Highland Care Center of Redlands

In the surveyor’s words

From the most serious findings on record at Highland Care Center of Redlands, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 26, 2023

  Based on observation, interview, and record review, the facility failed to provide supervision to one of three sampled resident (Resident 1), when Resident 1 was left unattended and unsupervised by staff while in the Memory Care Unit patio on a hot day. This failure potentially contributed to the death of Resident 1, a clinically compromised resident with dementia (memory loss), on [DATE]. Findings: An unannounced visit was conducted on [DATE], at 12:20 PM, to investigate a complaint regarding death of a resident (Resident 1). During the tour and observation of the facility's Memory Care Unit patio, with the Director of Nursing (DON), on [DATE], at 1:50 PM, the DON stated there was no door alarm to alert the staff that someone is going out to the patio. […]

• No harm, potential for more than minimal, widespreadF812Feb 21, 2025

  Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen as required by the facility policy when: 1.The floors under equipment had accumulation of food crumbs, trash, and black grime (dirt). The food prep sink drain had residue build-up on the drainpipe and the wall. 2. The dry storage room had food crumbs and trash underneath shelves. The shelves had spill of a powder substance. 3. There were broken tiles, which provided a surface for an accumulation of food crumbs, in the dry storage room and in the main kitchen. 4. Food equipment (food processor, plate warmer, blender, and can opener) were stored with food crumbs and build up. 5. The clean utensil bins had food splash and crumbs. 6. […]

• No harm, potential for more than minimal, widespreadF812Jul 29, 2022

  Based on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when: 1. The top of the mantle above the stove, the coffee maker, and the beverage machine were dusty. 2. Inside the fridge, there was an opened package of slice ham in a closed plastic container, labeled with an expiration date of [DATE] (three days expired), and one plastic four-quart container, which had unlabeled Styrofoam cups containing pink yogurt. 3. Two (2) sinks in the kitchen did not have an air gap (a separation of the drainpipe on a sink to prevent backflow of contaminated water during negative pressure). 4. […]

• No harm, potential for more than minimal, patternF552Jun 11, 2026

  Based on interview and record review, the facility failed to ensure informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained and maintained for two out of four sampled residents (Resident 4 and 68) receiving psychotropic medications (medications affecting brain activities associated with mental processes and behaviors). This failure had the potential for residents and/or their representatives to make treatment decisions without being fully informed of the risks, benefits, alternatives, and potential adverse effects associated with psychotropic medications. Findings:1. […]

• No harm, potential for more than minimal, patternF641Jun 11, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents' Minimum Data Set (MDS- a federally mandated resident assessment tool) assessments accurately reflected residents' status per Resident Assessment Instrument (RAI- comprehensive assessment and care planning process used by nursing home) guidelines for three of 24 sampled residents (Resident 68, 59, and 47) when:1. Resident 68's tobacco use in the annual comprehensive assessment was not accurately coded.2. Resident 59's restorative nursing program was not coded accurately in the recent quarterly assessment.3. Resident 47's visual abilities in the latest quarterly assessment were not accurately coded. […]