Highland Care Center of Redlands

Name: Highland Care Center of Redlands
Address: 700 E Highland Ave, Redlands, CA, 92374, US
Telephone: 9097932678

700 E Highland Ave, Redlands, CA 92374 · San Bernardino County · 80 certified beds · avg 75 residents/day · certified since Dec 31, 1971

Part of chain: CAMBRIDGE HEALTHCARE SERVICES (32 facilities, chain avg rating 2.5★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.40

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (45)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 11, 2026	E · Potential for harm, repeated	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jun 11, 2026	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jun 11, 2026	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jun 11, 2026	E · Potential for harm, repeated	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Jun 11, 2026	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Jun 11, 2026	D · Potential for harm, one-off	The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require.
Jun 11, 2026	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 11, 2026	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jun 11, 2026	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jun 11, 2026	D · Potential for harm, one-off	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Jun 11, 2026	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jun 11, 2026	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jun 11, 2026	D · Potential for harm, one-off	The facility did not dispose of garbage and refuse properly.
Sep 26, 2025	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Sep 25, 2025	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Mar 27, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Feb 21, 2025	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Feb 21, 2025	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Feb 21, 2025	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Feb 21, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Feb 21, 2025	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Feb 21, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Feb 21, 2025	D · Potential for harm, one-off	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Feb 21, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 21, 2025	D · Potential for harm, one-off	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Feb 21, 2025	D · Potential for harm, one-off	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Feb 21, 2025	B · Minimal risk, repeated	The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
Nov 14, 2024	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Aug 22, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Dec 18, 2023	D · Potential for harm, one-off	The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. · from a complaint
Sep 12, 2023	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Aug 12, 2023	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Aug 12, 2023	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Jul 29, 2022	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jul 29, 2022	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jul 29, 2022	D · Potential for harm, one-off	The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings.
Jul 29, 2022	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Jul 29, 2022	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jul 29, 2022	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jul 29, 2022	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jul 29, 2022	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Jul 29, 2022	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jul 29, 2022	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jul 29, 2022	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 29, 2022	B · Minimal risk, repeated	The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (11 → 13).

Year	Citations	Worst severity that year
2022	12	F
2023	4	D
2024	2	D
2025	14	F
2026	13	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.40	4.31	3.95	top 33% in California; top 26% in the U.S.
Registered Nurse hours	0.41	0.61	0.69	bottom 36% in California; bottom 24% in the U.S.
Weekend total nurse staffing	3.81	3.90	3.50	top 45% in California; top 29% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.27	0.51	0.48	bottom 26% in California; bottom 26% in the U.S.
Total nursing staff turnover (%)	48.5	36.7	45.8	bottom 17% in California; bottom 41% in the U.S.
RN turnover (%)	40.0	38.1	42.9	bottom 47% in California; top 46% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.30, RN 0.40, weekend 3.72. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 5/5 · short-stay residents: 2/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Ag Facilities Operations, LLC	Organization	5% or Greater Direct Ownership Interest	100%	08/11/2003
Ira E Smedra Living Trust	Organization	5% or Greater Indirect Ownership Interest	48%	08/11/2003
Win Win Enterprises, LLC	Organization	5% or Greater Indirect Ownership Interest	48%	08/11/2003
Butenko, Julie	Individual	Operational/Managerial Control	NOT APPLICABLE	07/24/2023
Butenko, Julie	Individual	ADP of the SNF	NOT APPLICABLE	07/24/2023
Cambridge Healthcare Services LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	10/01/2013
Cambridge Healthcare Services LLC	Organization	ADP of the SNF	NOT APPLICABLE	07/12/2025
Capela, Heidi	Individual	Operational/Managerial Control	NOT APPLICABLE	04/03/2023
Capela, Heidi	Individual	ADP of the SNF	NOT APPLICABLE	04/03/2023
Chimwaza, Pearson	Individual	Operational/Managerial Control	NOT APPLICABLE	02/12/2025
Consolidated Industries, INC.	Organization	Operational/Managerial Control	NOT APPLICABLE	07/01/2018
Consolidated Industries, INC.	Organization	ADP of the SNF	NOT APPLICABLE	07/01/2018
Hassell, Lance	Individual	Operational/Managerial Control	NOT APPLICABLE	04/25/2022
Hassell, Lance	Individual	ADP of the SNF	NOT APPLICABLE	04/25/2022
Latterell, Kyle	Individual	Managing Control - Governing Body	NOT APPLICABLE	08/13/2025
Latterell, Kyle	Individual	Operational/Managerial Control	NOT APPLICABLE	08/13/2025
Latterell, Kyle	Individual	ADP of the SNF	NOT APPLICABLE	08/21/2025
Lutz, Linda	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2012
Lutz, Linda	Individual	ADP of the SNF	NOT APPLICABLE	02/01/2012
Pai, Shantharam	Individual	Operational/Managerial Control	NOT APPLICABLE	09/09/2013

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you explain health changes and treatment options to residents and their families?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"How do you make sure resident assessments are completed and submitted to the state on time?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Plymouth Village	0.6 mi	Redlands, CA	★★★★☆	4/5
Madison Grove Post Acute	2.3 mi	Redlands, CA	★★★☆☆	3/5
Redlands Healthcare Center	2.4 mi	Redlands, CA	★★★★☆	4/5
Redlands Comm Hosp D/P SNF	2.4 mi	Redlands, CA	★★★★☆	5/5
Brookside Healthcare Center	2.9 mi	Redlands, CA	★★★☆☆	3/5
University Post Acute	3.2 mi	Mentone, CA	★★★★★	5/5
Asistencia Villa Healthcare Center	4.0 mi	Redlands, CA	★★☆☆☆	3/5
Totally Kids Rehabilitation Hospital - D/P SNF	4.9 mi	Loma Linda, CA	★★★★★	4/5
Heritage Gardens Health Care Center	5.2 mi	Loma Linda, CA	★★★★☆	3/5
Loma Linda Post Acute	5.2 mi	Loma Linda, CA	★★★★☆	4/5

Compare this facility with the 3 closest →

All facilities in Redlands →

Facility data as of CMS processing date 2026-08-01. CCN 055650.

The Care File

Visit checklist — Highland Care Center of Redlands

700 E Highland Ave, Redlands, CA 92374 · 9097932678

Health inspection rating 3/5 · CMS overall 3/5· Fines (3y): $0

Questions for the administrator:

☐ "How do you explain health changes and treatment options to residents and their families?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "How do you make sure resident assessments are completed and submitted to the state on time?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 055650 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)