Redlands Healthcare Center

Based on observation, interview, and record review, the facility failed to follow the menu for 70 of 71 residents when residents were served one (1) ounce of strawberry topping instead of two (2) ounces for Regular and Small portions and four (4) ounces for Large portions as indicated on the menu, during breakfast on April 22, 2026.This failure had the potential to result in lower caloric content of meals served and contribute to a decline in nutritional status and undesirable weight loss when recipes are not followed for 70 medically compromised residents.During tray line (when cook serves food on plates for each resident according to the menu) observation on April 22, 2026, at 07:03 AM, in the kitchen, the cook served strawberry topping using a 1-ounce purple-handle scoop to all 70 Residents, instead of #16 scoop and #8 scoop as indicated on the facility approved menu.During a review of the facility document titled, Spring Cycle Menu, dated April 22, 2026, the Spring Cycle Menu indicated, strawberry topping #16 scoop (1/4 cup = 2 ounces) for all diets Regular and Small portions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices when:1) A Certified Nursing Assistant (CNA3) did not performing hand hygiene when providing care between Resident 93 and Resident 89.2) Treatment Nurse 1 (TN 1) did not wear a gown while applying a wound dressing to a skin tear (a wound where the top layer of skin gets torn away from the layer right beneath it.) on Resident 47's hand while Resident 47 was on enhanced barrier precautions (EBP - a set of infection control practices focused on using personal protective equipment (PPE) like gowns and gloves during specific high-contact resident care activities for residents at increased risk of acquiring infection).These failures resulted in increased risk for the cross contamination (the spread of microorganisms from one surface to another) of infectious microorganisms within the environment and amongst a vulnerable population of 70 residents who lived in the facility.1) During a review of Resident 93's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one of six sampled Residents (Resident 7) was provided care in a manner that maintained dignity during meal assistance when Certified Nursing Assistant (CNA 1) was standing while assisting Resident 7 to eat. This failure had the potential to negatively impact Resident 7's dignity and psychosocial well-being by failing to provide a respectful, person-centered approach to Resident 7 dining experience.A review of Resident 7's admission Record, (contains demographic and medical information), indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and schizophrenia (a mental illness that can affect thoughts, mood, and behavior).During an observation on April 20, 2026, at 1:04 PM, in Resident 7's Room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure controlled substances (medications that are controlled by the government because it may be abused or cause addiction) were accurately accounted for and documented for one of one sampled residents (Resident 30), when Resident 30's Controlled Drug Receipt/Record/Disposition Form (CDR - document used to record the administration or destruction of a controlled drug for tracking purposes) for Oxycodone's ( a pain medication) 5 mg (milligram- unit of measurement) count was found inaccurate.This failure had the potential to result in inaccurate count of narcotic drugs and drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 70 residents.During a review of Resident 30's clinical records, the admission Record, indicated Resident 30 was admitted on [DATE], with diagnoses which included, fracture of right tibia ( a crack in the large bone on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the kitchen stove was maintained in a clean and sanitary condition, when the six (6)-burner stove had accumulation of dirt and food residue.This failure had the potential to lead to the growth of harmful microorganisms, including bacteria, viruses, and fungi, and cause food-borne illness to 70 residents served by the kitchen.During an observation on April 20, 2026, at 8:35 AM, in the kitchen, the 6 burner commercial stove had substantial accumulations of burnt grease and food debris on both the burner grate and surrounding surfaces.During a concurrent interview and record review with the Dietary Supervisor (DS) on April 20, 2026, at 8:37 AM, the kitchen document titled, Cleaning log, undated, was reviewed. The log indicated, Convention Ovens Deep Clean. When: Fridays. Description: Wash/Clean/Sanitize. The log was left blank for Sunday to Saturday. The DS stated the stove is typically cleaned at the end of each day. The DS further stated that the stove, flat top griddles, and surrounding surfaces were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a device that allows patients to communicate with nursing staff when they need assistance) was within resident's reach for two of three sampled residents (Resident 55 and 7) when,Resident 55's call light was on the floor between bed 1 and bed 2, unreachable by the resident.Resident 7's call light was observed on the floor next to the resident's bed and out of resident's reach.These failures had the potential to result in Resident 55 and 7's needs not being addressed, placing both residents at risk for injury.1.During a review of Resident 55's clinical record, the admission Record (list of diagnoses and demographic information), the admission Record indicated, Resident 55 was admitted to the facility on [DATE], with diagnoses which included history of falling, acquired absence of right hand, dementia (a decline in brain function that is severe enough to interfere with daily life, characterized by memory loss,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to maintain infection control practices for one of thirty-nine residents (Resident 60), when Resident 60's oxygen tubing (a thin, flexible tube that delivers oxygen to a patient during oxygen therapy) it had not been changed every seven (7) days, as per facility policy. This failure placed Resident 60 at risk for developing a respiratory infection (caused by bacteria, viruses, fungi, or parasite). Findings: During a review of Resident 60's admission Record (clinical record with demographic information), the admission Record indicated, Resident 60 was admitted on [DATE], with the diagnoses of acute respiratory failure (a serious condition that makes it difficult to breathe on your own), pleural effusion (a collection of fluid around your lungs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a concurrent observation and interview on February 3, 2025, at 11:02 AM, with Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, call light (a device that allows patients to communicate with nursing staff when they need assistance) was within reach for one of six sampled residents (Resident 51) who has hemiplegia (partial paralysis on left side of her body with left hand contracture). This failure had the potential to place Resident 51 at risk of harm, as Resident 51 experiencing an emergency or needing assistance would not be able to call for help. Findings: During a review of Resident 51's clinical record, the admission Record (a document that gives a summary of resident information), the admission Record indicated, Resident 51 was admitted to the facility on [DATE], with diagnoses which included, hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side (partial paralysis on left side of the body), spondylosis, lumbar region (an age-related degeneration of the vertebrae and disks of the lower back). During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure and follow its policy and procedure in one of three sampled resident (Resident 1 ) , when they failed to administer oral medications in a safe and timely manner, and as prescribed. This failure had the potential to place clinically compromised Residents (Resident 1) health and safety at risk. When Resident 1 was given a wrong medication. Findings: During a record review of Resident 1 admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses to include malignant neoplasm of thyroid gland (Cancer of the thyroid), muscle wasting and atrophy (thinning or loss of muscle tissue), depression(lowering of a person's mood), anxiety disorder (feelings of worry that interferes with one's daily activities, acute embolism and thrombosis (form of a blood clot that travels to the lungs). During an interview with Licensed Vocational Nurse 1 (LVN 1) on April 3, 2024, at 12:10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Crumbs were found on the bottom shelf of second reach-in freezer. This had the potential for microorganism growth to be inadvertently transferred to food. 2. Black greasy grime on the floor in the space between the stove and stainless steel counter. This had the potential for microorganism growth and to attract pests. 3. Four Bulk bin container, that were storing flour, sugar, thickener and oats, the lids were broken and were held together with masking tape. This had the potential to attract pests. Findings: 1. During a concurrent observation and interview on January 29, 2024, at 9:03 AM, in kitchen, with the Dietary Services Supervisor (DSS), crumbs were noted on the bottom shelf of second reach- in freezer, DSS stated, crumbs might be from the boxes in the freezer, but it should be kept clean. During an interview on February 1, 2024, at 8:38 AM, in the dining room, with the Registered Dietician (RD), RD stated, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the gluten free menu and meet nutritional needs for 3 residents ( Resident 11, 71, 45). This failure had the potential to affect the nutritional status of these already medically compromised residents. Findings: During an observation on January 29, 2024, at 11:50 AM, in the kitchen, the [NAME] was serving residents lunch and for Resident 11 and 71 the [NAME] served two bowls of 3 bean chili and did not serve the corn bread. During an interview on February 1, 2024, at 8:33 AM, with Cook, [NAME] stated, I did not make an alternative for gluten free diet on Monday, so I served an additional serving of the 3 bean chili for the residents on a regular gluten free diet and mashed potato with gravy for puree gluten free diet. During an interview on February 1, 2024, at 8:38 AM, in the dining room, with the Registered dietician (RD), RD stated, the expectation is to make a substitute for gluten free diet according to the recipe. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to safeguard the money of one of two sampled residents (Resident 20) investigated for personal property when upon admission to the facility, on September 30, 2023, Resident 20 gave the facility $2,200 dollars for safe keeping but the money eventually went unaccounted for and the facility had no documented evidence of its whereabouts after the money was received from Resident 20. This failure resulted in emotional distress and excessive worry on behalf of Resident 20 who was concerned about the possible loss or theft of his money which he had entrusted the facility to safeguard. Findings: A review of Resident 20's admission Record (contains medical and demographic information), indicated Resident 20 was initially admitted to the facility on [DATE], with diagnoses which included muscle weakness, acute respiratory failure, end stage renal disease (kidney failure), and muscle wasting and atrophy (the wasting [thinning] or loss of muscle tissue). During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 12) reviewed for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys no longer function) was provided assessment and monitoring of Resident 12's left arm dialysis shunt (a surgical connection between a vein and an artery used to connect the patient to the dialysis machine) when: 1. The facility did not assess Resident 12's shunt for warmth, color, and edema (swelling), in the frequency specified by the physician's orders. 2. The facility did not have documented evidence that a pre and post (before and after) dialysis assessment was done for the resident on November 1, 2023, and January 22, 2024, as specified by the facility's policy and procedure. These failures had the potential for a delay in the staff identification and subsequent treatment of possible dialysis associated complications such as infection, clotting, and excessive bleeding from the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accurate medication storage and administration procedures were followed when: 1. Five (5) medication tablets were left unattended on Resident 62's bedside table. This failure had the potential for medications to be diverted and used inappropriately that may cause harm for Resident 62. 2. A Licensed Vocational Nurse (LVN 1) documented five (5) medications in the Medication Administration Record (MAR - a report detailing the medications administered to a resident) as given and were not administered to Resident 62. This failure had potential for erroneous or inconsistent medical care and medication administration that may cause harm and sub- therapeutic effect for Resident 62. Findings: 1. During an observation and interview on January 29, 2024, at 11:47 AM, Resident 62 was observed lying on bed. Resident 62 stated she was in the facility due to stroke. Five (5) different medication tablets (pills), [two (2) pink and three (3) white…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.