Inspection·August 22, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on August 19,2024, at 3:40 PM, It was noted that room where the resident was staying during the last fall incident, This private room is designed to a single resident room and is notably one of the farthest rooms from the nursing station. A post fall care plan reviewed dated July 10, 2024, indicated that the interventions include frequent visual monitoring and moving resident closer to the nursing station. During a telephone interview with the facility administrator (ADM 1) on August 20, 2024, at 2:16 PM, ADM 1 has acknowledged that Resident 1 was staying in a room at that time of the fall incident, and this room was one of the farthest from the nursing station. This situation contradicts one of the interventions outlined in the post-fall care plan dated July 10, 2024, which was to move Resident 1 closer to the nursing station after a fall incident on July 10, 2024. Upon review of the interdisciplinary team meeting summary conducted by the facility on July 10, 2024, at 11:50 AM following a fall incident on the same day at 11:35 AM, it was indicated that there was a high risk for falls and risk for fractures. One of the interventions mentioned was to move Resident 1 ' s room closer to the nursing station. During an interview with the ADM 1 on August 21, 2024, at 3:48 PM, I informed ADM 1 that the interdisciplinary meeting conducted on July 10, 2024, following a fall incident, indicated that one of the mentioned interventions was to move Resident 1 closer to the nursing station. Additionally, the care plan following a fall incident on July 10, 2024, included two interventions: frequent visual monitoring and moving the resident closer to the nursing station. ADM 1 acknowledged that during the fall incident on July 18, 2024, Resident 1 was in room [ROOM NUMBER], which happened to be one of the farthest rooms from the nursing station. During an interview with the director of rehabilitation (Director 1) on August 21, 2024, at 3:38 PM, Director 1 stated that Resident 1 required standby assistance during ambulation during the initial assessment upon admission. Furthermore, it was noted that on July 18, 2024, prior to the second fall incident at the facility, Resident 1 continued to require assistance during ambulation based on rehabilitation department ' s recommendation. During an interview with the Certified Nursing Assistant (CNA 1) on August 21, 2024, at 3:38 PM, CNA 1 admitted to helping Resident 1 to go to the bathroom. However, CNA 1 mentioned that he went to see another resident who needed help while Resident 1 was in the bathroom. Additionally, he revealed that a resident in an adjacent room called the front desk for help because Resident 1 had fallen in the bathroom. During a interview with resident 2 on August 22, 2024, at 9:59 AM, Resident 2 stated that her room is near Resident 1 ' s room during the fall incident on July18, 2024. Resident 2 reported that a staff member initially helped Resident 1 to the bathroom and then assisted her in using the bedpan around 3:50 PM. However, after 10 to 15 minutes, the staff did not return despite her repeated calls for help using the call light and shouting for staff to come, during which time Resident 1 was still in the bathroom. Resident 2 mentioned that she had been sitting on the bedpan for over half an hour when she heard a loud noise, described as a big bang. When she asked Resident 1 if she was okay, she stated she was not, and was unable to use the emergency call light when she instructed her. Despite Resident 2 ' s attempt to call for help, by using her call light and shouting for assistance no staff responded to help, during that time Resident 2 was continuously in communication with Resident 1 while she was in the bathroom, Resident 1 eventually became quiet. At 4:41 PM, Resident 2 contacted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055650 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Care Center of Redlands 700 E Highland Ave Redlands, CA 92374 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the nursing station using her cell phone, explaining that Resident 1 had fallen in the bathroom and needed assistance. The staff promptly responded and immediately contacted 911, and the paramedics arrived at 5:05 PM. During an interview with the nurse supervisor in charge (Supervisor 1) on August 19, 2024, at 3:50 PM regarding the alleged fall incident on July 18, 2024, Supervisor 1 stated that the charge nurse reported to her that Resident 1 had fallen in the bathroom, and when she went and checked, Resident 1 was found lying on the floor in the bathroom on her left side. She was told that one of the CNAs had placed Resident 1 on the toilet and the resident had tried to get up. During a review of Resident 2 ' s records, the progress notes dated July 18, 2024, at 5:45 PM, of supervisor 1, it was noted that the charge nurse reported to Supervisor 1 that Resident 1 had fallen, upon entry to the room, Resident 1 was in the bathroom laying left lateral with feet positioned towards toilet/sink and head at doorway entry to the bathroom on roommates ' side, resident had pants and brief at knees with noted bleeding in the forehead. Also noted was a left laceration in the left forehead and left eye with significant swelling. Paramedics arrived at 5:00 PM and Resident 1 was transferred to the emergency room (ER) for further evaluation. During a review of the undated facility ' s policy and procedure (P&P) titled, Fall Risk Assessment, the P&P indicated The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. During a telephone interview with Director of Nursing (DON 1) on August 27, 2024, at 2:53 PM, DON 1 acknowledged that the facility ' s fall risk assessment policy was not followed when Resident 1 had a fall incident on July 18, 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055650 If continuation sheet Page 3 of 3