Health inspection·September 26, 2025

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 Page 1 of 2 055650 055650 09/26/2025 Highland Care Center of Redlands 700 E Highland Ave Redlands, CA 92374

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 055650 Page 2 of 2