Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Redlands Healthcare Center during CMS and state inspections, most recent first.
Failure to Follow Approved Menu Portion Sizes: During breakfast tray line, a cook used a 1-oz scoop to serve strawberry topping to 70 residents instead of the menu-specified #16 scoop for regular and small portions and #8 scoop for large portions. The DS, cook, and RDN all acknowledged the recipe and Spring Cycle Menu were not followed, and facility P&P required recipes and menus to be followed and reviewed by the RDN.
Failure to Follow Hand Hygiene and EBP During Resident Care: A CNA did not perform hand hygiene while providing care to two residents in the same room, and an RN/TN applied a dressing to a resident’s skin tear without wearing a gown while the resident was on EBP. The resident receiving wound care had diabetes, a foot ulcer, osteomyelitis, CHF, and an order for EBP during high-contact care activities. Facility leadership confirmed the hand hygiene and EBP policies were not followed.
Dignity During Meal Assistance: A resident with dementia, Parkinson's disease, and schizophrenia was observed lying in bed while a CNA stood next to the bed and fed the resident lunch. The CNA said the resident was not positioned well and it was uncomfortable to sit, and acknowledged the resident should have been repositioned. The DON reviewed training and the facility P&P stating staff should sit beside residents and not stand over them while assisting with meals, and stated the policy was not followed.
A resident receiving oxycodone had a controlled substance count discrepancy when the CDR showed 59 tablets available but the physical count showed 57. An LVN stated 10 mg had been given for pain, but the MAR had no documentation of the dose, and the DON acknowledged the required concurrent documentation on the CDR and EMR/MAR was not followed.
Kitchen Stove Not Kept Clean and Sanitary: A 6-burner stove was observed with substantial burnt grease and food debris on the burner grate and surrounding surfaces. The DS stated the stove is typically cleaned daily and had been cleaned three days earlier per the schedule, but could not explain the buildup. DA1 said kitchen equipment is wiped clean daily and deep cleaned weekly, and the DS acknowledged the facility’s Ranges and Ovens and Sanitation policies were not followed.
The facility failed to keep call lights within reach for two residents. One resident with dementia, a history of falling, and other diagnoses had the call light on the floor between beds, and the resident said he could not reach or locate it. Another resident with dementia, Parkinson’s disease, and schizophrenia had the call light hanging from the bed and resting on the floor while the resident was awake, agitated, and confused. An LVN observed both situations, and the DON and Admin acknowledged the facility policy requiring call lights to be within easy reach was not followed.
A resident with legal blindness and a history of falls was not given the required verbal reminder to request assistance before standing, as established by the IDT. After being assisted to the bathroom, the CNA left the resident unattended without instructing them to remain seated, resulting in the resident attempting to stand independently, falling, and sustaining a head injury that required hospitalization.
A resident with acute respiratory failure and COPD did not have their oxygen tubing changed every seven days as required by the facility's infection control policy. The tubing, dated January 23, was found unchanged during an observation, despite the facility's protocol to replace it weekly. Interviews with staff confirmed the oversight.
A resident with hemiplegia was unable to reach the call light due to its improper placement, contrary to facility policy. The resident expressed difficulty in getting assistance, often relying on her roommate. Observations showed the call light was placed in inaccessible positions, such as under a pillow or on the left upper arm, which the resident could not reach due to her condition. The DON acknowledged the issue, noting it was against the facility's policy.
A resident with multiple diagnoses was given the wrong medication by an LVN who failed to verify the resident's identity, contrary to the facility's policy. The incident was confirmed by the DON during an interview and record review.
Failure to Follow Approved Menu Portion Sizes
Penalty
Summary
The facility failed to follow the approved menu during breakfast when strawberry topping was served in an amount less than what was listed on the Spring Cycle Menu for 70 of 71 residents. During tray line observation in the kitchen, the cook served strawberry topping with a 1-ounce purple-handle scoop to all 70 residents instead of the #16 scoop for regular and small portions and the #8 scoop for large portions as specified on the menu. The census list showed 70 residents in the facility, including one resident who was NPO, 43 residents on regular portions, 2 on small portions, and 2 on large portions. The Dietary Supervisor stated the purple-handle scoop measured 1 ounce, while the #16 scoop measured 1/4 cup, or 2 ounces, and the #8 scoop measured 1/2 cup, or 4 ounces, and acknowledged the wrong scoop was used, resulting in less strawberry topping being served to 70 in-house residents. The cook stated he grabbed the wrong scoop and served the strawberry topping not according to the recipe, and the RDN stated the recipe and Spring Cycle Menu should have been followed. Facility policies reviewed stated that food shall be prepared to conserve nutritive value and that recipes are specific as to portion yield and ingredient amounts, and that menus will be reviewed and approved by the Facility Registered Dietitian.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain infection control practices when a CNA did not perform hand hygiene while providing care to two residents in the same room. Resident 93 was admitted with diagnoses including type 2 diabetes mellitus, hypertension, hyperlipidemia, and a right artificial knee joint. Resident 89 was admitted with diagnoses including pulmonary embolism, COPD, and alcohol cirrhosis of the liver with ascites. During observation, the CNA entered the room, obtained a blood pressure reading for Resident 93, then obtained a blood pressure reading for Resident 89 without performing hand hygiene between residents, and later exited and re-entered rooms without performing hand hygiene. The CNA acknowledged that hand hygiene should be performed before and after each resident contact and between resident care, and stated this was not done. The facility also failed to follow enhanced barrier precautions for Resident 47 during wound care. Resident 47 was admitted with acute osteomyelitis of the right ankle and foot, type 2 diabetes mellitus with foot ulcer, and congestive heart failure. A physician order directed enhanced barrier precautions during high-contact resident care activities secondary to wounds every shift. During observation, a sign outside the room indicated gown and glove use was required for activities including wound care, and the treatment nurse entered the room to apply a new dressing to a skin tear on Resident 47's hand without wearing a gown. The nurse stated Resident 47 was on enhanced barrier precautions because of a recent amputation and believed the gown requirement applied only to the foot wound, not the hand wound. The DSD/IP and DON reviewed the facility's hand hygiene and enhanced barrier precautions policies and stated the policies were not followed. The DSD/IP stated enhanced barrier precautions were intended for residents with a port of entry for infection such as wounds, and that staff were supposed to wear a gown and gloves during wound care for any wound with open skin, including a skin tear requiring a bandage. The DON stated staff were supposed to wear a gown and gloves during any high-contact care activity for a resident on enhanced barrier precautions, including care of any open skin wound requiring a dressing.
Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that Resident 7 was provided care in a manner that maintained dignity during meal assistance when CNA 1 stood while feeding the resident. Resident 7 was admitted with diagnoses including dementia, Parkinson's disease, and schizophrenia. During an observation in Resident 7's room, Resident 7 was lying in bed while CNA 1 stood next to the bed and provided feeding assistance during lunch. During an interview, CNA 1 stated she was standing because Resident 7 was not positioned well in bed and it was uncomfortable to sit in a chair next to the bed. CNA 1 acknowledged that Resident 7 should have been repositioned and stated she had not been trained or educated that standing over a resident during feeding was inappropriate. The DON reviewed an inservice training record titled Properly Feeding a Resident During Meal Time, which included positioning, hand hygiene, safe feeding techniques, and sitting beside the resident, and stated CNAs are educated on maintaining residents' dignity during meals, including not standing over residents while feeding them. The Administrator and DON also reviewed the facility policy Assistance with Meals, which stated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals, and stated the policy was not followed.
Controlled Substance Count and Documentation Discrepancy
Penalty
Summary
Controlled substances were not accurately accounted for and documented for one sampled resident receiving oxycodone 5 mg tablets. Resident 30 was admitted with diagnoses including fracture of the right tibia, cirrhosis of the liver, and COPD. The resident’s order summary dated April 22, 2026, showed oxycodone HCI 5 mg tablets, 2 tablets by mouth every four hours as needed for severe hip pain. During a concurrent observation, interview, and record review at the Unit 1 medication cart, LVN 3 and LVN 4 completed the controlled substance count and identified a narcotic discrepancy for Resident 30. The CDR showed 59 oxycodone 5 mg tablets available, while the physical count of the resident’s bubble pack showed 57 tablets remaining, leaving two tablets unaccounted for. LVN 3 stated Resident 30 had been given oxycodone 10 mg at approximately 6:30 AM, but review of the EMR and MAR showed no documentation of that administration. The DON reviewed the CDR and acknowledged the two-tablet discrepancy and stated the facility process required controlled substances to be documented at the time of removal and administration on both the CDR and the EMR/MAR. During follow-up interview, LVN 5 acknowledged administering oxycodone 10 mg for LVN 3 but stated the medication was not documented at the time of removal or administration and that the information was only written down with the intent to give it to LVN 3. Facility policy reviewed by the DSD/IP stated medication administration must be documented after giving each medication, and the controlled substances policy stated controlled substances are to be inventoried and reconciled to identify loss or potential diversion.
Kitchen Stove Not Kept Clean and Sanitary
Penalty
Summary
The facility failed to ensure the kitchen stove was maintained in a clean and sanitary condition when a 6-burner commercial stove was observed with substantial accumulations of burnt grease and food debris on the burner grate and surrounding surfaces. The observation occurred in the kitchen during survey, and the Dietary Supervisor was present during the concurrent interview and record review. The Dietary Supervisor stated the stove is typically cleaned at the end of each day and that the stove, flat top griddles, and surrounding surfaces had been cleaned three days earlier according to the cleaning schedule, but could not explain the significant buildup that was observed. Dietary Aide 1 stated that all kitchen equipment, including the stove, is wiped clean daily at the end of each day and that a weekly deep cleaning is performed in accordance with the Cleaning Log. During a later interview and record review, the Dietary Supervisor acknowledged that the facility’s Policy and Procedure for Ranges and Ovens was not followed when the stove was found with significant accumulations of burnt built-up grease and food debris. The Dietary Supervisor also acknowledged that the facility’s Sanitation policy was not followed. The Administrator stated that all kitchen equipment is expected to be maintained in sanitary conditions.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for two sampled residents. Resident 55 was admitted with diagnoses including history of falling, acquired absence of the right hand, dementia, cognitive communication deficit, and acute respiratory failure with hypoxia. During observation, Resident 55 was lying in bed and his call light was on the floor between bed 1 and bed 2, out of reach. Resident 55 stated he was unable to reach and locate the call light, and an LVN confirmed it was on the floor away from the resident. Resident 7 was admitted with diagnoses including dementia, Parkinson's disease, and schizophrenia. During observation, Resident 7 was awake, agitated, and confused, and the call light was observed hanging from the bed and resting on the floor, out of reach. An LVN observed the same condition and acknowledged the call light was not within reach. The facility's policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach, and the Admin and DON acknowledged that the policy was not followed.
Failure to Provide Verbal Reminders Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to implement a post-fall intervention established by the Interdisciplinary Team (IDT) for a resident with legal blindness, a history of falls, and muscle wasting. The intervention required staff to provide verbal reminders and cues to the resident to request assistance as needed. On the day of the incident, a CNA assisted the resident to the bathroom but left the resident seated on the toilet to close a sliding door, without providing a verbal reminder to remain seated or to call for help before standing. The CNA assumed the resident would stay seated, but the resident attempted to stand up independently and subsequently fell, resulting in a head injury that required hospitalization. Review of facility records confirmed that the resident had a prior unwitnessed fall and that the IDT had specifically recommended verbal reminders as a preventive measure. The Director of Nursing acknowledged that staff should consistently educate the resident on the importance of asking for help before getting up. The facility's fall protocol also emphasized monitoring and documenting the effectiveness of interventions for residents at high risk of falls. The failure to provide the required verbal reminder directly preceded the resident's fall and injury.
Failure to Change Oxygen Tubing as Per Policy
Penalty
Summary
The facility failed to adhere to its infection control practices by not changing the oxygen tubing for one resident, identified as Resident 60, every seven days as per the facility's policy. Resident 60, who was admitted with acute respiratory failure, pleural effusion, and chronic obstructive pulmonary disease (COPD), was found using oxygen via nasal cannula with tubing that had not been changed since January 23, 2025. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged that the tubing should have been changed. Further interviews with the Infection Preventionist and the Director of Nursing revealed that the facility's protocol required the oxygen tubing to be changed weekly, specifically every Thursday. However, the tubing for Resident 60 was four days overdue for a change, as it should have been replaced on January 30, 2025. The facility's policy, titled 'Prevention of Infection Respiratory Equipment,' clearly stated the need for changing the oxygen cannula and tubing every seven days, which was not followed in this instance.
Call Light Accessibility Deficiency for Resident with Hemiplegia
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident with hemiplegia, which is partial paralysis on the left side of the body. This resident, identified as Resident 51, was observed in her room with the call light placed on the left bed rail, which she could not reach due to her condition. During an interview, Resident 51 expressed that the call light was not answered unless she screamed, and she often relied on her roommate to call for assistance. Further observations revealed that the call light was sometimes placed under her pillow or on her left upper arm, both positions making it inaccessible for her to reach due to her limited mobility. The Director of Nursing (DON) acknowledged that the call light was not within easy reach of Resident 51, which was against the facility's policy and procedure for answering call lights. The policy, revised in October 2010, clearly stated that the call light should be within easy reach when a resident is in bed or confined to a chair. Despite multiple observations and interviews, the call light was consistently found in positions that Resident 51 could not access, highlighting a failure in ensuring the resident's ability to call for help when needed.
Medication Administration Error
Penalty
Summary
The facility failed to administer oral medications in a safe and timely manner, as prescribed, for one of three sampled residents. Specifically, a Licensed Vocational Nurse (LVN) gave the wrong medication to a resident without verifying the resident's identity by checking the name band or asking for the resident's full name. The resident, who was admitted with diagnoses including malignant neoplasm of the thyroid gland, muscle wasting and atrophy, depression, anxiety disorder, and acute embolism and thrombosis, was given Seroquel, metoprolol, and vitamins C and B complex, which were not prescribed for them. This incident was confirmed during an interview and record review with the Director of Nursing (DON). The facility's policy and procedure for administering medications, which requires verification of the resident's identity before medication administration, was not followed.
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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 Comm Hosp D/p Snf | 0 mi | ★★★★★ | 8 | 0 |
| Madison Grove Post Acute | 0.1 mi | ★★★★★ | 17 | 0 |
| Brookside Healthcare Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Plymouth Village | 1.8 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.