Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Highland Care Center Of Redlands during CMS and state inspections, most recent first.
A CNA took a resident's credit card out of the facility to make purchases, contrary to facility policy that prohibits staff from using residents' credit cards. This action was confirmed by both the CNA and the DON. Later, the resident experienced fraudulent charges on the card. The facility's abuse prevention policy, which includes safeguards for resident property, was not followed in this instance.
A resident with multiple risk factors and total dependence for mobility developed a right heel pressure ulcer after the facility failed to initiate a care plan for pressure injury prevention, such as offloading and daily skin assessments, despite policy requirements and the absence of a wound at admission.
A resident with dementia eloped from the facility due to inadequate supervision and failure to reset the alarm system. Despite being brought back after an initial attempt, the resident managed to leave again, requiring police intervention. Staff interviews revealed lapses in monitoring and adherence to the facility's safety policy.
The facility failed to maintain sanitary conditions in the kitchen, with food crumbs, trash, and grime found under equipment and in storage areas. Food equipment and utensil bins were dirty, and the ice machine had black spots and discoloration. These conditions were observed by the Dietary Services Supervisor and Registered Dietician, who acknowledged the need for cleanliness according to facility policies and FDA guidelines.
Two residents experienced a lack of dignity during dining observations. An LVN stood over a resident while feeding her, contrary to policy requiring staff to be at the same level. A CNA pulled a resident in a wheelchair with feet dragging, failing to secure them properly. Both actions violated the facility's dignity policy.
A resident with hemiplegia and hemiparesis was not wearing a physician-ordered hand splint to prevent contractures, as observed during multiple checks. The splint was found in the nightstand instead. Interviews with the resident, family, and staff confirmed the splint was not applied as required, violating the facility's policy on assistive devices.
A resident with COPD did not receive proper oxygen therapy as their oxygen tubing was disconnected from the concentrator for 15 minutes. The resident, who was supposed to receive continuous oxygen, reported feeling tired and not sensing the oxygen flow. The facility's policy on oxygen administration was not followed, as confirmed by the DON, posing a health risk to the resident.
The facility failed to maintain accurate records of controlled medications for a narcotic medication cart, with missing signatures on the Narcotic Count Record for several shifts. This oversight, confirmed by the DON, indicated non-compliance with the facility's policy for verifying narcotic counts, posing a risk of medication diversion for 38 residents in Unit Station A.
A facility failed to follow its policy for self-administration of medications, resulting in unsecured pills found in a resident's room. The resident, with multiple sclerosis and other conditions, was deemed capable of self-administering medications. However, pills were discovered on the floor and under the bed, indicating a breach in secure storage protocols. The DON and Administrator confirmed the policy was not adhered to, risking exposure to other residents.
A resident with Alzheimer's and schizoaffective disorder did not receive their physician-ordered finger food diet, instead being served a regular diet. The diet order, revised in 2023, specified a fortified/high protein diet with finger foods, which was not followed, as confirmed by the RD. This failure was observed during a dining observation and contradicted the facility's menu policy.
The facility failed to follow infection control practices, with two residents having unlabeled oxygen nasal cannula tubing, and a coffee cup found on an IV medication cart. These oversights were confirmed by staff and acknowledged by the DON, posing a risk of cross-contamination among vulnerable residents.
The facility failed to maintain essential equipment safely, with a refrigerator missing screws, another with condensation, and an unlocked electrical panel in the memory care unit. These issues were confirmed by staff and violated facility policies, posing risks to residents.
A resident with hemiplegia and other medical conditions was found to have their call light placed inside a drawer, making it inaccessible. This was confirmed by a CNA and was against the facility's policy, which requires call lights to be within reach. The Director of Nursing acknowledged the failure to adhere to the policy.
The facility did not meet the required minimum of 80 square feet per resident in four rooms, as confirmed during an environmental tour. The rooms measured between 71.8 and 75.24 square feet per resident. Despite having room waivers, the rooms were not crowded, posed no safety hazards, and residents did not complain about space issues.
A resident with epilepsy did not receive their prescribed Keppra medication due to unavailability, as it was not ordered in time. This oversight, contrary to facility policy, led to the resident experiencing a seizure and being transferred to a hospital for evaluation.
A resident with a history of falls and mobility issues was not moved closer to the nursing station as required by their care plan, leading to two fall incidents. The resident was left unattended in the bathroom, resulting in injuries and hospital transfers. Facility staff confirmed the care plan was not followed, and the fall risk assessment policy was not adhered to.
Failure to Implement Abuse Prevention Policy for Resident Property
Penalty
Summary
A Certified Nurse Assistant (CNA) failed to follow facility policy by taking a resident's credit card out of the facility to make purchases on two occasions, after the resident requested assistance in buying cigarettes. The CNA acknowledged that this action was against facility policy, which prohibits staff from using residents' credit cards or making purchases on their behalf with credit cards or checks. The facility's Social Services staff confirmed that only Social Services or Activities staff are permitted to make purchases for residents, and only with cash, not credit cards. The Director of Nursing (DON) and the CNA both confirmed that the CNA took the card despite knowing it was not allowed under facility policy. Subsequently, the resident reported fraudulent charges totaling approximately $833 on her credit card, which occurred after the CNA had returned the card. The facility's policy on incidents of theft and misappropriation of resident property requires prompt and thorough investigation of all reports and includes measures to safeguard resident valuables, such as controlled access and locked safes. The DON stated that staff did not follow the established policy in this matter, resulting in a failure to implement abuse prevention procedures designed to prohibit misappropriation of resident property.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide proper care to prevent the development of a right heel pressure ulcer for a resident who was clinically compromised and totally dependent on staff for mobility. Upon admission, the resident had multiple diagnoses, including muscle wasting, spastic quadriplegic cerebral palsy, and impaired lower extremities, making them at high risk for pressure injuries. The admission assessment did not identify any existing pressure sores or wounds on the right heel, and there was no care plan initiated to prevent pressure injuries, such as offloading the feet or conducting daily skin assessments. The deficiency was identified when the wound treatment nurse discovered a darkened area with 100% necrosis on the resident's right heel during wound care, which was not present at admission. Interviews with staff confirmed that a care plan for pressure injury prevention, including offloading and daily skin checks, was not in place at the time of admission. The facility's policy required daily skin inspections and individualized interventions based on risk factors, but these were not implemented for this resident prior to the development of the pressure ulcer.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a resident who eloped from the facility without the staff's knowledge. The resident, who was admitted with diagnoses including dementia, hypertension, and mood affective disorder, was in the Memory Care Unit. On the night of the incident, the resident attempted to leave the facility and was found wandering outside. Although the resident was initially brought back inside, he managed to elope again shortly after, prompting the facility to call the police to return him. The nursing notes indicated that the alarm system was not activated during the second elopement attempt, allowing the resident to leave the premises undetected. Interviews with staff revealed that the alarm system was not reset in a timely manner after the resident's first elopement attempt. The Registered Nurse and the Director of Nursing both acknowledged that the resident was not adequately monitored after being brought back to the facility. The facility's policy on resident safety and supervision, which emphasizes the importance of monitoring based on individual needs and environmental hazards, was not adhered to in this instance. The failure to reset the alarm and monitor the resident contributed to the deficiency in supervision.
Sanitation Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. The floors under kitchen equipment were found to have an accumulation of food crumbs, trash, and black grime. The food prep sink drain had residue build-up on the drainpipe and adjacent wall. The dry storage room also had food crumbs and trash underneath the shelves, with a spill of a powder substance on the shelves. Additionally, broken tiles were present in the dry storage room and main kitchen, providing surfaces for food crumbs to accumulate. Food equipment, including a food processor, plate warmer, blender, and can opener, were stored with food crumbs and build-up. The clean utensil bins had food splash and crumbs inside. The ice machine had black spots in the ice bin ceiling and yellow discoloration in the ice chute. These conditions were observed during interviews and inspections with the Dietary Services Supervisor and Registered Dietician, who both acknowledged the need for cleanliness and adherence to facility policies and procedures. The facility's policies and procedures, as well as the U.S. Food and Drug Administration Food Code, require that nonfood-contact surfaces of equipment be kept free of dust, dirt, food residue, and debris. The presence of food debris or dirt on these surfaces can provide an environment for the growth of microorganisms, which may be transferred to food. The facility's failure to maintain cleanliness in these areas has the potential to compromise food safety and increase the risk of foodborne illness for the residents receiving food from the kitchen.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain the dignity of two residents during dining observations. In the first instance, a Licensed Vocational Nurse (LVN) was observed standing over a resident while feeding her lunch in the Memory Care Unit's dining room. This action was contrary to the facility's policy, which requires staff to be at the same level as residents to ensure their comfort and dignity. Interviews with staff confirmed that the expectation was to sit beside residents while feeding them, and the facility's policy emphasized the importance of not standing over residents during meals. In the second instance, a Certified Nursing Assistant (CNA) was observed pulling a resident in a wheelchair into the dining room with the resident's feet dragging on the floor. This action did not align with the facility's policy, which requires staff to ensure residents' feet are elevated and secured on the wheelchair footrest before moving them. Interviews with staff confirmed that the proper procedure was not followed, which compromised the resident's dignity and comfort. The facility's policy on dignity emphasizes treating residents with respect and ensuring their well-being and self-esteem.
Failure to Apply Hand Splint as Ordered
Penalty
Summary
The facility failed to implement its policy for assistive devices and equipment for a resident with limited range of motion (ROM) due to hemiplegia and hemiparesis following a cerebral infarction. The resident was ordered by a physician to have a resting hand splint applied to the left upper extremity seven times a week to decrease the risk of contracture. However, during multiple observations, the resident was found not wearing the hand splint, which was instead located in the nightstand drawer or on top of the nightstand. Interviews with the resident, the resident's mother, and staff members, including a restorative nurse assistant (RNA), a physical therapist (PT), a certified nursing assistant (CNA), and a licensed vocational nurse (LVN), confirmed that the hand splint was not being applied as ordered. The Director of Nursing (DON) reviewed the facility's policy and procedure for assistive devices and equipment, which requires staff to demonstrate competency in the use of such devices and to assist and supervise residents as needed. The DON acknowledged that the facility staff failed to follow the policy, as the hand splint was not applied to the resident as per the physician's order, potentially leading to further contractures and impacting the resident's quality of life.
Failure to Ensure Proper Oxygen Therapy for a Resident
Penalty
Summary
The facility failed to provide proper respiratory care for a resident, identified as Resident 16, who was admitted with chronic obstructive pulmonary disease (COPD), dysphagia, and hypertension. According to the physician's orders, Resident 16 was to receive continuous oxygen therapy at 2-5 liters per minute via nasal cannula. However, during an observation, it was noted that Resident 16's oxygen tubing was disconnected from the oxygen concentrator for approximately 15 minutes during lunchtime, which was confirmed by the Director of Nursing (DON). This disconnection occurred despite the resident expressing that they did not feel the oxygen was running and feeling very tired. The facility's policy and procedure for oxygen administration, which includes checking the tubing for kinks and ensuring the oxygen is turned on, was not followed. The DON acknowledged that the policy was not adhered to, as the oxygen tubing was found disconnected, posing a serious health risk to Resident 16, including potential desaturation. The failure to ensure the oxygen tubing was properly connected and the oxygen therapy was administered as ordered placed Resident 16's health at risk.
Failure to Maintain Accurate Narcotic Records
Penalty
Summary
The facility failed to maintain accurate records of controlled medications for one of the narcotic medication carts, specifically Unit Station A Cart Number 2. This deficiency was identified through observation, interview, and record review, revealing missing signatures on the Narcotic Count Record (NCR) for several shifts between February 1, 2025, and February 20, 2025. The missing signatures were from both oncoming and off-going shifts, indicating that the required verification of narcotic medication counts was not consistently performed by the nursing staff. The Director of Nursing (DON) confirmed the discrepancies in the NCR and acknowledged that the facility's policy and procedure for controlled substances, which mandates that both oncoming and off-going nurses sign the form to verify the narcotic count, was not followed. The failure to adhere to this policy had the potential for diversion of controlled medications, posing a risk to the 38 residents in Unit Station A. The facility's policy, dated November 2022, emphasizes the importance of monitoring and reconciling controlled substance inventory to prevent loss or diversion, which was not effectively implemented in this instance.
Failure to Securely Store Self-Administered Medications
Penalty
Summary
The facility failed to implement its policy for the self-administration of medications for a resident, leading to a deficiency. The resident, who was admitted with multiple sclerosis, anemia, and osteomyelitis, was assessed as a candidate for safe self-administration of medications. However, during an observation, a white elongated pill with no markings was found on the floor after falling from the resident's bedding. Further inspection revealed two additional pills in the resident's room, one under the bed and another next to the bedside table. The facility's policy required that self-administered medications be stored in a safe and secure place, inaccessible to other residents. The interdisciplinary team was responsible for ensuring that the resident could safely store medications. During an interview, the Director of Nursing and the Administrator acknowledged that the policy was not followed, as the medications were not stored securely, posing a risk to other residents in the facility.
Failure to Provide Physician-Ordered Diet
Penalty
Summary
The facility failed to adhere to the physician-ordered diet for a resident, identified as Resident 40, who was supposed to receive a finger food diet. Instead, during a dining observation, the resident was served a regular diet. This discrepancy was noted during a review of the facility's diet order list, which confirmed that the resident had an active order for a fortified/high protein diet with regular texture, thin consistency, and finger foods with large portions for all meals. This order was initially placed on September 19, 2022, and revised on October 26, 2023. Resident 40, who was admitted to the facility with diagnoses including dehydration, Alzheimer's disease, and schizoaffective disorder, did not receive the prescribed diet on February 18, 2025. The Registered Dietician confirmed on February 20, 2025, that the resident should have been receiving the finger food diet. The facility's policy on menus, revised in October 2017, mandates that menus meet the nutritional needs of residents, including their dietary preferences and requirements, which was not followed in this instance.
Infection Control Lapses in Oxygen Tubing and Medication Cart
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by the unlabeled and undated oxygen nasal cannula tubing for two residents. Resident 10, who was admitted with acute respiratory failure, malignant neoplasm of the cerebellum, and was receiving palliative care, had an oxygen nasal cannula tubing that was not labeled or dated, contrary to the physician's order and facility policy. Similarly, Resident 16, diagnosed with chronic obstructive pulmonary disease, dysphagia, and hypertension, also had unlabeled oxygen tubing. Both instances were confirmed by nursing staff, who acknowledged the oversight and the importance of labeling for infection control purposes. Additionally, a warm coffee cup was found on top of an intravenous medication cart, which is against the facility's policy for maintaining medication storage areas in a clean and sanitary manner. This was observed by a CNA and confirmed by the DON, who acknowledged that the policy was not followed. These lapses in infection control practices had the potential to cause cross-contamination and preventable infections among the facility's vulnerable residents.
Equipment Maintenance Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as observed during a survey. One of the three refrigerators in the kitchen had missing side screws on the front grill, causing it to hang and potentially compromise its functionality. This was confirmed during an interview with the Dietary Services Supervisor, who acknowledged the issue. Additionally, the Registered Dietitian expressed that equipment should be clean, intact, and working properly. The facility's maintenance policy requires the maintenance department to keep equipment in a safe and operable manner, but this was not adhered to in this instance. Another deficiency was noted with a resident refrigerator that had condensation on the back wall, indicating improper functioning. The Registered Dietitian stated that the refrigerator should not have condensation, aligning with the U.S. Food and Drug Administration Food Code, which emphasizes proper maintenance to ensure equipment operates as designed. Furthermore, an electrical panel in the memory care unit was found open and unlocked, posing a risk of accidental electrical shock to residents. The Maintenance Supervisor confirmed the panel should be locked, and the facility's policy on electrical safety was not followed, as acknowledged by the Administrator.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a resident had adequate access to their call light system, which is a critical component for requesting assistance. Resident 28, who was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, and hypertension, was found to have their call light placed inside the first drawer of the bedside nightstand, making it inaccessible. This observation was confirmed by a Certified Nursing Assistant (CNA) during an interview, who acknowledged that the call light was not within the resident's reach. The facility's policy, which mandates that call lights be within reach upon admission and as needed, was not followed, as confirmed by the Director of Nursing during a review of the policy and procedure.
Room Size Deficiency in Four Resident Rooms
Penalty
Summary
The facility failed to ensure that four rooms, specifically Rooms 119, 122, 124, and 125, met the required minimum of 80 square feet per resident. During an interview and record review with the Administrator, it was revealed that the facility had room waivers for these rooms, which were below the required square footage. An environmental tour confirmed that the rooms measured between 71.8 and 75.24 square feet per resident, which did not meet the regulatory requirement. Despite this, the rooms were not crowded, did not pose safety hazards, and there were no complaints from the residents about space or room issues.
Failure to Administer Seizure Medication
Penalty
Summary
The facility failed to administer medication according to its policies and procedures for a resident diagnosed with epilepsy and hemiplegia. The resident was admitted with a prescription for Keppra, a medication used to treat seizures, to be taken twice daily. On May 2, 2024, the medication was not administered at 9:00 AM, as indicated in the Medication Administration Record (MAR). The Minimum Data Set Coordinator confirmed that the reason for not administering the medication was marked as 'Other,' but no further explanation was documented. The Licensed Vocational Nurse responsible for the resident's medication on that day stated that the Keppra was not available due to pending shipment and acknowledged that medication should be ordered before it runs out, as per facility policy. The policy requires medications to be ordered within seven days before the last dose. This oversight potentially led to the resident experiencing a tonic-clonic seizure on May 3, 2024, resulting in the resident being unresponsive and requiring transfer to a hospital for seizure evaluation.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a care plan intervention for a resident who was at high risk for falls. The resident, who had a history of repeated falls and was diagnosed with degenerative disease of the nervous system, osteoporosis, and other mobility issues, was not moved closer to the nursing station as specified in the care plan following a fall incident. This oversight occurred despite the resident's known high risk for falls, as communicated by the resident's daughter and documented in the interdisciplinary team meeting summary. On two separate occasions, the resident experienced falls that resulted in transfers to an acute general hospital for evaluation and treatment. The first fall occurred shortly after admission, and the second fall happened when the resident was left unattended in the bathroom by a CNA. The resident's room was one of the farthest from the nursing station, contrary to the care plan's directive to move the resident closer for frequent visual monitoring. Interviews with facility staff, including the administrator, director of rehabilitation, and director of nursing, confirmed that the care plan was not followed. The CNA admitted to leaving the resident unattended, and the director of nursing acknowledged that the facility's fall risk assessment policy was not adhered to. The resident sustained injuries, including a clavicular fracture and a laceration with significant swelling, as a result of the falls.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Redlands
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plymouth Village | 0.6 mi | ★★★★★ | 1 | 0 |
| Madison Grove Post Acute | 2.3 mi | ★★★★★ | 17 | 0 |
| Redlands Healthcare Center | 2.4 mi | ★★★★★ | 6 | 0 |
| Redlands Comm Hosp D/p Snf | 2.4 mi | ★★★★★ | 8 | 0 |
| Brookside Healthcare Center | 2.9 mi | ★★★★★ | 0 | 0 |
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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.