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Inspection visit

Inspection

Highland Care Center of RedlandsCMS #0556501 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0607GeneralS&S Dpotential for harm

    F607 - The facility must develop and implement written policies and procedures that:

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

FAQ · About this visit

Common questions about this visit

What happened during the September 26, 2025 survey of Highland Care Center of Redlands?

This was a inspection survey of Highland Care Center of Redlands on September 26, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Highland Care Center of Redlands on September 26, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.