Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Failure to Obtain Documented Informed Consent for Psychotropic Medications: The facility could not provide documented informed consent for psychotropic medication use for two residents. One resident had quetiapine ordered for psychosis, and another resident with schizophrenia had multiple Seroquel dose increases plus initiation and increase of Wellbutrin XL. The MRA and DON confirmed there was no documentation showing the residents and/or their representatives were informed of the risks, benefits, and alternatives and agreed to treatment.
Inaccurate MDS coding affected three residents. One resident who smoked cigarettes was coded as not using tobacco despite records, a smoking list, and direct observation confirming smoking. Another resident with hemiplegia and restorative nursing orders had quarterly MDS restorative items coded inconsistently with the RNA documentation. A third resident with cataracts and blurred vision was coded as having adequate vision even though the resident, family, RN, and ophthalmology note described impaired vision.
A resident with dementia, aphasia, COPD, and hospice needs had delayed vaccine coordination, with influenza, pneumococcal, and COVID-19 immunizations not administered in a timely manner after consents were obtained. The hospice binder’s nursing assessment section was empty, and the hospice agency did not have a copy of the resident’s comprehensive care plan from the facility, despite expectations in the hospice agreement and staff acknowledgment that these records were needed for communication and coordination.
Failure to Provide Ordered Restorative ROM Services: A resident with hemiplegia, polyneuropathy, and muscle spasm did not receive multiple ordered restorative nursing interventions, including PROM, AAROM, splinting, and orthotic donning/doffing for BLEs and BUEs. The RNA stated these services should be documented the same day or before shift end, and the DON confirmed several ordered services were not provided as scheduled.
Failure to Notify Ombudsman of Resident Discharge: The facility failed to notify the LTC Ombudsman of a resident discharge for one of three sampled discharged residents. A resident with acute respiratory failure with hypoxia, Type II DM, and HTN was discharged home with home health services and DME, but the MRD could not locate documentation showing the discharge notice was faxed to the Ombudsman. RN and DON stated the discharge notification should have been sent as required by the Notice of Transfer or Discharge.
Failure to complete and transmit required MDS assessments: one resident’s discharge MDS was not done after a hospital transfer, and another resident’s quarterly MDS was completed but not sent to CMS. The MDSC confirmed the missed assessment and the lack of transmission during record review. The residents had significant medical histories including schizophrenia, COPD, HTN, and toxic encephalopathy.
A resident with chronic respiratory failure with hypoxia, pneumonia, and pleural effusion had an order for continuous oxygen via NC and was receiving oxygen on the MAR and MDS, but no care plan for oxygen therapy was in place. During observation, the resident was on oxygen, and an MRA confirmed the absence of an oxygen care plan while noting licensed nurses were responsible for care planning.
An LVN administered enoxaparin subcutaneously to a resident even though the physician order specified IM use, and the order was not clarified despite the MAR documenting the medication as IM on multiple days. In a separate issue, staff changed a resident’s aripiprazole-related diagnosis from depression to psychosis and incorporated psychosis into the diagnosis list, care plan, PASRR, and behavior monitoring without supporting clinical documentation or physician clarification.
A resident with chronic respiratory failure with hypoxia, pneumonia, and pleural effusion had an order for continuous oxygen via NC at 4 LPM, but was observed with the concentrator set at 3 LPM. An LPN confirmed the incorrect flow rate and that no oxygen in use sign was posted outside the room, despite the facility policy requiring the sign.
A resident with dementia, aphasia, and COPD was observed in bed with bilateral padded grab bars attached, despite a Side Rail Utilization Assessment showing side rails were not in use or requested. The MDSC and DON stated that a physician order, informed consent, risk assessment, and care plan were required for siderail/grab bar use, but the record had no order, consent, or care plan for the grab bars, and the MDSC stated they should not have been installed.
Controlled substance accountability was inaccurate for a resident receiving tramadol with multiple orders, including PRN and routine dosing. The CDR showed a tramadol tablet was removed from the blister card and documented, but the MAR did not show the dose was administered or include related pain assessments. An LPN stated she removed the tablet, documented it in the CDR, and gave the medication, but did not enter it in the MAR; the DON confirmed the discrepancy.
A discontinued COVID-19 vaccine for a resident remained in the Nursing Station A medication refrigerator after a one-time order had ended. The MAR showed the vaccine was not given, the DON confirmed the order was discontinued, and the facility policy stated discontinued medications shall be destroyed.
Open Dumpsters in Outside Garbage Area: During an observation tour and interview, two of three outside metal dumpsters were found open with trash bags and refuse exposed. The DS confirmed the lids were left open and stated they needed to be closed at all times to prevent harboring pests. The facility policy stated outside dumpsters will be kept closed and free of surrounding litter.
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 Obtain Documented Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained and maintained for psychotropic medications for two sampled residents. Resident 4 had an order for quetiapine 25 mg by mouth twice a day for psychosis manifested by mood swing, and during a concurrent interview and record review, the MRA stated the facility was unable to provide documented informed consent for the medication. Resident 68 received Seroquel for schizophrenia manifested by hallucinations and delusional thoughts, with multiple dose increases over time, including increases to 200 mg at bedtime, then 300 mg at bedtime, then 400 mg at bedtime, and the addition of 100 mg in the morning. Resident 68 also had Wellbutrin XL initiated at 150 mg daily and later increased to 300 mg daily. During interview and record review, the MRA stated the facility was unable to provide documented informed consents for the Seroquel dose increases, the initiation of Wellbutrin XL, or the later dose increase. The DON confirmed the facility was unable to provide documentation showing the residents and/or their representatives had been informed of the risks, benefits, and alternatives associated with the psychotropic medications and agreed to treatment.
Inaccurate MDS Coding for Tobacco Use, Restorative Nursing, and Vision
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected resident status for three sampled residents. The report identified inaccurate coding in an annual comprehensive MDS for one resident’s tobacco use, an inaccurate quarterly MDS for another resident’s restorative nursing program, and an inaccurate quarterly MDS for a third resident’s vision status. The deficiencies were identified through observation, interview, and record review, and the MDS Coordinator and MDS Assistant acknowledged the coding errors during interviews. For the resident with tobacco use, the record showed a diagnosis of nicotine dependence, progress notes identifying the resident as a smoker, and the facility’s smoking list placing the resident on the smoking schedule. The resident was also observed smoking on the back patio under supervision. Despite this information, the annual MDS coded current tobacco use as no. During interview, the MDS Coordinator stated the resident was a smoker and that the item should have been coded yes, and acknowledged the assessment was not coded accurately. For the resident receiving restorative nursing services, the quarterly MDS coded restorative range of motion, active range of motion, and splinting/brace assistance in a way that did not match the restorative nursing orders and documentation. The resident had diagnoses including hemiplegia affecting the left nondominant side and was observed awake, verbally responsive, and using bilateral lower leg orthotics while lying in bed. The MDS Coordinator reviewed the restorative documentation and stated the section should have been coded differently based on the month’s documentation, and confirmed the quarterly MDS items were not coded accurately. For the resident with visual impairment, the record and interviews showed blurred vision in both eyes due to cataracts, including an ophthalmology note documenting blurred vision for about 6 years. The resident and a family member both reported worsening blurry vision, and RN 2 stated the resident had poor vision and an upcoming cataract surgery. However, the MDS coded vision as adequate. The MDS Assistant stated the resident complained of blurry vision during the assessment, read only large print, and acknowledged that smaller print was not assessed and that the item should have been coded as impaired vision.
Delayed Hospice Coordination and Missing Care Communication
Penalty
Summary
The facility failed to ensure adequate and timely collaboration and coordination with the contracted hospice agency for a resident with unspecified dementia, aphasia, COPD, and palliative care needs who was unable to make health care decisions. The resident was admitted to hospice services, and during observation was awake but did not respond when spoken to while lying in bed. The deficiency involved three areas: delayed coordination of vaccines, hospice nursing assessments not being readily available in the facility hospice binder, and the hospice agency not having a copy of the resident’s comprehensive plan of care from the facility. For immunizations, the Infection Preventionist reviewed the resident’s vaccine consents and stated that influenza, pneumococcal, and COVID-19 consents were obtained, but the orders were faxed to the pharmacy and the hospice agency was told should provide the vaccines. The Infection Preventionist stated she did not follow up with the hospice nurse until months later. Hospice physician orders later directed administration of pneumococcal, COVID-19, and influenza vaccines, and the immunization audit showed the influenza and COVID-19 vaccines were administered first, with the pneumococcal vaccine given later. Staff interviews confirmed that vaccines were expected to be administered during the winter season and that timely communication with hospice was expected. The hospice binder for the resident had an empty nursing assessment tab. An LVN stated hospice nurses came almost every day and assessed the resident, and acknowledged the assessments should have been placed in the binder as a communication tool between hospice and facility staff. The DON also reviewed the binder and acknowledged the tab was empty, stating it was his expectation that hospice nursing assessments be filed there and be accessible to facility staff. The hospice agency’s Director of Patient Care Services stated the agency did not have a copy of the resident’s comprehensive care plan from the facility. The MDS Coordinator was unsure whether hospice had received it. The DPCS stated the plan of care was expected to be shared because it served as a communication tool between the two agencies and to ensure the resident’s care and services were provided. The DON also stated it was his expectation that hospice have a copy of the resident’s comprehensive plan of care, and acknowledged the hospice agreement regarding mutual responsibilities was not followed when the care plan was not provided.
Failure to Provide Ordered Restorative ROM Services
Penalty
Summary
The facility failed to ensure that needed restorative nursing services were provided to maintain range of motion for one resident with hemiplegia affecting the left side, polyneuropathy, and muscle spasm. During observation, the resident was awake, verbally responsive, and lying in bed with bilateral lower leg orthotics in place, and stated she was paralyzed on the left side of her body. The resident’s MDS indicated cognitive intactness with a BIMS score of 15 and documented impairment on one side of the body for functional limitation in range of motion. The resident’s orders included multiple restorative nursing interventions, including PROM to both lower extremities, AAROM to the right lower extremity, BLE splinting, PROM to the left lower extremity, donning and doffing of BLE orthotics, and PROM to both upper extremities. The resident’s care plan also included restorative nursing interventions for AAROM to the right lower extremity, PROM to the left lower extremity, and PROM to both upper extremities. During interview, the RNA stated restorative services included splinting and active and passive ROM exercises and were to be documented the same day or before the shift ended. Record review and interviews showed the ordered restorative services were not provided as scheduled. The DON acknowledged that PROM to BLEs, AAROM to the right lower extremity, BLE splinting, PROM to the left lower extremity on several dates, donning and doffing of BLE orthotics on multiple dates, and PROM to both upper extremities on several dates were not provided. The RN, DOR, and DON stated staff were expected to follow physician orders and document the services performed, and the DON confirmed the missing services in the documentation survey report.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of a resident discharge for one of three sampled discharged residents, Resident 80. Resident 80 was admitted with acute respiratory failure with hypoxia, Type II Diabetes Mellitus without complications, and Essential Hypertension. The record showed Resident 80 was discharged home with home health services and durable medical equipment (DME), and the discharge records included notification information stating that the facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. During interview and record review, RN 2 stated nursing staff were responsible for faxing the discharge notification to the Ombudsman and providing the transmittal notification to medical records. The Medical Records Director stated he was unable to locate documentation verifying that the discharge notification was faxed to the Ombudsman for Resident 80. The DON stated a discharge notification should have been faxed to the Long-Term Care Ombudsman upon discharge, as indicated in the Notice of Transfer or Discharge.
Failure to Complete and Transmit Required MDS Assessments
Penalty
Summary
The facility failed to ensure timely completion and transmission of MDS assessments for two sampled residents. For one resident, the discharge MDS assessment was not completed after the resident was transferred to the hospital and did not return. For another resident, the quarterly MDS assessment was completed but was not transmitted to CMS and was described by the MDS Coordinator as missed. Resident 33 was admitted with diagnoses including paranoid schizophrenia, COPD, and essential hypertension. A physician telephone order dated 2/22/26 indicated the resident could transfer to a hospital for further evaluation. During interview and record review, the MDS Coordinator stated the resident had prior quarterly and admission MDS assessments that were completed and accepted by CMS, but after the hospital transfer, a discharge MDS assessment should have been done when the resident was discharged. Resident 72 was readmitted with diagnoses including toxic encephalopathy, COPD, and essential hypertension. During interview and record review, the MDS Coordinator stated the resident’s latest quarterly MDS had an ARD of 4/27/26 and was completed on 5/1/26, but it was not transmitted. The MDS Coordinator stated it was missed and that the assessment should have been transmitted within 14 days after completion per RAI guidelines.
Missing Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to develop a care plan for oxygen administration for one of 25 sampled residents, Resident 82. Resident 82 was admitted with diagnoses of chronic respiratory failure with hypoxia, pneumonia, and pleural effusion. The physician's orders dated 6/2/26 directed oxygen at 4 LPM via nasal cannula continuously every shift, and the June MAR showed oxygen at 4 LPM via nasal cannula was administered from 6/3/26 to 6/8/26 on all shifts. The quarterly MDS dated 6/6/26 indicated oxygen therapy was administered. During a concurrent observation and interview on 6/8/26 at 10:06 AM, Resident 82 was observed wearing a nasal cannula with an oxygen concentrator set at 3 LPM, and LVN 3 confirmed the oxygen was set at 3 LPM. During an interview on 6/11/26 at 6:15 PM, the MRA confirmed Resident 82 had no care plan for oxygen therapy and stated licensed nurses were responsible for making the care plan for residents. The facility policy on Care Plans stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident, and the Oxygen Administration policy stated to review the resident's care plan for special needs.
Unclarified enoxaparin route order and unsupported psychosis diagnosis
Penalty
Summary
Nursing staff failed to clarify a physician order for enoxaparin for Resident 84, whose hospital transfer record listed enoxaparin 40 mg subcutaneously once daily. A physician order dated 6/5/26 instead directed enoxaparin sodium injection 40 mg intramuscularly one time a day for DVT prevention. During medication administration observation, an LVN administered enoxaparin subcutaneously to the resident’s left lower abdomen, and the MAR documented the medication as given intramuscularly on multiple days. The LVN acknowledged the order specified intramuscular administration, stated she gave the medication subcutaneously because she knew that was the correct route, and confirmed the physician was not contacted to clarify the discrepancy. The DON reviewed the order and MAR and stated nursing staff should have clarified the physician order and corrected the route of administration. The enoxaparin prescribing information reviewed during the survey stated the medication should not be administered intramuscularly and should be administered by subcutaneous injection only. The facility policy on administering medications stated that if a medication is identified as having potential adverse consequences or is suspected of being associated with adverse consequences, the person preparing or administering it will contact the prescriber, attending physician, or medical director to discuss the concern. Nursing staff also entered and used a diagnosis of psychosis for Resident 6 without supporting clinical documentation. The resident’s record showed depression as the documented diagnosis, and aripiprazole was ordered for depression manifested by persistent low mood. The diagnosis associated with aripiprazole was later changed in the MAR from depression to psychosis, and psychosis was then added to the resident’s diagnosis list, care plan, PASRR screening, and behavioral monitoring. The record review did not identify physician assessment, psychiatric evaluation, consultation, or other documentation supporting psychosis, and the DON stated an RN mistakenly associated aripiprazole with psychosis and entered the diagnosis without physician clarification.
Oxygen Order Not Followed and Sign Missing
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not followed for Resident 82. Resident 82 was admitted with chronic respiratory failure with hypoxia, pneumonia, and pleural effusion. The physician's order dated 6/11/26 directed oxygen at 4 LPM via nasal cannula continuously every shift, and the June MAR showed the oxygen was administered from 6/3/26 to 6/8/26 on all shifts. The quarterly MDS dated 6/6/26 also indicated that oxygen therapy was being administered. During a concurrent observation and interview on 6/8/26 at 10:06 AM, Resident 82 was observed in the room with a nasal cannula attached to an oxygen concentrator set at 3 LPM, and there was no oxygen in use sign outside the room. LVN 3 confirmed that the oxygen was set at 3 LPM instead of 4 LPM and that no oxygen in use sign was present. The facility's Oxygen Administration policy required verification of a physician's order and placement of an oxygen in use sign on the outside of the room entrance door.
Failure to Assess and Authorize Grab Bars
Penalty
Summary
The facility failed to ensure Resident 52 was assessed for the appropriate use of affixed grab bars based on acceptable standards of practice and facility policy. Resident 52 was readmitted with diagnoses including unspecified dementia, palliative care encounter, and COPD. The resident's H&P stated the resident was unable to make decisions concerning health care because of cognitive deficit and aphasia. The quarterly MDS indicated the resident was dependent on staff for eating, toileting, oral hygiene, personal hygiene, and rolling in bed. The latest Side Rail Utilization Assessment dated 3/19/26 indicated side rails were not in use or requested. During observations, Resident 52 was found asleep and later awake in bed with bilateral padded grab bars in place while the bed was in low position. The MDS Coordinator stated residents were assessed for side rail/grab bar use during admission, quarterly, and as needed, and that an assessment, doctor's order, consent, and care plan were needed whenever side rails or grab bars were used. The MDS Coordinator later reviewed the record and stated there were no doctor's orders, informed consent, or care plan for the grab bars, and that the grab bars should not have been installed. The DON stated residents using siderails/grab bars needed a doctor's order, consent, risk assessment, and care plan, and that the facility's policy and procedure was not followed for Resident 52.
Controlled Substance Documentation Discrepancy
Penalty
Summary
Accurate accountability of controlled substances was not maintained for one resident who had multiple tramadol 50 mg orders, including as-needed and routine dosing schedules. During review of Medication Cart 1, the resident’s tramadol blister card and related records were examined, and the Controlled Drug Record showed that one tramadol 50 mg tablet was removed from the blister card on 6/8/26 at 1:30 PM and documented in the CDR. The resident’s June 2026 MAR did not show corresponding documentation that the tramadol dose was administered, and it also did not show associated pain assessments for that dose. During interview, the LVN stated she removed the tramadol tablet, recorded the removal in the CDR, and administered the medication, but did not document it in the MAR. The DON reviewed the records and confirmed the discrepancy between the CDR and MAR, and the facility policy required the person administering the medication to record the date and time administered, symptoms, results, and signature in the resident’s medical record.
Discontinued COVID-19 Vaccine Left in Medication Refrigerator
Penalty
Summary
The facility failed to remove a discontinued medication from active medication storage in one of two medication rooms, specifically the Nursing Station A Medication Room. During a medication room inspection, a prefilled syringe of Spikevax 2025-2026 (COVID-19 vaccine) labeled for Resident 17 was observed in the medication refrigerator with a date of 5/14/26. The resident’s physician’s telephone order showed a one-time order for a COVID vaccine that ended on 5/14/26, and the Medication Administration Record showed the vaccine was not administered on that date. A review of Resident 17’s clinical record did not identify documentation that staff obtained a subsequent physician order for COVID-19 vaccination or made additional attempts to administer the vaccine after 5/28/26. During interview and record review, the DON confirmed the order was discontinued and stated nursing staff should have removed the vaccine from the medication refrigerator and medication storage area. The facility policy titled Discontinued Medications stated that staff shall destroy discontinued medications.
Open Dumpsters in Outside Garbage Area
Penalty
Summary
The facility failed to keep the lids of two of three outside dumpsters closed, leaving trash bags and refuse exposed in the garbage area. During a concurrent observation tour and interview on 6/8/26 at 8:53 AM, the Dietary Supervisor confirmed that two metal dumpsters were left open and stated they needed to be closed at all times to prevent harboring pests. A review of the facility policy titled, Food-Related Garbage and Refuse Disposal, revised 10/2017, stated that outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.
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.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 648 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
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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 | ★★★★★ | 2 | 0 |
| Redlands Healthcare Center | 2.4 mi | ★★★★★ | 6 | 0 |
| Redlands Community Hospital D/p Snf | 2.4 mi | ★★★★★ | 8 | 0 |
| Brookside Healthcare Center | 2.9 mi | ★★★★★ | 9 | 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 October 2026) and official state health department websites.