F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings:
During a review of Resident 1 ' s clinical record, the face sheet (contains demographic and medical
information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included
dementia (brain disorder that causes loss of memory, language, thinking abilities severe enough to interfere
with daily life), hypertension (condition where the force of blood pushing against your artery walls is
consistently too high), and mood affective disorder (mental health condition that affects your emotional
state, causing long periods of extreme happiness or sadness). Further review indicated Resident 1 was in
the Memory Care Unit (a unit specifically for residents who have diagnoses such as dementia or Alzheimer
' s [a brain disorder that slowly destroys memory, thinking skills, and the ability to perform everyday tasks]).
During a review of Resident 1 ' s nursing notes, dated March 13, 2025, at 7:53 PM, it indicated, At 11:45
PM on 3/12/25, resident attempted to leave facility and was seen wandering outside. Resident was brought
in back to the facility. Several minutes later, he was able to get out again. Resident not found in facility
premises, so police were called in. Resident was brought back to facility by police. MD was notified.
Resident's son was notified.
During a concurrent observation and interview with Resident 1, on March 14, 2025, at 3:26 PM, in Resident
5 ' s room, Resident 1 was lying on his bed, resting. He had no visible injuries. Resident 5 stated he does
not recall eloping from the facility March 13, 2025.
During a concurrent observation and interview with the Maintenance Director (MD), on March 14, 2025, at
3:38 PM, in the Memory Care Unit, the MD demonstrated the alarm activation and how to access the door
for the emergency exit door across the hall from Resident 1 ' s room. After the demonstration, the MD reset
the alarm, and stated the alarm is checked daily to ensure proper efficiency, and it needs to be reactivated
per use.
During a telephone interview with Registered Nurse (RN 1), on March 14, 2025, at 4:00 PM, RN 1
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055650
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
03/27/2025
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
stated Resident 1 had two elopement attempts last March 13, 2025, one of which was timely intervened,
and the other one required police intervention to bring Resident 1 back to the facility. RN 1 further stated
staff did not monitor Resident 1 after he was brought back to the facility after the first elopement attempt.
RN 1 stated the alarm was not activated during Resident 1 ' s second attempt, allowing him to successfully
elope.
Residents Affected - Few
During a telephone interview with the Director of Nursing (DON), on March 14, 2025, at 4:15 PM, the DON
stated the alarm was not reset in a timely manner after Resident 1 was brought back to the facility following
the first elopement attempt. The DON further stated that he was unsure if Resident 1 was monitored by
staff following his return to the facility. The DON stated the alarm should have been reset in a timely manner
and there should have been staff to monitor Resident 5.
During a concurrent telephone interview and record review on March 26, 2025, at 11:26 AM, with the
Administrator (Admin), the facility ' s policy and procedure (P&P) titled, Safety and Supervision of
Residents, revised July 2023, was reviewed. The P&P indicated, .Resident supervision is a core component
of the systems approach to safety. The type of frequency of resident supervision is determined by the
individual resident's assessed needs and identified hazards in the environment .Resident supervision may
need to be increased when there are temporary hazards in the environment (such as construction) or if
there is a change in the resident's condition. The Admin stated the facility staff should have followed the
P&P.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055650
If continuation sheet
Page 2 of 2
