Redwood Healthcare Center LLC

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one of five sampled residents (Resident 1) received scheduled pain medications as prescribed by the physician when Resident 1 did not receive Hydromorphone (brand name Dilaudid, a strong pain medication) and Lidocaine Patch (a topical patch used to relieve localized pain) as ordered for multiple days, from 3/20/26 to 3/29/26. This failure to administer the prescribed pain medications resulted to Resident 1 experienced uncontrolled pain and was sent back to the hospital on 3/29/26 for pain evaluation and management. During a review of Resident 1's admission Record (AR), printed on 6/15/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of spinal cord (a long, tubular bundle of nervous tissue that runs from the brainstem down to the lower back) injury. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of five sampled residents (Resident 1), was provided physician-ordered physical therapy (PT) five times per week. Multiple PT sessions were not provided to Resident 1 during the first three weeks of admission from 3/20/26 through 4/9/26. This failure to provide PT sessions to Resident 1 had a potential risk for delayed recovery following a spinal cord surgery. During a review of Resident 1's facility document admission Record (AR) printed on 6/15/26, AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of spinal cord (a long, tubular bundle of nervous tissue that runs from the brainstem down to the lower back) injury. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide adequate supervision to reduce the risk of elopement (leaving the facility unauthorized, without notifying staff), for three out of three sampled residents, when their wander guards (electronic monitoring devices, usually worn as a bracelet or anklet) were not being consistently monitored for functioning (performance of the system).1. For Resident 1, there was no documented evidence that the wander guard was monitored for functioning, every shift, from 12/15/25 until 4/17/26 (approximately four months).2. For Resident 2, there was no documented evidence that the wander guard was monitored for functioning, every shift, from 3/13/26 until 3/17/26 (13 days).3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool used to direct care) for one of three sampled residents (Resident 2) was completed and coded accurately for wander guard [an electronic monitoring device, usually worn as a bracelet or anklet]. This failure placed Resident 2 at risk of not receiving the care and services appropriate to his needs, due to an inaccurate reflection of Resident 2's clinical status on the MDS assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall risk care plan interventions were implemented for two out of two sampled residents (Residents 1 and 2) who were at risk for falls, when their call lights were not within reach. This deficient practice had the potential to result in falls, injury, and harm to the residents.1. A review of Resident 1's admission record, undated, indicated Resident 1 had diagnoses that included compression fracture of the vertebra (a break in a vertebra - a bone in the spine, which may be caused by a fall or accident), and repeated falls. During an observation on 3/16/26 at 11:55 a.m. in Resident 1' room, Resident 1 was observed from the hallway. Resident 1 stood up from her bed, grabbed her walker, held onto it, and went to the bathroom unassisted. Resident 1 appeared unsteady on her feet. [...]

Inspectors wroteBased on interview and record review, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietician and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of qualified, full-time person to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food borne illness for 43 residents eating facility prepared foods.

Inspectors wroteBased on observation, interview, and record review, the facility failed to trim and clean fingernails for three out of four sampled residents when Residents 30, 32, and 33 had long fingernails with dirty substances underneath them. This failure had the potential to result in Resident 30, Resident 32, and Resident 33's poor personal hygiene and risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage of drugs and biologicals when: 1. Outdated or expired medications were stored in the medication room 2. A discontinued medication, including food items were stored in the medication cart These failed practices could contribute to unsafe medication use and storage in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 27 of 43 residents in resident Rooms A, B, C, D, E, F, G, H, and I with at least 80 square (sq) feet (ft) of living space per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, and lack of sufficient space for residents to have personal belongings at the bedside.

Inspectors wroteBased on observation, interview and record review the facility failed to meet food safety requirements for food storage and kitchen sanitation when multiple surfaces had dust, food particles and/or granular particles, two cans were dented, two items were missing use by dates, and one bag potatoes contained potatoes with roots. These failures has the potential to compromise the safety of the food served through cross contamination and cause illness or hospitalization to residents who consume it.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction), and availability of routine and emergency drugs when: 1. Two out of 2 medication cart controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were missing signatures of the outgoing and incoming nursing shift; 2. There was no record of controlled drug destruction available upon request; 3. One out of 5 emergency kits (e-kit, a kit containing medications and supplies for immediate use during a medical emergency) was not replaced in a timely manner in accordance with the facility policy and procedures (P&P); 4. Two out of 5 e-kits expired; and 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 6.9% error rate when two medication errors out of 29 opportunities were observed during a medication pass for two of seven Residents (Residents 1 and 30). These failures resulted in medications not given in accordance with the prescriber's orders and may affect the resident's clinical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage of medications when: 1. Medications and biologicals requiring refrigeration were not stored within manufacturer's specifications; and 2. Medication storage room and medication refrigerator temperatures were not monitored routinely per facility policy and procedure (P&P) The deficient practices had a potential for improperly stored and inadequately monitored medications, which could lead to unsafe and ineffective medication use for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bowel movements (BMs) were documented for three of 12 sampled residents (Residents 9, 20 and 28), on 8/1/22 through 8/5/22. This failure had the potential to result ineffective bowel management for Residents 9, 20 and 28.

Inspectors wroteBased on interview and record review, the facility failed to ensure competency skills checks for one of three licensed nursing staff and one of two certified nurse assistants were completed. This failure had the potential for care to be provided by licensed nurses and certified nurse assistant in an unsafe and incompetent manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. The facility had nine resident rooms (room A, B, C, D, E, F, G, H, I) with a total of 27 licensed beds that were occupied by 25 residents, that provided less than 80 square feet (sq. ft.) per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, and lack of sufficient space for residents to have personal belongings at the bedside.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve therapeutic diets (diet ordered by a physician for treatment of a disease or clinical condition) as ordered for the Controlled Carbohydrate Diet (CCHO), low sodium, fortified and pureed diets for approximately 25 residents. This failure resulted in under and overserved portions of food and meals not served according to the planned menu. This also had the potential for compromised medical and nutritional status for residents. During an observation of the tray line on 2/10/20 at 11:45 a.m., and review of the winter menu for Monday Week 2, showed the following: 1. The menu indicated for 4 ounce (oz) servings. [NAME] 1 weighed 1 cooked beef patty at 3 oz for the CCHO regular diet. [NAME] 1 served 3 oz of the meat patty for the CCHO regular diets. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not notify the physician for changes in condition for four(Residents 24, 28, 194 and 297) of nine sampled residents. Resident 297 had incomplete vital sign (temperature, pulse, respiratory rate, blood pressure) records, and was subsequently sent to the hospital's emergency department (ED). The doctors were not notified when Resident 28 stopped eating, and of Residents 24 and 194's elevated blood pressure (BP). These failures resulted in the staff's failure to identify and monitor for changes in condition which had resulted in, or had the potential, for a decline in the resident's health. Findings 1. A record review of the document, Face Sheet showed Resident 24 had diagnoses that included cerebrovascular disease (condition that affects blood supply to the brain- also known as a stroke). [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide education to families regarding food brought in from home for the residents. The facility also failed to have a system for staff to ensure food from home was re-heated to a safe temperature. This had the potential to result in burn injuries from hot food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff performed hand hygiene after contaminating their hands while passing meal trays. This failure resulted in a certified nursing assistant passing meal trays to residents after contaminating her hands by touching her nose and lips.

Inspectors wroteBased on observation, interview and record review, the facility did not treat one (Resident 2) of nine sampled residents in a dignified manner. Resident 2 asked to have his brief (diaper) changed and staff denied his request. This failure resulted in Resident 2 experiencing unnecessary distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide personal hygiene care in a timely manner for one (Resident 2) of nine sampled residents. Resident 2 gestured to have his brief (diaper) changed and staff did not immediately respond. This failure resulted in Resident 2 experiencing discomfort and had the potential for skin breakdown.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure competencies and skills for one of three sampled licensed nursing staff. This failure resulted in the licensed nurse not receiving the required skills competency check to ensure safe care of residents. [Refer to F 726 and F 759]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a medication error rate of 5% or less. The medication error rate was 7.69%. Resident 17 was administered the incorrect amount of pain medication. This failure resulted in the potential for ineffective pain relief.

Inspectors wroteBased on observation, interview and record review, licensed nursing staff did not store medication in a secured manner. A lidocaine patch (pain reliever] was left unattended on top of the medication cart. This failure had the potential for unauthorized access and use of medication by other persons which could result in harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure competencies and skills for kitchen staff. This failure resulted in the potential for food borne illness, inaccurate temperature testing of cooked foods, and physician ordered therapeutic diets not being made correctly by kitchen staff.

Inspectors wroteBased on observation and record reviews, the facility failed to ensure food for residents was prepared under sanitary conditions. This failure had the potential to cause food borne illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure that one of two dumpsters were closed shut. This failure resulted in unsanitary conditions and attracted flying pests. During an observation on 2/10/20 at 10:15 a.m., one of two dumpsters was left open and overfilled with garbage that had insects flying above it. During an interview on 2/11/20 at 9 a.m. with Maintenance Director, he stated that the garbage is picked up on Monday, Wednesdays and Fridays. No trash was picked up on Monday. Review of the facility's policy titled, Food-Related Garbage and Rubbish Disposal indicated, all garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored. Outside dumpsters .will be kept closed and free of surrounding litter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of eight sampled residents (Resident 20), that the call light was in working order. This failure resulted in Resident 20 being unable to turn the call light on to request help from facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 23 of 43 residents in resident Rooms 9,10,11,12,14,15,16,18, and 19 with at least 80 square (sq) feet (ft) of living space per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, and lack of sufficient space for residents to have personal belongings at the bedside.