Upland Rehabilitation and Care Center

Name: Upland Rehabilitation and Care Center
Address: 1221 E Arrow Hwy, Upland, CA, 91786, US
Telephone: 9099851903

1221 E Arrow Hwy, Upland, CA 91786 · San Bernardino County · 206 certified beds · avg 183 residents/day · certified since Jan 1, 1967

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.37

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (32)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Sep 22, 2025	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint
May 9, 2025	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 9, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
May 9, 2025	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
May 9, 2025	D · Potential for harm, one-off	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
May 9, 2025	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
May 9, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 9, 2025	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
May 9, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
May 9, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
May 9, 2025	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
May 9, 2025	D · Potential for harm, one-off	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
May 9, 2025	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 9, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 9, 2025	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
May 9, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Oct 1, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Sep 20, 2024	D · Potential for harm, one-off	The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint
Sep 19, 2024	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Jul 2, 2024	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Jun 27, 2024	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
May 1, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Aug 16, 2023	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 6, 2022	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 6, 2022	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
May 6, 2022	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 6, 2022	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
May 6, 2022	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 6, 2022	D · Potential for harm, one-off	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Aug 9, 2019	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Aug 9, 2019	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Aug 9, 2019	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (6 → 15).

Year	Citations	Worst severity that year
2019	3	F
2022	6	F
2023	1	D
2024	6	D
2025	16	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.37	4.31	3.95	top 35% in California; top 27% in the U.S.
Registered Nurse hours	0.38	0.61	0.69	bottom 27% in California; bottom 19% in the U.S.
Weekend total nurse staffing	3.99	3.90	3.50	top 34% in California; top 23% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.42	0.51	0.48	top 42% in California; top 45% in the U.S.
Total nursing staff turnover (%)	35.0	36.7	45.8	top 46% in California; top 24% in the U.S.
RN turnover (%)	10.0	38.1	42.9	top 5% in California; top 4% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.32, RN 0.46, weekend 4.86. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	07/24/2018
Caretrust GP LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/06/2005
Caretrust Reit INC	Organization	ADP of the SNF	NOT APPLICABLE	08/06/2005
Cedar Avenue Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/06/2005
Ctr Partnership LP	Organization	ADP of the SNF	NOT APPLICABLE	08/06/2005
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	10/25/2002
Jergensen, Jeremy	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
McMillan, Kip	Individual	Managing Control - Governing Body	NOT APPLICABLE	09/17/2018
McMillan, Kip	Individual	Operational/Managerial Control	NOT APPLICABLE	09/17/2018
McMillan, Kip	Individual	ADP of the SNF	NOT APPLICABLE	07/09/2025
Port, Barry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	07/09/2025
Sato, Ami	Individual	Corporate Officer	NOT APPLICABLE	09/09/2024
Takhar, Daljinder	Individual	Managing Control - Governing Body	NOT APPLICABLE	07/29/2016
Takhar, Daljinder	Individual	Operational/Managerial Control	NOT APPLICABLE	07/29/2016
Takhar, Daljinder	Individual	ADP of the SNF	NOT APPLICABLE	07/09/2025
Willits, Adam	Individual	Corporate Director	NOT APPLICABLE	01/01/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
"What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Villa Mesa Care Center	0.2 mi	Upland, CA	★★★☆☆	4/5
Heritage Park Nursing Center	0.6 mi	Upland, CA	★★★★★	5/5
Ontario Grove Healthcare & Wellness Centre, LP	0.9 mi	Ontario, CA	★★★☆☆	4/5
Las Colinas Post Acute	1.3 mi	Ontario, CA	★★☆☆☆	2/5
Rancho Mesa Care Center	2.8 mi	Alta Loma, CA	★★★★☆	4/5
Community Extended Care Hospital of Montclair	3.2 mi	Montclair, CA	★★★★★	5/5
Montclair Manor Care Center	3.7 mi	Montclair, CA	★★★★★	4/5
Ontario Healthcare Center	3.9 mi	Ontario, CA	★★★★★	5/5
Inland Christian Home	4.6 mi	Ontario, CA	★★★★☆	4/5
Claremont Heights Post Acute	4.7 mi	Claremont, CA	★★☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Upland →

Facility data as of CMS processing date 2026-08-01. CCN 055374.

The Care File

Visit checklist — Upland Rehabilitation and Care Center

1221 E Arrow Hwy, Upland, CA 91786 · 9099851903

Health inspection rating 4/5 · CMS overall 5/5· Fines (3y): $0

Questions for the administrator:

☐ "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
☐ "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 055374 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)