented for their specific needs, including anticoagulant medication management and dental care. One resident on apixaban lacked a care plan for anticoagulant use, another resident with lost dentures and dental issues had no dental care plan, and a third resident on Lovenox did not have care plan interventions for monitoring bruising implemented after a fall. Staff confirmed the absence or lack of implementation of these care plans.
A resident with functional quadriplegia, fully dependent on staff for personal hygiene, was found with untrimmed and dirty fingernails. Staff acknowledged that nail care was not provided as required by facility policy, which mandates daily cleaning and regular trimming during ADL care. The DON confirmed that the facility's expectations and procedures for grooming were not followed.
A resident with MASD on the buttocks did not receive consistent weekly wound assessments as required by facility policy, despite ongoing physician-ordered treatment. Nursing staff confirmed missing documentation for two weeks, which is necessary to monitor wound progression and guide care.
A resident with obstructive sleep apnea who used a CPAP machine nightly did not have the machine's filter replaced according to manufacturer guidelines. Staff observed the filter was discolored and could not identify who was responsible for its maintenance. There was no documentation of filter inspection or replacement, despite the manufacturer's recommendation for regular checks and changes.
A resident with end stage renal disease who received regular dialysis had a bandage left on their dialysis access site for more than four hours after treatment, contrary to facility policy. Both an LVN and the DON observed the bandage the morning after dialysis, and records confirmed it should have been removed within three to four hours as part of post-dialysis care.
A resident with contractures and impaired upper extremity mobility was assessed as able to use bed rails for mobility, despite being fully dependent on staff and unable to utilize the rails. Documentation and staff interviews confirmed inconsistencies between the resident's actual abilities and the bed rail assessment, resulting in improper use of side rails.
A resident with chronic heart failure and on dialysis did not receive a prescribed dose of furosemide after an LVN withheld the medication due to an unclear order to hold all blood pressure meds on dialysis days. The nurse did not clarify whether the diuretic, ordered for heart failure, should be held, resulting in a missed dose. The DON confirmed that facility policy requires clarification of any questionable orders.
Surveyors identified that medications in one medication room were stored at temperatures exceeding manufacturer recommendations, with the room temperature recorded at 78°F on two days. Multiple medications requiring storage at or below 77°F were found in this room, and both the ADON and DON acknowledged the facility's policy to follow manufacturer guidelines for medication storage.
A resident with osteoarthritis and a history of stroke had physician orders for daily RNA services for ambulation, but documentation was incomplete, with only a few entries in one month and none in the following month. The RNA and DON confirmed that services provided or refused should have been documented, and facility policy requires complete documentation of care.
A single-dose acetic acid container was not discarded after opening and was stored in a treatment cart for several days, contrary to manufacturer instructions and facility policy. Additionally, a non-laundry staff member entered the clean area of the laundry department and removed clean linens, despite facility protocols restricting this area to laundry staff only. Both actions were inconsistent with infection control procedures.
A resident with limited mobility was left uncovered in bed by a CNA, violating privacy standards. Another CNA delayed attending to the resident for a change, failing to request assistance. These actions did not adhere to the facility's policy on resident dignity and timely care.
A LTC facility failed to provide a resident's medical records to their legal representative after a written request. The resident, with multiple health conditions, had a legal representative who claimed to have successfully faxed a request for the records. However, the facility's staff denied receiving the fax until a follow-up call was made. This failure potentially violated the resident's rights to access their medical records.
A resident's dignity and rights were compromised when an LVN entered her room without permission and removed her oxygen tubing, mistaking it for another resident's. The resident, who was cognitively intact and required assistance for daily activities, was left confused and upset. The facility's policy on resident rights, emphasizing respect and dignity, was not followed, as confirmed by the DON.
A resident with multiple serious health conditions developed an unstageable pressure ulcer on the coccyx and left buttocks while in the facility. Despite being assessed as high risk for pressure sores, preventive measures such as turning and repositioning and the use of a low air loss mattress were implemented only after the ulcer developed. The facility's failure to prevent the pressure ulcer placed the resident's health and safety at risk.
A resident with limited mobility was not provided a bedside commode or assisted to the bathroom, despite the facility's policy to assess and assist residents with toileting needs. This failure potentially impacted the resident's dignity and psychological well-being.
Failure to Provide Restorative Ambulation Services After PT Discharge
Penalty
Summary
A resident with diagnoses including muscle weakness, type 2 diabetes, hypertension, and gait abnormalities was admitted to the facility and required assistance to maintain or improve mobility. The resident's care plan indicated a need to improve functional mobility and reduce fall risk, with interventions to address limited physical mobility. After the resident completed physical therapy, facility staff failed to continue restorative nursing assistance (RNA) exercises for ambulation, despite the care plan and recommendations from the rehab staff that the resident should have been placed on an RNA program for walking. Observations and interviews revealed that the resident remained in bed and only received RNA for the upper body, with no ambulation exercises provided. The CNA and LVN confirmed the resident stayed in her room and had not been observed walking, while the restorative nursing assistant stated that only upper body RNA was performed. The facility administrator acknowledged that there was no continuation of therapy for RNA after physical therapy ended, and the resident was not placed on the RNA program for ambulation as required by facility policy.
Failure to Maintain and Document Fire Sprinkler System Inspections
Penalty
Summary
The facility failed to maintain the automatic fire sprinkler system in accordance with regulatory requirements. During a document review and interview, surveyors found that the Auxiliary Drain information sign located on the west outside wall near the generator was faded and illegible. The Maintenance Director stated that the contractor responsible for replacing sprinkler system signs during the semi-annual inspection had been informed about the need for replacement approximately two months prior, but the sign had not yet been replaced. Additionally, the facility was unable to provide records of the required annual sprinkler system inspection and testing. The only documentation available was from a five-year sprinkler inspection/test conducted previously. The Maintenance Director indicated that the facility was under contract with a sprinkler company that was supposed to conduct annual inspections automatically, but no records for the most recent annual inspection could be located. This deficiency affected all staff and all 192 residents across six smoke compartments.
Plan Of Correction
K353 NFPA 101 Sprinkler System - Maintenance and Testing How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The automatic fire sprinkler system inspection and testing was immediately scheduled and completed on 5/27/25. The auxiliary Drain Information sign was replaced on 5/27/25. No residents were affected by the finding. The automatic fire sprinkler system inspection and testing was immediately scheduled and completed on 5/27/25. The auxiliary Drain Information sign was replaced on 5/27/25. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to have been affected by this finding. Maintenance director completed audit to ensure all inspections and testing are up to date. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Maintenance staff were in serviced on 5/27/25 by the Administrator regarding policy on ensuring that all sprinkler inspections and testing are completed to ensure compliance. Maintenance director will ensure that all logs are reviewed monthly for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: The Administrator or designee will review inspection and testing records for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025. K 353
Failure to Maintain Smoking Area Cleanliness
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed approximately five cigarette butts on the ground near the designated smoking area. The Maintenance Director stated that he was unaware of the cigarette butts being present and did not know how long they had been there. This observation indicated that the facility failed to properly maintain the smoking area as required by regulations, specifically regarding the disposal of cigarette butts. The deficiency affected all 192 residents across six smoke compartments. No information was provided regarding the medical history or condition of any specific residents at the time of the deficiency.
Plan Of Correction
K741 NFPA 101 Smoking Regulations How corrective action will be accomplished for those residents found to have been affected by the identified practice: All cigarette butts were immediately picked up from the smoking area ground. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to have been affected by the practice. Housekeeping staff will ensure that all smoking areas are cleaned daily, ash trays are emptied out, and any cigarette butts are picked up daily. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Housekeeping staff were in serviced on 5/27/25 by the Administrator regarding keeping smoking areas free of smoking debris on the floor. Housekeeping supervisor or designee will check smoking areas to ensure compliance weekly for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: The Administrator or Designee will do rounds weekly and for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: Імие 9, 2025.
Unsealed Wall Penetration Compromises Fire Barrier
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed a deficiency related to the building's construction. Specifically, in Room 203, there was a drain cap underneath the restroom sink that was not flush with the wall, resulting in an approximately seven-inch crescent-shaped penetration. This opening was identified as a potential pathway for smoke and gases to travel between different parts of the building, which is not in compliance with fire safety requirements for health care occupancies. The Maintenance Director was interviewed at the time of the observation and stated that he was unsure how long the penetration had been present. This deficiency affected 32 out of 192 residents in one of the six smoke compartments within the facility. The report does not provide additional details about the specific medical history or condition of the residents affected at the time of the deficiency.
Plan Of Correction
The following Plan of Correction is submitted by the facility in accordance with the pertinent terms and provisions of 42 CFR Section 488 and/or related state regulations and is intended to serve as a credible allegation of our intent to correct the practices identified as deficient. The Plan of correction should not be construed or interpreted as an admission that the deficiencies alleged did, in fact, exist; rather, the facility is submitting this document in order to comply with its obligations as a provider participating in Medicare/Medicaid program(s). K161 NFPA 101 Building Construction type and height. How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The Penetration in Room 203 was immediately fixed. No residents were affected by this finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken. All residents have the potential to have been affected by the practice. Maintenance director and assistant checked all other drain caps in all restrooms and no issues were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur. Maintenance Staff were in serviced on June 2, 2025 by administrator regarding the policy penetrations in the facility. Maintenance Director or designee will check all storage rooms and hallways to ensure there are no penetrations weekly for the next 3 months. Dept heads or designee will check their Guardian Angel rooms weekly for any penetrations for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator or designee will do rounds weekly for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025. K 161
Failure to Maintain Self-Closing Door Latching Mechanism
Penalty
Summary
During a facility tour and interview with the Maintenance Director, it was observed that a corridor kitchen door equipped with a self-closing device did not latch when tested. The Maintenance Director acknowledged at the time of observation that he had just realized the door was not latching. This deficiency affected 32 out of 192 residents in one of six smoke compartments. The report documents that the door's failure to latch could allow the passage of smoke and gases from one part of the building to another, as the door was not maintained in accordance with NFPA 101 requirements for self-closing devices.
Plan Of Correction
K223 NFPA 101 Doors with self-closing devices How corrective action will be accomplished for those residents found to have been affected by the identified practice: Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The door with self-closing device that did not latch when released was immediately fixed by maintenance staff. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to be affected by this practice. Maintenance director and assistant conducted a sweep of all self-closing doors to ensure they latch upon release. No other findings identified. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Maintenance staff were in serviced on June 2, 2025 by the administrator regarding policy on self-closing devices. Maintenance Director or Designee will check all self-closing devices biweekly to ensure compliance for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained: The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator or Designee will do rounds monthly for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025
Employee Food Improperly Stored in Residents' Refrigerator
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety when an employee's food was found inside a refrigerator designated for residents' food only. During an observation, a box of sponge cakes labeled with a name and date was discovered in the residents' refrigerator on Station 1, which had signage indicating it was for residents' food only and not for employee use. Staff interviews revealed uncertainty about the ownership of the food, and it was later confirmed that the food belonged to a housekeeper working at night. The administrator acknowledged that staff should not have placed their food in the residents' refrigerator and that the facility's policy required daily monitoring of these refrigerators by designated staff. A review of facility records showed that Station 1 had 56 residents, with 50 on oral diets, making them potentially susceptible to cross-contamination from improper food storage. The facility's policy on resident/personal food storage required monitoring for food safety, but this policy was not followed in this instance. The FDA Food Code was also referenced, indicating that ready-to-eat food potentially contaminated by an employee should be discarded. The failure to adhere to these standards and policies resulted in a deficiency related to food storage and safety.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
A deficiency was identified when a Certified Nurse Assistant (CNA) failed to treat a resident with dignity during a meal. The resident, who had diagnoses including unstable angina, atherosclerosis, hypertension, and diabetes, required one-on-one assistance during meals. During an observation, the CNA was seen standing over the resident while assisting with feeding, despite the resident expressing a preference for the CNA to be seated. The CNA acknowledged that the correct procedure was to be seated facing the resident during feeding. Further interviews with facility leadership confirmed that the expectation and facility policy required CNAs to be seated at eye level with residents during feeding to promote dignity and ensure safe feeding practices. Review of the facility's feeding techniques document also specified that staff should never stand above or lean over residents while feeding them. The Director of Nursing confirmed that the CNA did not follow the facility's established procedure in this instance.
Failure to Document and Offer Advance Directives to Residents
Penalty
Summary
The facility failed to honor residents' rights to formulate Advance Directives for five sampled residents. For three residents, the Advance Directives Checklist forms did not indicate whether they were provided an opportunity to formulate an Advance Directive. Specifically, one resident's form acknowledged receipt of information but did not document whether the resident wished to formulate an Advance Directive, and the resident reported not being offered assistance. Another resident's form was incomplete, with unchecked boxes and a responsible party who was unsure what an Advance Directive was or if it had been offered. A third resident's form was undated, unsigned, and did not indicate whether the responsible party was provided with information, despite the resident being severely cognitively impaired and unable to follow commands. For another resident with severe cognitive impairment and no decision-making capacity, the Advance Directives Checklist was faxed to the responsible party for signature, but the form remained unsigned and there was no documentation that the responsible party received the information or was given the opportunity to complete the Advance Directive. In the case of a fifth resident, who had full decision-making capacity, there was no Advance Directives Checklist in the medical record, and the POLST form was incomplete regarding the Advance Directive section. Interviews with facility staff, including the Director of Social Services and the Director of Nursing, confirmed that the process for providing and documenting Advance Directive information was not consistently followed. The facility's policy required that residents or their representatives be provided with written information about Advance Directives upon admission and that this be documented in the health record, but this was not done for the affected residents.
Lack of Documentation for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the medical record contained documentation demonstrating the rationale for extending a PRN (as needed) psychotropic medication order for a resident. Specifically, a resident with chronic respiratory failure had a PRN order for hydroxyzine for anxiety, which was later changed to a scheduled dose, and subsequently, clonazepam was started as a PRN medication for anxiety. The clonazepam PRN order was extended beyond the initial 14-day period without documentation from the prescribing practitioner explaining the medical necessity for this extension in the resident's medical record. Review of the resident's records showed that the medication was administered as ordered, and observations confirmed the resident was sleeping after receiving the medication. During interviews and record reviews with the DON, it was acknowledged that the required documentation for the rationale behind the continued PRN use of clonazepam was missing, which was not in accordance with the facility's own policy on psychoactive drug monitoring. The policy requires that the medical necessity for psychoactive medications be documented and regularly reassessed, with any continuation clearly indicated in the medical record.
Failure to Notify Ombudsman Prior to Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman prior to the discharge of a resident who had been admitted for orthopedic aftercare following a left below-the-knee amputation. The resident was determined to have the capacity to understand and make decisions. According to the facility's own policy and federal requirements, the Ombudsman should be notified at least 30 days before a resident is transferred or discharged, or as soon as practicable before the event. Record review and staff interviews revealed that the Notice of Proposed Transfer/Discharge for the resident was faxed to the Ombudsman's office after the resident had already been discharged. The Director of Social Services confirmed the late notification, and both the Director of Nursing and the Administrator acknowledged that the required notification timeframe was not met. The facility's policy was reviewed and found to be consistent with the regulatory requirement for advance notification.
Failure to Develop and Implement Individualized Care Plans for Medication and Dental Needs
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents, resulting in deficiencies related to medication management and dental care. For one resident with atrial fibrillation who was prescribed apixaban, there was no care plan developed to address the use of this anticoagulant, despite documentation confirming the medication was being administered as ordered. Staff interviews confirmed the absence of a care plan and acknowledged the necessity of such a plan to guide monitoring and care. Another resident, who was cognitively intact and had both upper and lower dentures upon admission, experienced the loss of their dentures while at the facility. Despite dental assessments, recommendations for tooth extraction, and ongoing issues with eating and appearance, there was no care plan developed to address the resident's dental care needs. Staff and social services confirmed awareness of the dental issues and the lack of a corresponding care plan. A third resident, with a history of stroke and on anticoagulant therapy (Lovenox), had a care plan that included interventions for daily skin inspections and monitoring for complications such as bruising. However, after the resident sustained a fall and developed bruising, there was no evidence that the care plan interventions were implemented, as required. The DON confirmed that the resident's bruising should have been monitored according to the care plan, but this was not documented or carried out.
Failure to Provide Proper Nail Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with functional quadriplegia, who was dependent on staff for personal hygiene, was observed with untrimmed and dirty fingernails on the right hand. The resident's Admission Record indicated a diagnosis of functional quadriplegia, and the Minimum Data Set confirmed functional limitations in both upper and lower extremities, requiring staff assistance for personal hygiene. During an observation, the resident's fingernails were found to be untrimmed and dirty, and a Certified Nurse Assistant acknowledged that the nails should have been trimmed and clean, in accordance with facility expectations. A review of the facility's policy and procedure for nail care revealed that daily cleaning and regular trimming of nails during activities of daily living (ADL) care were required to prevent infections and skin problems. The Director of Nursing confirmed that the facility's policy was not followed in this instance and that the expectation for grooming services for the resident was not met.
Failure to Consistently Assess and Document Wound Care
Penalty
Summary
The facility failed to provide consistent wound assessments for a resident with moisture-associated skin damage (MASD) on the buttocks, as required by the facility's policy and procedure. The resident, who had a history of peripheral vascular disease and chronic obstructive pulmonary disease, was admitted with a physician's order for daily wound care and a reevaluation after 21 days. However, a review of the medical record revealed that there were no documented assessments of the wound for two consecutive weeks, despite the ongoing treatment. During interviews and record reviews, a licensed vocational nurse confirmed the absence of wound assessment documentation for the specified weeks and acknowledged the importance of such documentation in guiding care and monitoring the wound's progress. Observations confirmed the presence of scattered areas of skin redness and shallow open areas on the resident's buttocks. The facility's policy required weekly head-to-toe assessments by licensed nursing staff, which were not completed as documented for the resident during the identified period.
Failure to Replace CPAP Filter According to Manufacturer Guidelines
Penalty
Summary
The facility failed to provide appropriate respiratory care services for one resident with obstructive sleep apnea who required nightly use of a CPAP machine. The resident's care plan and physician's order specified the use of the CPAP machine at bedtime. During multiple observations and interviews, it was found that the filter in the resident's CPAP machine was discolored, appearing light grey and dark grey, rather than the white color of a new filter. Staff, including a licensed vocational nurse, the assistant director of nursing, and the respiratory therapy supervisor, acknowledged the filter's condition and were unsure who was responsible for checking or replacing it. A review of the manufacturer's user guide indicated that the CPAP filter should be checked and replaced at least every six months, or more frequently if dirty or blocked. However, there was no documentation that the filter had been inspected or changed for this resident. The director of nursing confirmed that nursing staff were responsible for ensuring the CPAP machine was functioning and that the respiratory department was responsible for settings, but acknowledged the facility did not follow the manufacturer's guidelines for filter replacement.
Failure to Timely Remove Dialysis Site Bandage
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, who required regular dialysis treatments, was found to have a bandage left on their dialysis access site for more than four hours after returning from dialysis. The resident was admitted with a diagnosis of irreversible kidney failure and had physician orders for dialysis three times a week. On the morning following a dialysis session, a bandage was observed on the resident's left arm by both an LVN and the DON. Upon review, it was confirmed that the bandage had been in place since the previous day's dialysis treatment. Facility records, including the Facility/Dialysis Center Nursing Communication Record and the facility's inservice lesson plan, indicated that post-dialysis care required bandages to be removed within three to four hours after treatment. The DON acknowledged that the bandage should have been removed within this timeframe, but it remained on the resident's arm for longer, contrary to facility policy and best practices for post-dialysis care.
Inaccurate Bed Rail Assessment and Use for Dependent Resident
Penalty
Summary
The facility failed to ensure that the bed rail assessment for a resident with significant functional limitations was accurate and that the use of side rails was appropriately indicated. The resident in question had contractures and impaired range of motion in both upper extremities, as documented in multiple assessments, including the Minimum Data Set and Occupational Therapy evaluation. Despite these limitations, a physician's order and a Bed Rail Safety Evaluation indicated that side rails were to be used to aid in bed mobility, and the evaluation inaccurately stated that the resident could move freely in bed without signs of impaired mobility. Observations and staff interviews confirmed that the resident was dependent on staff for all mobility and activities of daily living, and was unable to use the side rails due to contractures. During care, the resident did not reach for or hold onto the side rail when prompted, and staff acknowledged the resident's inability to use the rails. The Director of Rehabilitation Services also confirmed that the side rails could not aid the resident's mobility due to the functional limitations. The facility's policy required ongoing assessment to ensure bed rails met the resident's needs, but this was not accurately reflected in the resident's documentation or practice.
Failure to Clarify Medication Orders Leads to Missed Dose
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for a resident with a history of chronic congestive heart failure, hypertension, and dependence on renal dialysis. The resident had a physician's order for furosemide, a diuretic, to be administered twice daily for congestive heart failure. A subsequent order instructed staff to hold all blood pressure medications on the morning of dialysis days. However, the furosemide, which was prescribed for heart failure and not specifically for blood pressure, was withheld by the nurse on a dialysis day without clarifying the order with the physician. During interviews and record reviews, the nurse acknowledged that the furosemide was categorized as a diuretic and not a blood pressure medication, and that the two orders should have been clarified to avoid confusion. The Director of Nursing confirmed that facility policy requires verification of any order that appears inappropriate considering the resident's condition or diagnosis. The failure to clarify the medication orders resulted in the resident not receiving the prescribed furosemide dose as intended.
Medications Stored Above Manufacturer-Recommended Temperature
Penalty
Summary
Surveyors found that the facility failed to store medications at the appropriate temperature in one of three medication rooms, specifically the Station 2 Medication Room. The daily temperature log showed that the room temperature reached 78°F on two consecutive days, exceeding the maximum storage temperature of 77°F indicated on the product labeling for several medications. During an inspection, multiple medications, including acetaminophen, senna syrup, loperamide, and docusate sodium, were observed stored in this room. The Assistant Director of Nursing confirmed that the product labels required storage at or below 77°F. A review of the facility's policy on medication storage, approved in January 2025, stated that medications and biologicals must be stored safely and according to manufacturer recommendations. The Director of Nursing acknowledged this policy during the interview and record review. The failure to maintain the required storage temperature for these medications constituted a deficiency in following both manufacturer guidelines and facility policy.
Failure to Document Restorative Nursing Services
Penalty
Summary
The facility failed to ensure complete and accurate documentation of Restorative Nursing Assistant (RNA) services for one resident. The resident, who had diagnoses including osteoarthritis in both knees and a history of stroke, was admitted with physician orders specifying RNA services for ambulation with a front wheel walker five times a week. Review of the resident's medical record showed only four RNA entries for March and no entries for April, despite the ongoing order for daily services on weekdays. During an interview and record review, the RNA stated that documentation should be completed after providing or attempting RNA services, including noting if the resident refused. The Director of Nursing confirmed the absence of documentation for RNA services from March 9 through the end of April. Facility policies reviewed indicated that appropriate documentation is required to address program goals and resident tolerance, as well as to provide a complete account of care and treatment.
Failure to Discard Single-Dose Acetic Acid and Unauthorized Access to Clean Laundry Area
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in two distinct situations. In the first instance, a single-dose container of acetic acid, used to prevent blockage in tubes connected to residents, was not discarded after being opened. The container was labeled with the date it was opened and was found stored in a treatment cart several days later. Interviews with the LVN, DON, and Infection Preventionist confirmed that the acetic acid was a single-dose, preservative-free solution, and manufacturer instructions required prompt use and immediate disposal of any unused portion. Facility policy also required medications to be stored and handled according to manufacturer recommendations, which was not followed in this case. In the second situation, a non-laundry staff member entered the restricted clean area of the laundry department and removed clean linens from a linen cart. Observations and interviews with the Environmental Services Supervisor, Infection Preventionist, and DON confirmed that only laundry staff were permitted to handle clean linens in the clean area, and non-laundry staff were required to remain outside this area. Facility policies on infection prevention and laundry services emphasized the importance of restricting access and handling of clean linens to prevent the spread of infection. Both deficiencies were identified through direct observation, staff interviews, and review of facility policies and manufacturer instructions. The actions taken by staff in both cases were inconsistent with established infection control protocols and facility procedures, leading to the cited deficiencies.
Failure to Ensure Resident Privacy and Timely Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who was admitted with diagnoses including an internal right hip prosthesis, heart failure, and hypertension. The resident's care plan emphasized the need for privacy to promote dignity. However, a Certified Nursing Assistant (CNA 1) left the resident naked and uncovered in bed with the curtain halfway open, failing to ensure privacy as required by the care plan. This action was acknowledged by CNA 1, who admitted to forgetting to cover the resident with a sheet before leaving the room. Additionally, another CNA (CNA 2) took an extended period to attend to the resident for a change. During an interview, CNA 2 mentioned being occupied with other residents, which delayed attending to the resident's needs. The Director of Nursing (DON) indicated that CNA 2 should have requested assistance to ensure timely care. Both instances were noted as failures to adhere to the facility's policy and procedure, which mandates treating residents with respect and dignity.
Failure to Provide Medical Records Upon Request
Penalty
Summary
The facility failed to provide a resident or their legal representative with a copy of medical records following a written request. This deficiency was identified for one of the three residents reviewed for resident rights. The resident in question was admitted to the facility with multiple diagnoses, including sepsis, urinary tract infection, generalized muscle weakness, type 2 diabetes mellitus, and dementia. The legal representative of the resident claimed to have sent a fax request for the medical records, with a successful transmission confirmation, but the facility's Medical Record Director (MRD) denied receiving such a request. Interviews with the MRD and the Administrator revealed that the facility did not acknowledge receiving the faxed request on the date specified by the legal representative. The facility's policy requires a 48-hour notice for such requests, excluding weekends and holidays. Despite the legal representative's confirmation of the fax transmission, the facility maintained that they did not receive the request until a later date, when a follow-up phone call was made by the legal representative's law office. The facility's failure to provide the requested medical records within the stipulated time frame potentially violated the resident's rights.
Failure to Respect Resident's Dignity and Rights
Penalty
Summary
The facility failed to treat a resident with dignity and respect when a staff member entered the resident's room and removed her oxygen tubing without permission. The incident involved a resident who was cognitively intact and required maximal assistance for daily living activities. The resident had been admitted with diagnoses including heart failure, Type 2 diabetes mellitus, and hypertension. On the day of the incident, a Licensed Vocational Nurse (LVN) entered the room without announcing herself and mistakenly removed the resident's oxygen tubing, assuming it belonged to another resident. This action was taken without verifying the ownership of the oxygen concentrator or explaining the action to the resident. The resident was left confused and upset by the removal of her oxygen tubing, which was reported to the facility administrator the following day. The resident's daughter also reported the incident, and the resident expressed her distress to a Certified Nursing Assistant (CNA) who assisted her afterward. The Director of Nursing (DON) confirmed that the facility's policy on resident rights, which emphasizes respect and dignity, was not followed in this instance. The failure to adhere to these policies compromised the resident's dignity and violated her rights.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate care to prevent the development of a pressure ulcer in a resident who was admitted with multiple serious health conditions, including metabolic encephalopathy, acute respiratory failure, and acute kidney failure. Upon admission, the resident had scar tissue on the coccyx and unstageable tissue depth blisters on the heels, but no open wounds. The resident was assessed as high risk for pressure sores, with a Braden Scale score of 7. Despite this, the resident developed an unstageable pressure ulcer on the coccyx and left buttocks while in the facility. The facility's records indicate that the resident was initially observed with moisture-associated skin damage to the buttocks, and interventions such as turning and repositioning every two hours and the use of a low air loss mattress were ordered. However, these measures were implemented after the pressure ulcer had already developed. Interviews with the treatment nurse and the DON revealed that the resident's fragile condition and comorbidities contributed to the development of the ulcer, but the facility's policy required preventive measures to be in place to avoid such occurrences. The facility's failure to prevent the pressure ulcer placed the resident's health and safety at risk.
Failure to Accommodate Resident's Toileting Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as Resident 1, by not providing a bedside commode and not assisting the resident to the bathroom for toileting. This deficiency was identified during a review of Resident 1's admission record and care plan, which indicated a self-care performance deficit related to limited mobility. The care plan aimed for the resident to perform activities of daily living with modified independence, including toilet use, while promoting dignity and ensuring privacy. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) revealed that the facility's usual practice is to assess residents upon admission for their ability to transfer and to assist them to the bathroom upon request. The facility's policy and procedure for admission, transfer, and discharge rights outlined the objectives to admit residents who can be adequately cared for by the facility. However, the failure to provide the necessary toileting assistance and equipment for Resident 1 had the potential to impact the resident's psychological well-being by affecting their respect and dignity.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 2,073 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Upland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Mesa Care Center | 0.2 mi | ★★★★★ | 19 | 0 |
| Heritage Park Nursing Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Ontario Grove Healthcare & Wellness Centre, Lp | 0.9 mi | ★★★★★ | 1 | 0 |
| Las Colinas Post Acute | 1.3 mi | ★★★★★ | 24 | 0 |
| Rancho Mesa Care Center | 2.8 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.