Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Redlands Comm Hosp D/p Snf during CMS and state inspections, most recent first.
Infection control practices were not maintained when an RN administered medications via a G tube to a resident on EBP without wearing the required gown, despite posted precautions and the resident's feeding tube status. In a separate event, a glucose monitor was found visibly soiled at the nurse's station, and staff acknowledged that patient care equipment was expected to be cleaned between resident uses; the DON confirmed the facility policy for cleaning blood glucose monitors was not followed.
Missed Blood Glucose Monitoring for a Resident with Type II Diabetes: A resident with breast cancer, metastatic spine cancer, and type II DM had an MD order for morning blood glucose monitoring, but two AM checks were not completed. The DON reviewed the EMR and confirmed the missing blood glucose results, and acknowledged the facility did not follow its policy for carrying out MD orders.
Failure to post required daily staffing information. The in-unit staffing list in the TCU was shown on a TV monitor but did not include the facility name or the actual hours worked per shift for licensed and unlicensed staff. RN 1 stated DHPPD was not posted in the unit, and the DON stated DHPPD had only just started being calculated and that the facility did not have a policy for it and had not followed the regulations.
Improper Labeling of Enteral Feeding Supplies: A resident receiving PEG tube feeding had a formula bottle that lacked the initiating nurse’s initials and a water flush bag that lacked the prescribed rate. RN and CNE interviews confirmed the labels were incomplete, and the facility policy required enteral feeding bags to include patient information, formula details, date, time, and initials.
Failure to Submit Accurate PBJ Staffing Data: The facility failed to successfully transmit complete and accurate PBJ staffing data to CMS for two quarters. The DON stated the submissions were thought to have gone through, but system issues and a wrong code caused the staffing information to be erased, resulting in transmissions with no staffing data. The DON also stated the facility did not have a policy and just followed the regulations.
Two residents in an LTC facility received meals in a manner that lacked dignity, with food served in plastic bags and disposable containers without trays or plates. This practice was explained as standard for isolation precautions, yet there was no evidence that these residents required such precautions. The facility's policy on resident rights, which emphasizes dignity and a homelike environment, was not followed.
A facility failed to submit a quarterly MDS assessment for a resident within the required timeframe, resulting in inadequate monitoring of the resident's condition. The assessment, due 36 days earlier, was delayed due to CMS system updates. The resident had multiple diagnoses, including diabetes and end-stage renal disease. The facility lacked a specific policy for MDS assessments, relying on the MDS RAI manual, and the MDS Coordinator's role emphasized timely completion of assessments.
The facility failed to follow infection control policies during medication administration and IV therapy. An LVN did not perform hand hygiene when administering medication to multiple residents, contrary to facility policy. Additionally, IV tubing for a resident was not changed according to updated standards, and the facility lacked sterile caps for intermittent use. These deficiencies increased the risk of infection.
Infection Control Practices Not Followed for EBP and Glucose Monitor Cleaning
Penalty
Summary
Infection prevention and control practices were not maintained when Resident 4, who had diagnoses including intraparenchymal hemorrhage of the brain, dysphagia, and hypertension, was observed receiving medication administration via G tube while on Enhanced Barrier Precautions. An EBP sign was posted on the door, and the sign indicated that a gown was to be worn with resident contact. However, RN 2 administered rosuvastatin, sertraline, lisinopril, and acetaminophen/hydrocodone via the G tube without wearing the required protective gown. During a follow-up interview, RN 2 verified that Resident 4 was on EBP precautions and confirmed that no protective gown was worn during the medication administration. A separate infection control failure was observed at the Transitional Care Unit nursing station when a glucose monitoring device was found visibly soiled with dried white substance while docked at the nurse's station. RN 1 acknowledged the monitor was dirty and stated the facility's expectation was for patient care equipment to be cleaned after use on each resident. The DON and Infection Control Nurse stated that patient care equipment is to be cleaned prior to and immediately after use for each resident, and the facility policy for blood glucose monitors required wiping the device with hospital-approved disinfectant wipes in between each patient use. The DON confirmed the policy was not followed.
Missed Blood Glucose Monitoring for Resident with Type II Diabetes
Penalty
Summary
The facility failed to ensure nursing staff provided treatment according to the MD order for one resident with diagnoses that included breast cancer with metastatic cancer to the spine and type II diabetes mellitus. Resident 18 stated she had type II diabetes and was taking oral medications for blood sugar control, not insulin. The MD order, started November 27, 2025, directed blood glucose monitoring every morning. During record review with the DON, the resident’s blood glucose results were reviewed for the period from November 27, 2025, through December 1, 2025, and two morning blood glucose checks were missing. The missing checks were for November 30, 2025, and December 1, 2025. The DON verified the missing blood glucose monitoring and acknowledged that it was important to check the resident’s blood glucose for patient safety and overall quality of care. The DON also acknowledged that the facility’s policy for orders for medication, treatment, and diagnostic testing was not followed.
Failure to Post Required Daily Staffing Information
Penalty
Summary
The facility failed to post the facility name and the total number and actual hours worked per shift for licensed and unlicensed staff daily. During a concurrent observation, interview, and record review on December 3, 2025, at 5:51 AM in the Transitional Care Unit, the in-unit staffing list was displayed on a television monitor, but it did not show the facility's name or the actual hours worked per shift for licensed and unlicensed staff. RN 1 stated that the Direct Hours Per Patient Day (DHPPD) was not posted anywhere in the unit. During a later interview and record review on December 4, 2025, the DON stated that the DHPPD had only started being calculated the day before because the DON did not know it had to be done, and that the expectation was for DHPPD to be posted daily so residents, family, and staff would know if the facility had appropriate staffing. The DON also stated the facility did not have a policy for this and that the regulations were not followed.
Improper Labeling of Enteral Feeding Supplies
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles for one sampled resident receiving enteral nutrition. Resident 7 was admitted with diagnoses including gastric cancer, recent gastric/intestinal perforation repair, and GERD, and had a PEG tube in place. The resident’s nutrition therapy recommendations dated November 21, 2025, called for [Brand Name] tube feeding at 65 mL/hr, and the physician order dated November 20, 2025, ordered short bowel tube feeding of [Brand Name] 1 each PEG every 24 hours at 1400 at 65 mL/hr. A later physician order dated December 2, 2025, ordered free water every 4 hours with an amount of 200 mL. During observation of the resident’s feeding setup, the formula bottle was labeled with the resident’s name, starting date and time, and formula rate, but the nursing staff initial who started the formula was missing. The water flush bag was labeled with the resident’s name, room number, and starting date and time, but the prescribed water rate was missing. RN 3 stated tube feeding labels must include resident name, room number, formula type, rate, date, start time, and nurse initials, and confirmed the formula bag was missing nurse initials and the water flush bag was missing the prescribed rate. The CNE also stated that all formula bags and water flush bags must be labeled with patient information, date, time, rate, and nurse initials, and the facility policy required the bag to be labeled with patient information, enteral access type, tube feeding formula type, strength, amount, date, time, and initials.
Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to ensure successful electronic submission of complete and accurate direct care staffing information to CMS for two quarters, with the PBJ submissions on May 13, 2025, and August 14, 2025, transmitted without staffing information. During interview, the DON stated the PBJ is supposed to be submitted quarterly and that the submissions were thought to have gone through, but did not because of issues with the facility’s system, [Name of Company]. The DON further stated that the company used erased the information because of the wrong code, resulting in transmission with no staffing information, and acknowledged that the information is important to show the facility has enough staff to care for residents. On a later interview, the DON stated the facility did not have a policy and just followed the regulations.
Failure to Provide Dignified Meal Service
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the manner in which meals were served to two residents. Resident 55, who was admitted for physical and occupational therapy following a right humerus fracture, received meals in a plastic bag with disposable containers and utensils, without a placemat, tray, or plate. This method of serving meals was likened to takeout service, and Resident 55 expressed that this was the norm since admission. The resident noted that having a proper plate and utensils made a significant difference, especially given the difficulty in using her right arm due to the fracture. Similarly, Resident 56, admitted for therapy after a left hip fracture, experienced the same issue with meal service. Meals were delivered in a plastic bag with disposable items, requiring the resident to place food items directly on the table. The Director of Dietary Services explained that this practice was standard for residents on isolation precautions, but there was no documented evidence that Residents 55 and 56 were under such precautions. The facility's policy on resident rights emphasizes the importance of maintaining dignity and providing a homelike environment, which was not upheld in these instances.
Failure to Submit Timely MDS Assessment
Penalty
Summary
The facility failed to ensure that the quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS) was completed and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required federal submission timeframes for one resident. This deficiency was identified during an interview and record review, where it was found that the quarterly MDS assessment for a resident, which was due on September 18, 2024, was not submitted until 36 days past the due date. The MDS Nurse attributed the delay to CMS updating their system, but acknowledged that the assessment should have been submitted by October 2, 2024. The resident involved was admitted to the facility with multiple diagnoses, including diabetes mellitus, end-stage renal disease, and osteomyelitis in the left foot. The lack of timely submission of the MDS assessment resulted in inadequate monitoring of the resident's progress or decline and the absence of resident-specific information for CMS's payment and quality measure monitoring. The facility did not have a specific policy regarding MDS assessments, relying instead on the MDS RAI manual, and the MDS Coordinator's job description emphasized the timely completion of resident assessments in accordance with current regulations.
Infection Control Deficiencies in Hand Hygiene and IV Therapy
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during medication administration for four residents. Licensed Vocational Nurse 1 (LVN 1) did not perform hand hygiene after leaving Resident 106's room and before administering medication. Similarly, LVN 1 failed to wash or sanitize hands when administering medication to Residents 55 and 56. Despite the facility's policy requiring hand hygiene to prevent the spread of infection, LVN 1 did not follow these procedures, as confirmed by interviews with the Infection Preventionist Nurse and the Director of Skilled Nursing. Additionally, the facility did not follow updated standards of practice for intravenous (IV) therapy for Resident 57. The IV tubing was not changed according to the current standards, and the facility's policy did not include instructions for capping IV tubing during intermittent use. The tubing was observed to be looped and connected to its medication port without a sterile cap, which is not in line with the Infusion Nurses Society Standard referenced in the facility's policy. This oversight was acknowledged by the Nurse Manager and the Director of Skilled Nursing, who confirmed that the facility lacked sterile caps for intermittent IV tubing. These deficiencies in hand hygiene and IV therapy practices had the potential to increase the risk of infection among residents. The facility's failure to update its policies and ensure staff compliance with infection control procedures was evident in the observations and interviews conducted during the survey.
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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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Nursing homes near Redlands
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Redlands Healthcare Center | 0 mi | ★★★★★ | 6 | 0 |
| Madison Grove Post Acute | 0.1 mi | ★★★★★ | 17 | 0 |
| Brookside Healthcare Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Plymouth Village | 1.8 mi | ★★★★★ | 0 | 0 |
| Asistencia Villa Healthcare Center | 1.9 mi | ★★★★★ | 18 | 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 June 2026) and official state health department websites.