Highland Care Center of Redlands

Inspectors wroteBased 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.

Inspectors wroteBased 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. These deficient practices had the potential for Resident 68, 59 and 47 not to receive the necessary care, treatment, and/or services to attain their highest practicable level of functioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate and timely collaboration and coordination with the contracted hospice agency for one of two sampled residents (Resident 52) when:1. Resident 52's vaccines were not coordinated for timely administration.2. Resident 52's hospice nursing assessments in the hospice binder were not readily available to facility staff.3. The hospice agency did not have a copy of Resident 52's comprehensive plan of care from the facility. These failures resulted in the delay of care and had the potential to cause miscommunication among staff and unmanaged health concerns for Resident 52.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needed treatment and services were provided to maintain range of motion (ROM- full movement potential of a joint) for one of four sampled residents (Resident 59) when Resident 59's Restorative Nursing Program (a nursing-driven service in long-term care settings that helps residents maintain or improve their functional abilities to their highest possible level) orders were not followed in accordance with Resident 59's plan of care. These failures had the potential to cause further decline in functional mobility, ROM, and quality of life for Resident 59.

Inspectors wroteBased on interview and record review, the facility failed to notify the Long-Term Care Ombudsman of a resident discharge for one of three sampled discharged residents (Resident 80). This failure had the potential to limit ombudsman involvement and advocacy related to Resident 80's discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely completion and transmission of the Minimum Data Set (MDS - a federally mandated resident assessment tool) assessments in accordance with the Centers of Medicare and Medicaid Services (CMS) federal completion timeframes for two of three sampled residents (Resident 33 and 72) reviewed for Resident Assessments when:1. Resident 33's discharge MDS assessment was not done.2. Resident 72's quarterly MDS assessment was not transmitted after completion. These failures had the potential to result in inadequate monitoring of Residents 33 and 72's progress and decline, and the lack of resident specific information to CMS for payment and quality measure monitoring.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan for oxygen administration for one of 25 sampled residents (Resident 82). This failure had the potential to prevent Resident 82 from receiving individualized respiratory care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were followed when:1. For one of five residents observed during medication administration (Resident 84), nursing staff failed to identify and clarify a physician order for enoxaparin (an anticoagulant [blood thinner]) that specified intramuscular (injected into a muscle) administration, which was inconsistent with manufacturer instructions for subcutaneous (injection into the fatty tissue beneath the skin) administration. This failure had the potential to result in unresolved medication order discrepancies and inaccurate clinical documentation regarding the route of administration, and medication administration inconsistent with the physician order and manufacturer instructions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician's order for oxygen administration and place an oxygen in use sign outside the room, in accordance with the oxygen administration policy for one of 25 sampled residents (Resident 82). This failure had the potential to result in ineffective oxygen therapy, potential respiratory distress, or compromised safety for Resident 82.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 52) was assessed for the appropriate use of grab bars (safety devices anchored to bed to provide stability, maintain balance and prevent falls) based on acceptable standards of practice and per facility policy. This failure placed Resident 52 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaced around the bed) and injury from the use of the affixed grab bars.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled substances (medications with a high potential for abuse and dependence) for one of five randomly selected residents reviewed for controlled substance accountability (Resident 83). The facility's Controlled Drug Record (CDR - inventory records used to document receipt, use, and count of controlled substances did not match the Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). This failure resulted in inaccurate accountability of a controlled substance and had the potential to result in diversion (controlled substances used by someone other than the resident for whom the medication was prescribed) or misuse of controlled substances and compromised resident medication safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove a discontinued medication from active medication storage in one of two medication rooms (Nursing Station A Medication Room). This failure had the potential to result in inadvertent administration of a discontinued medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the lids of two of three dumpsters closed which exposed the trash inside. This failure had the potential to attract pests to the premises which could spread disease to residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policies and procedures (P&P), which were designed to prohibit misappropriation of resident property, for one of three sampled residents (Resident 1) when Certified Nurse Assistant 1 (CNA 1) took Resident 1's credit card out of the facility. This failure resulted in Resident 1 to receive fraudulent charges and violation of resident trust in facility safeguards.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper care was provided to prevent a right heel pressure ulcer (an injury to the skin or underlying tissue that develop from prolonged pressure), for one of three sampled residents (Resident 1). This failure had the potential to place Resident 1, a clinically compromised resident, at risk for further skin breakdown, which could affect his health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to one of three sampled residents (Resident 1) when Resident 1 eloped from the facility without the facility ' s knowledge on March 12, 2025. This failure had the potential to place Resident 1 at increased risk for falls and injuries, heat or cold exposure, dehydration, and/or death.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for two of eleven residents (Residents 40 and 475) reviewed for dining observation when: 1. Licensed Vocational Nurse (LVN 2) was standing over Resident 40 while feeding her lunch on February 18, 2025. 2. Certified Nursing Assistant (CNA 4) pulled Resident 475 while he was on his wheelchair into the dining room, with his feet dragging on the floor, on February 18, 2025. These failures resulted in staff not maintaining and enhancing Residents 40 and 475's individuality and dignity, and had the potential to devalue and dishonor their self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their policy for assistive device and equipment (tool that helps a person with disability perform daily tasks) was being implemented for one of four residents (Resident 8) reviewed for range of motion (ROM - full movement potential of a joint) when Resident 8's hand splint (device applied to prevent or reduce contractures) was not applied as ordered. This failure had the potential to cause further contractures (when muscles, tendons or skin around a joint become permanently tight and shortened) discomfort and loss functional mobility negatively impacting Resident 8's quality of life and increasing the risk for preventable physical deterioration and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 16) reviewed for respiratory received proper respiratory care in accordance with physicians' orders and professional standards of practice. Resident 16's oxygen tubing was found disconnected from the oxygen concentrator (medical device that provides extra oxygen) for approximately 15 minutes on February 18, 2025. This failure had the potential to cause respiratory distress, oxygen deprivation and other health complications due to insufficient oxygen supply, placing Resident 16's health at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (also called narcotics; medications that are controlled by the government because it may be abused or cause addiction) for one of three narcotic medication carts (Unit Station A Cart Number 2). This failure had the potential for a diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 38 residents, who are in Unit Station A.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their policy for self-administration of medications was being implemented for one of four residents (Resident 50) reviewed for environment when Resident 50's self-administered medications were not stored in a safe and secure place. (Three white elongated pills were found in different areas in Resident 50's room.) This failure had the potential to place 72 medically compromised residents at risk for accidental ingestion or exposure to a medication that was not prescribed by the residents' physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the diet ordered by the physician was followed for one of eleven residents (Resident 40) reviewed for dining observation when Resident 40 did not receive her physician ordered finger food diet (small, bite-sized foods that can be easily picked up and eaten with the fingers) for lunch on February 18, 2025. (Alternatively, Resident 40 received the regular diet.) This failure had the potential to result in Resident 40 to experience weight loss manifested by Resident 40 not meeting nutritional needs for 1 of 64 medically compromised residents who receive therapeutic food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when: 1. Resident 10's oxygen nasal cannula tubing (device used to deliver oxygen into the nose via a tube) was found unlabeled and undated. 2. Resident 16's oxygen nasal cannula tubing was found unlabeled and undated. 3. A warm coffee cup was found on top of an intravenous (IV) medication cart (cart used for storage of intravenous medication solutions). These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 72 highly vulnerable residents whose health conditions are already compromised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition when: 1. One of three refrigerators in the kitchen had missing side screws on the front grill leading to a detachment (falling off). 2. Resident Refrigerator had condensation (excessive moisture or water) on the back wall. 3. The electrical panel in the memory care unit (units designed to prevent wandering and specialized care for people with memory loss) was found open and unlocked These failures had the potential to place the health and safety of 72 of 72 medically compromised residents at risk. It had the potential to cause food to not be cooled properly, compromising 64 residents who could receive food from these refrigerators. And it also had the potential to place 34 medically compromised memory care residents at risk for accidental electrical shock.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 28) reviewed for environment was provided with adequate access to their call light system when Resident 28's call light was not accessible. This failure had the potential to place Resident 28's health and safety at risk because it could lead to delayed care and increased risk of harm in an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four rooms (Rooms 119, 122, 124, and 125) measured at least 80 square feet per resident. This failure had the potential for the residents housed in Rooms 119, 122, 124, and 125 to not have the ability to move about freely if the square footage limited their personal space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was administered according to the facility ' s policies and procedures (P&P) for one of three sample resident (Resident 1) when Keppra (medication used to treat and prevent seizures-an abnormal electrical activity in the brain that temporarily affects consciousness, muscle control, and behavior) was not administration to Resident 1. This failure potentially has caused Resident 1, who is clinically compromised, being transferred to Hospital for Seizure evaluation on May 3, 2024.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure a resident Care Plan was fully implemented for one of four sampled residents (Resident 1) when Resident 1was not placed closer to the nursing station as indicated in the plan of care as a specified intervention following a fall. This failure had the potential to put a clinically compromised resident (Resident 1) at risk for serious injury due to falling. Resulting in Resident 1falling and being transferred to a general acute hospital for evaluation and treatment of injuries.

Inspectors wroteBased on interview and record review, the facility failed to allow one of three sampled residents (Resident 1) to return to the facility after a transfer to the hospital for evaluation. This failure resulted in the resident being denied reentry and being transferred to another acute hospital where he remains until new placement is found.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order to monitor the whereabouts for one of six sampled residents (Resident 5). This failure had the potential to result in accident hazards and safety concerns for Resident 5.

Inspectors wroteBased 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 July 23, 2022 (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. The floors under the stove had broken pieces of a plate, food crumbs, and trash. These failures had the potential to expose 74 highly vulnerable residents who received food from the kitchen to food-borne illness (food poisoning).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for one resident (Resident 64) reviewed for urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) which was not covered by a dignity bag (bag that covers the urine collection bag). This failure had the potential to compromise Resident 64's dignity and violate his right to privacy, which could cause psychosocial harm and lead to low self-esteem, feeling irritated, sad, and anxious.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal belongings were inventoried and documented upon admission, in accordance with the facility's policy and procedure, for one resident (Resident 181) reviewed for personal property. This failure had the potential to hinder the facility's ability to investigate any allegations of theft or loss due to a result in a lack of documentation of Resident 181's personal belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prior or upon admission, the staff inquired about any existing advance directive (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) for four of five residents (Residents 19, 59, 73, and 75) reviewed for advance directives. This failure had the potential for Residents 19, 59, 73, and 75 to receive an end of life care which was not in accordance with their wishes, and to recieve life sustaining measures to be rendered against what the residents wanted.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set Assessment (MDS- a computerized assessment instrument) for one resident (Resident 41) reviewed for restraints. This failure had the potential to cause inaccuracy in identifying Resident 41's care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe oxygen administration for two of four residents (Residents 59 and 79) reviewed for respiratory care, when Residents 59 and 79's rooms did not have oxygen in use/no smoking signs posted outside their entrance doors as indicated in the facility's policy and procedure. This failure had the potential to increase the risk of fire in the facility, due to the lack of signage indicating a gas (oxygen) was in use in the rooms of Residents 59 and 79.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe oxygen administration were provided in accordance with the physician's orders and care plans (an individualized plan for the medical care of a resident) for two of four residents (Residents 59 and 53) reviewed for respiratory care when Residents 59 and 53's nasal cannulas (a device which delivers oxygen utilizing a tube) were not replaced after seven days of use. This failure had the potential for unmet care needs for Resident's 59 and 53 due to them not receiving care and services specified in their physician's and care plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff members were provided training on advance directives (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) in accordance with the facility's policies and procedures. This failure had the potential for 76 residents to not be properly assessed for current existing advance directives, or educated on, and assisted with the process of establishing a new advance directive.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for two of three medication carts (Unit A Cart 2 and Unit B Cart 3). These failures had the potential for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 76 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate documentations for three residents (Residents 73, 24, and 26) when: 1. For Resident 73, the code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was documented as full code (attempt full resuscitation measures) in the physical chart, and indicated Do Not Resuscitate (DNR - do not attempt resuscitative measures) in the electronic health record (EHR). This failure had the potential for a delay in treatment due to conflicting documented code status for Resident 73. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their infection control program was implemented for one resident (Resident 64) reviewed for urinary catheter (a bag that collects urine, which connects to a tube that drains the bladder) when Resident 64's urinary catheter bag was found completely resting on the floor. This failure had the potential to jeopardize Resident 64's health and safety due to cross contamination of infectious microorganisms via his urinary catheter bag.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of 47 resident rooms (Rooms 119, 122, 124 and 125) had the required 80 square feet (sq ft- unit of measurement) of space for each resident when: 1. For room [ROOM NUMBER], the room measured 143.92 sq ft = 71.96 sq ft per resident. 2. For room [ROOM NUMBER], the room measured 150.26 sq ft =75.13 sq ft per resident. 3. For room [ROOM NUMBER], the room measured 148.70 sq ft = 74.35 sq ft per resident. 4. For room [ROOM NUMBER], the room measured 150.59 sq ft = 75.29 sq ft per resident. This failure has the potential to limit the freedom of movement for the residents that occupied the rooms, which could place them at risk for injury.