The resident at the center of the findings, identified in inspection records as R2, had been re-admitted from the hospital.
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At The Palms Nursing & Rehabilitation on Everhart Road, federal inspectors conducting a complaint investigation found that the facility had failed that test.
The facility ignored that for two months.
The inspection, conducted on September 25, 2025, produced a deficiency citation under the category of Quality of Life and Care.
That finding sits at the center of a federal complaint inspection completed at Highland Care Center of Redlands in September 2025.
The deficiency, recorded on September 25, 2025, fell under the category of Quality of Life and Care.
Inspectors also found the facility had not made prompt efforts to resolve those grievances.
What it did not do was ask the other residents whether they had been hurt too.
The pharmacy sent recommendations, including guidance on whether to discontinue the medication or keep the orders the same.
Federal health inspectors visited the facility on September 26, 2025, responding to a complaint.
The requirement exists for a reason.
The violation, recorded on September 25, 2025, fell under the category of resident assessment and care planning deficiencies.