Redlands Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for 70 of 71 residents when residents were served one (1) ounce of strawberry topping instead of two (2) ounces for Regular and Small portions and four (4) ounces for Large portions as indicated on the menu, during breakfast on April 22, 2026. This failure had the potential to result in lower caloric content of meals served and contribute to a decline in nutritional status and undesirable weight loss when recipes are not followed for 70 medically compromised residents. During tray line (when cook serves food on plates for each resident according to the menu) observation on April 22, 2026, at 07:03 AM, in the kitchen, the cook served strawberry topping using a 1-ounce purple-handle scoop to all 70 Residents, instead of #16 scoop and #8 scoop as indicated on the facility approved menu. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when:1) A Certified Nursing Assistant (CNA3) did not performing hand hygiene when providing care between Resident 93 and Resident 89.2) Treatment Nurse 1 (TN 1) did not wear a gown while applying a wound dressing to a skin tear (a wound where the top layer of skin gets torn away from the layer right beneath it.) on Resident 47's hand while Resident 47 was on enhanced barrier precautions (EBP - a set of infection control practices focused on using personal protective equipment (PPE) like gowns and gloves during specific high-contact resident care activities for residents at increased risk of acquiring infection). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of six sampled Residents (Resident 7) was provided care in a manner that maintained dignity during meal assistance when Certified Nursing Assistant (CNA 1) was standing while assisting Resident 7 to eat. This failure had the potential to negatively impact Resident 7's dignity and psychosocial well-being by failing to provide a respectful, person-centered approach to Resident 7 dining experience. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled substances (medications that are controlled by the government because it may be abused or cause addiction) were accurately accounted for and documented for one of one sampled residents (Resident 30), when Resident 30's Controlled Drug Receipt/Record/Disposition Form (CDR - document used to record the administration or destruction of a controlled drug for tracking purposes) for Oxycodone's ( a pain medication) 5 mg (milligram- unit of measurement) count was found inaccurate. This failure had the potential to result in inaccurate count of narcotic drugs and drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 70 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen stove was maintained in a clean and sanitary condition, when the six (6)-burner stove had accumulation of dirt and food residue. This failure had the potential to lead to the growth of harmful microorganisms, including bacteria, viruses, and fungi, and cause food-borne illness to 70 residents served by the kitchen. During an observation on April 20, 2026, at 8:35 AM, in the kitchen, the 6 burner commercial stove had substantial accumulations of burnt grease and food debris on both the burner grate and surrounding surfaces. During a concurrent interview and record review with the Dietary Supervisor (DS) on April 20, 2026, at 8:37 AM, the kitchen document titled, Cleaning log, undated, was reviewed. The log indicated, Convention Ovens Deep Clean. When: Fridays. Description: Wash/Clean/Sanitize. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device that allows patients to communicate with nursing staff when they need assistance) was within resident's reach for two of three sampled residents (Resident 55 and 7) when,Resident 55's call light was on the floor between bed 1 and bed 2, unreachable by the resident. Resident 7's call light was observed on the floor next to the resident's bed and out of resident's reach. These failures had the potential to result in Resident 55 and 7's needs not being addressed, placing both residents at risk for injury.1. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain infection control practices for one of thirty-nine residents (Resident 60), when Resident 60's oxygen tubing (a thin, flexible tube that delivers oxygen to a patient during oxygen therapy) it had not been changed every seven (7) days, as per facility policy. This failure placed Resident 60 at risk for developing a respiratory infection (caused by bacteria, viruses, fungi, or parasite).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, call light (a device that allows patients to communicate with nursing staff when they need assistance) was within reach for one of six sampled residents (Resident 51) who has hemiplegia (partial paralysis on left side of her body with left hand contracture). This failure had the potential to place Resident 51 at risk of harm, as Resident 51 experiencing an emergency or needing assistance would not be able to call for help.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure and follow its policy and procedure in one of three sampled resident (Resident 1 ) , when they failed to administer oral medications in a safe and timely manner, and as prescribed. This failure had the potential to place clinically compromised Residents (Resident 1) health and safety at risk. When Resident 1 was given a wrong medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Crumbs were found on the bottom shelf of second reach-in freezer. This had the potential for microorganism growth to be inadvertently transferred to food. 2. Black greasy grime on the floor in the space between the stove and stainless steel counter. This had the potential for microorganism growth and to attract pests. 3. Four Bulk bin container, that were storing flour, sugar, thickener and oats, the lids were broken and were held together with masking tape. This had the potential to attract pests.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the gluten free menu and meet nutritional needs for 3 residents ( Resident 11, 71, 45). This failure had the potential to affect the nutritional status of these already medically compromised residents.

Inspectors wroteBased on interview, and record review, the facility failed to safeguard the money of one of two sampled residents (Resident 20) investigated for personal property when upon admission to the facility, on September 30, 2023, Resident 20 gave the facility $2,200 dollars for safe keeping but the money eventually went unaccounted for and the facility had no documented evidence of its whereabouts after the money was received from Resident 20. This failure resulted in emotional distress and excessive worry on behalf of Resident 20 who was concerned about the possible loss or theft of his money which he had entrusted the facility to safeguard.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 12) reviewed for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys no longer function) was provided assessment and monitoring of Resident 12's left arm dialysis shunt (a surgical connection between a vein and an artery used to connect the patient to the dialysis machine) when: 1. The facility did not assess Resident 12's shunt for warmth, color, and edema (swelling), in the frequency specified by the physician's orders. 2. The facility did not have documented evidence that a pre and post (before and after) dialysis assessment was done for the resident on November 1, 2023, and January 22, 2024, as specified by the facility's policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate medication storage and administration procedures were followed when: 1. Five (5) medication tablets were left unattended on Resident 62's bedside table. This failure had the potential for medications to be diverted and used inappropriately that may cause harm for Resident 62. 2. A Licensed Vocational Nurse (LVN 1) documented five (5) medications in the Medication Administration Record (MAR - a report detailing the medications administered to a resident) as given and were not administered to Resident 62. This failure had potential for erroneous or inconsistent medical care and medication administration that may cause harm and sub- therapeutic effect for Resident 62.