Highland Care Center of Redlands: Heel Wound Neglect - CA
The injury was documented in a Situation, Background, Assessment and Recommendation communication record dated June 22, 2025. The resident had complained of pain in the right heel. The treatment nurse assessed the area and noted the darkened wound. The necrosis was total. The depth couldn't be determined.
A wound reaching 100 percent necrosis doesn't get there overnight. Tissue dies in stages, and the process that produces a five-centimeter patch of complete destruction takes time, time during which daily skin checks are supposed to catch exactly this kind of progression before it reaches an irreversible point.
The facility had a policy for that. It was called "Prevention of Pressure Injuries," revised as recently as April 2020. Item three was direct: inspect the skin daily when performing or assisting with personal care or activities of daily living. Federal inspectors reviewed that policy. They also reviewed what happened to this resident's heel.
The gap between the two was the violation.
Records from a Physical Therapy Evaluation dated May 28, 2025, showed the resident already had impaired strength in both the right and left lower extremities nearly a month before the June documentation of the wound. Weakness in the lower limbs reduces a person's ability to reposition themselves, which concentrates pressure on bony points like the heel. The resident's Braden score, a tool used to assess pressure injury risk, was 15, placing them at mild to moderate risk.
A Braden score of 15 is not a score that should prompt complacency. It is a score that should prompt exactly the kind of daily monitoring the facility's own written policy required.
What the inspection record does not show is evidence that monitoring caught this wound at an earlier, more treatable stage. What it does show is a resident who had to complain of pain before anyone looked.
By then, the tissue was already dead.
Federal inspectors cited the facility under F0686, which covers the prevention and treatment of pressure injuries. The level of harm was listed as minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework's language, not necessarily the experience of a person whose heel has turned necrotic.
A wound with 100 percent necrosis and an undetermined depth is not a minor finding in the life of the person carrying it. Necrotic tissue cannot heal. It has to be removed before healing can even begin, a process that carries its own risks, particularly for someone already dealing with impaired strength in both legs.
The facility's policy said inspect the skin daily. The resident's risk score said pay attention. The physical therapy records from May said the lower extremities were already compromised. None of it, based on what inspectors found, produced a documented wound assessment before the resident reported pain in late June.
Highland Care Center of Redlands is located in San Bernardino County. The inspection was conducted as a complaint survey, meaning someone, a resident, a family member, or a staff member, raised a concern that prompted regulators to come and look.
The complaint led inspectors to a June 22 nursing note, a May 28 therapy evaluation, and a 2020 policy sitting in a binder somewhere in the building while a resident's heel quietly died.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Care Center of Redlands from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Highland Care Center of Redlands in Redlands, CA was cited for neglect violations during a health inspection on September 25, 2025.
The injury was documented in a Situation, Background, Assessment and Recommendation communication record dated June 22, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.