F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings: During a review of Resident 1's face sheet (contains demographic and medical
information), the face sheet indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses
which included partial intestinal obstruction (partial blockage of the intestines, but food, gas, and fluids can
still get through) and muscle wasting (muscles are shrinking and getting weaker over time).During an
interview on September 17, 2025, at 1:48 PM, with Resident 1, Resident 1 stated she requested CNA 1 to
buy cigarettes from a local store using Resident 1's own personal credit card on two occasions, August 4,
2025, and August 18, 2025. Resident 1 further stated CNA 1 agreed, completed the purchases, and gave
the card back to Resident 1 after the last request on August 18, 2025. During an interview on September
17, 2025, at 2:18 PM, with the Social Services (SS), the SS stated the facility does store funds for
residents, including cash and occasionally credit cards. The SS explained it was against facility policy for
staff to use a resident's credit card or to make purchases on behalf of residents with credit cards or checks.
The SS stated only the Social Services or the Activities staff may procure items for residents, and only with
cash. The SS further stated the staff were not allowed to pull cash out of residents' accounts using credit
cards. During an interview on September 17, 2025, at 2:54 PM, with CNA 1, CNA 1 acknowledged taking
Resident 1's credit card on two occasions to buy cigarettes at a nearby gas station after initially refusing.
CNA 1 stated the action was against facility policy but still she agreed to do so at the time because of
Resident 1's insistence. CNA1 further stated, I don't think I did anything bad. I was helping the resident
[Resident 1].During a concurrent interview on September 17, 2025, at 3:01 PM, with the Director of Nursing
(DON), the DON stated during an Interdisciplinary Team (IDT - multiple disciplines working together)
meeting on September 9, 2025, Resident 1 reported fraudulent charges on her credit card totaling
approximately $833, from August 22, 2025, through August 30, 2025. The DON further stated CNA1 did not
have possession of Resident 1's card on those dates but did not deny CNA1 taking the card to assist
Resident 1 with purchases outside of the facility. The DON stated the Activities and Social Services were
the only ones permitted to make purchases for residents, and CNA1 went against facility policy.During a
concurrent interview and record review on September 17, 2025, at 3:10 PM, with the DON, the facility's
P&P titled, Incidents of Theft and/or Misappropriation of Resident Property, revised April 2021, was
reviewed. It indicated, Policy Statement: All reports of exploitation, theft or misappropriation of resident
property are promptly and thoroughly investigated.1. Residents have the right to be free from exploitation,
theft and/or misappropriation of personal property.2.b.
Residents Affected - Few
(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
09/26/2025
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 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
providing measures to safeguard valuables from easy public access. DON stated the facility has physical
safeguards, such as controlled access, locked safes available for resident valuables; inventory tracking or
personal belongings; signed acknowledgements when residents withdraw cash; and staff education and
enforcement on abuse, neglect, and misappropriation. DON further stated facility staff did not follow policy
for this matter.A review of the job description titled, Certified Nurse Assistant, indicated, .Essential duties
and responsibilities:.Abiding with all facility policies and procedures including not disclosing user ID codes
and passwords.
Event ID:
Facility ID:
055650
If continuation sheet
Page 2 of 2