The Redwoods, a Community of Seniors

Inspectors wroteBased on observation, interview, and record review, the facility's dietary staff failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety for a census of 42 when:1. A manual can opener had missing metal on the tip, creating a potential physical contaminant hazard during food preparation; and,2. A resident was served a beverage in a glass tumbler with jagged, sharp edges during the lunch meal service. This failure decreased the facility's potential to prevent the spread of foodborne illnesses, physical injuries such as cuts, increased blood exposure risk, and unsanitary meal conditions for a vulnerable resident population.1. [...]

Inspectors wroteBased on observation, interview and record review, the nursing staff failed to ensure infection prevention and control practices were implemented for a census of 42 residents when:Hand hygiene was not performed during resident dining;Hand hygiene was not performed during medication administration;Shared resident equipment was not cleaned between uses; and,Appropriate Personal Protective Equipment (PPE-specialized clothing and gear which acts as a physical barrier to the wearer to minimize spread of infectious diseases) was not worn by nursing staff during a transfer of Resident 6 who had Enhanced Barrier Precautions (EBP-infection control measures used to prevent spread of multi-drug resistant organisms by using PPE during high contact resident care) in place .These failures decreased the facility's potential to prevent the spread of infection amongst the residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to implement an effective pest control program for a census of 42 when a fly was observed in the kitchen's food prep area. This failure had the potential to contribute to the spread of foodborne illnesses among a vulnerable resident population. During the initial kitchen tour on 5/19/26 at 8:29 a.m., a large, clear plastic storage container labeled Jam, Opened: Apricot was observed sitting completely uncovered on the stainless-steel prep table. A live fly was perched directly on the top rim of this uncovered container, in immediate proximity to the exposed food product. During an interview on 5/19/26 at 8:41 a.m. with the Registered Dietitian (RD), the RD confirmed a fly was in the kitchen, noting it posed a food safety and sanitation risk for resident meals. During an interview on 5/22/26 at 10:13 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the licensed nurses failed to remove the following expired items from Medication Cart One of two medication carts:One expired bottle of NSAIDs,One expired bottle of aspirin,One expired bottle of vitamin B-12, andOne expired Covid-19 test. In addition, the medication disposal container contained only pills, with no drug blocker or moisture activated agent to breakdown the medications. These failures decreased the facility's ability to safely administer medications and increased the risk of drug diversion (the illegal redirection of prescription or controlled medication from their intended medical use to unauthorized or illicit use).

Inspectors wroteBased on interview and record review, the Interdisciplinary Team (IDT-a coordinated group of healthcare professionals who collaborate and plan resident care) failed to review psychotropic medications (medications that affect brain activity associated with mental processes and behavior) for one resident (Resident 8) out of a sample of 14 residents when a gradual dose reduction (GDR) was recommended but not completed. This failure resulted in the continued use of psychotropic medications without reassessment and placed the resident at risk for unnecessary drug exposure and associated adverse outcomes. [...]

Inspectors wroteBased on interview and record review, the nursing staff failed to revise fall care plans for one resident (Resident 27) out 14 sampled residents when Resident 8's fall care plans were not updated after repeated falls. This failure decreased the facility's potential to prevent additional falls for both residents when Resident 27 to sustained additional falls with a minor injury.

Inspectors wroteBased on observation, interview and record review, the nursing staff failed to ensure necessary nail care services were provided to maintain good grooming and hygiene for one (Resident 6) of five sampled residents, when Resident 6 had long, untrimmed, and visibly dirty fingernails. This failure had the potential to expose Resident 6 to avoidable infection risks, skin breakdown, and injury from jagged or dirty nails. A review of Resident 6's admission record indicated he was last admitted in February 2023 with the diagnosis of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). A review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/18/25, indicated Resident 6 required extensive assistance of two for personal hygiene. [...]

Inspectors wroteBased on interview and record review, the nursing staff failed to ensure one resident (Resident 4) out of 14 sampled residents received appropriate care for a documented wound when the hospice (a specialized, compassionate model of end-of-life care focused on comfort, dignity, and quality of life rather than finding a cure) provider did not initiate treatment orders for Resident 4's excoriated (scraped or worn away), blistering (raw, sore skin) sacrum (an area located at the base of the spine and above the tailbone). This failure decreased the facility's potential to prevent infection and hinder continuous pain Resident 4 experienced as a result of the wound.

Inspectors wroteBased on interview and record review, the Social Services Director (SSD) failed to ensure one resident (Resident 13) of eight sampled residents received trauma-informed care when the SSD did not update Resident 13's Trauma Informed Care Assessment at least quarterly. This failure decreased the facility's potential to ensure Resident 13's nursing care needs were met.

Inspectors wroteBased on observation, interview and record review, the licensed nurse failed to ensure the medication error rate remained below 5 percent when four errors were observed during 29 medication administrations, which resulted in a 13.79% medication error rate. This failure decreased the facility's potential ensure the health and safety of residents by administering the correct dosage and effective therapeutic effect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident 28) of eight sampled residents remained free of significant medication errors when licensed nurses administered prescribed Parkinson's medications up to two hours late. This failure decreased the facility's potential to ensure medication was administered as ordered by the physician.

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards of practice were met for one of three sampled residents (Resident 1) when neurological (neuro, relating to the nervous system, includes: brain, spinal cord, and nerves) assessments and vital signs (blood pressure, temperature, pulse, respirations, and oxygen saturation [a measurement of how much oxygen is being carried by red blood cells]) were not conducted, monitored, or documented after a witnessed fall, in Resident 1's medical record per facility policy and protocol. These failures decreased the facility's potential to recognize a change in condition for Resident 1, which could have led to a delay in treatment with other negative outcomes. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment was accurate for one resident (Resident 1), when Resident 1's Physician Orders for Life-Sustaining Treatment (POLST, a set of medical orders, based on a patient's preferences, that guide medical care for individuals with serious illnesses) form information was different from the information documented on Resident 1's MDS assessment. This failure could result in inappropriate care and treatment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one resident (Resident 1) received treatment and care in accordance with the facility's Infection Control policy for influenza (flu- an illness caused by a virus [a germ] that is spread from person to person) when: Licensed Nurses (LNs) did not notify Resident 1's doctor (MD) that Resident 1 had symptoms of the flu and a report of Resident 1had been exposed to a family member who tested positive for flu; LNs did not notify the MD the facility ran out of flu tests; [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide written notice of transfer to the Long-Term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for two out of two sampled residents (Resident 1 and Resident 2), when they were transferred to the hospital in March of 2025 without the Ombudsman being notified. These failures could result in loss of residents ' advocacy and protection and prevent innapropriate transfers and discharges.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of fourteen sampled residents (Resident 34 and Resident 190) at risk for falls, were provided with supervision (visual checks) by direct care staff and had effective revisions and implementation of their nursing care plans to prevent further falls to keep them safe. Facility policies on safety and management of falls were not followed. As a result, Resident 190 suffered two falls with major injuries, consisting of hip fractures, at the facility, and one fall with no injuries. This caused severe pain to Resident 190 and may have contributed to her death, just 7 days after her last fall with major injury. Resident 34 fell 7 times in 4 months due to lack of supervision, revision, and implementation of care plans to prevent falls. This had the potential to result in falls with major injuries for Resident 34.

Inspectors wroteBased on interview and record review, the facility did not have a system to track staff compliance in required trainings, when: 1. Two of four sampled employees had mandatory trainings that were overdue (Licensed Staff K and Unlicensed Staff L). This finding had the potential to result in inadequate staff competency to care for the residents within professional standards or practice, poor quality of care, and harm to the residents of the facility. 2. The facility failed to provide a competent DSD to enforce training and verify competencies for Nursing staff when Unlicensed Staff F's (BLS) Basic Life Support Certification (CPR Cardiopulmonary Resuscitation the act of performing chest compressions and artificial respirations) was expired for 4.5 months while working in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the daily nursing staffing information was posted in a conspicuous place, during one of five days (7/08/24). This finding had the potential to result in inability for residents, visitors, and staff to review the staffing information, advocate for the residents' care, and identify issues with staffing numbers, which could have contributed to decreased quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pharmacist's Drug Regimen Review (DRR/Medication Regimen Reviews- a monthly summary report of each resident's medication irregularities) report was acted upon with timely responses from Physicians and Medical Director. This failed practice had the potential to affect all residents currently receiving medications (36 of 36 residents) and placed them at risk for negative clinical outcomes due to a potential urgent action not being communicated in a timely fashion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of fourteen sampled residents (Resident 16) was free of psychotropic drugs (Medications used to treat mental health disorders. These medications have many side and adverse effects) she did not need. This failure had the potential to result in adverse consequences such as medication interactions, depression, confusion, immobility, falls with fractures, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the temperature of one of one medication refrigerators in the medication room of the facility (Medication Refrigerator A), was kept within normal parameters for several months, to store resident medications. The medication room where Medication Refrigerator A was stored, was observed propped open with a stool, unattended, prior to entering the room. In addition, one expired medication was found stored with active medications in one of the two medication carts (Medication Cart B, cart for the south hall), stored with other active medications. This failure had the potential to result in medications that were no longer effective, causing harm to the residents involved, and access to unauthorized personnel to the resident medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records for 1 of 2 sampled residents that suffered multiple falls at the facility (Resident 190) were accurate. These documents consisted of the fall risk assessments for Resident 190, who suffered three falls at the facility, with two resulting in major injuries. As a result of the inaccurate responses in the fall risk assessments, one of these documents indicated Resident 190 was at low risk for falls, when that was not the case. This failure may have contributed to the lack of care planning and interventions to prevent further falls for Resident 190. It also had the potential to result in inability for staff to identify triggers and patterns necessary for fall prevention measures for Resident 190.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their Infection Control policy and QAPI (Quality Assurance and Performance Improvement) policy for 36 out of 36 residents when the facility failed to track and surveil data for resident's chronic UTI (Urinary Tract Infections). This failure had the potential to result in residents developing MRDO (multidrug resistant organisms).

Inspectors wroteBased on observation, interview and record review, the facility did not follow their Enhanced Barrier Precautions policy and their Hand Hygiene Policy's when 1 resident (Resident 31) out of 36 sampled residents had a staff member who did not practice hand hygiene or correct isolation techniques while administering hygiene care to a resident on Enhanced Barrier isolation.

Inspectors wroteBased on interview and record review, the facility did not provide three of four Unlicensed Staff (Unlicensed Staff N, Unlicensed Staff O & Unlicensed Staff P) with 12 hours of abuse and dementia training annually. This failure had the potential to result in inadequate staff competency to care for the residents within professional standards or practice, poor quality of care, and harm to the residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled resident's (Resident 3) medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information was provided to the resident and/or responsible parties and desire for physician orders for life sustaining treatment (POLST) were reviewed, signed and dated by a physician. This failure had the potential for the resident's wishes not to be honored during a medical emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility develop a resident-centered, comprehensive care plan for 1 of 14 sampled residents (Resident 18) with a stage 4 pressure ulcer (A pressure ulcer is a wound caused by prolonged pressure on an area of the skin. Stage 4 pressure ulcers are the most severe type of pressure ulcer, and can extend into muscle and/or tendons and bones). This had the potential to result in inability for the wound to heal, decline of Resident 18's medical condition, medical complications including the acquisition of serious infections and death.

Inspectors wroteBased on interviews and record reviews, the facility failed to 1. provide supervision and assistance for a toileting needs for one out of two sampled residents (Resident 4). 2. ensure the pharmacist conduct a medication regimen review (MRR, a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions) for fall to prevent avoidable accidents or falls. These failures led to Resident 4 ' s unwitnessed fall that resulted to hospitalization due to left leg severe pain. While at the hospital, Resident 4 was diagnosed with closed fracture (a break in the bone) of neck of left femur (thigh) and subsequently had to undergo left hip fracture hemiarthroplasty (a type of partial hip replacement procedure that involves replacing half of the hip joint).

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure 1. staff knew the correct time frame for reporting abuse allegations and injury of unknown source (source of the injury was not observed by any person; the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury) to the state, the Ombudsman (a person who investigates, reports on, and helps settle complaints) and the local law enforcement. 2. staff knew what injury of unknown source was 3. staff knew who to report abuse allegations and injury of unknown source 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, prevent, and treat a wound for one of thirteen residents (Resident 14) when the facility admitted Resident 14 with right shoulder Anti-subluxation brace/sling (a medical device intended to protect the shoulder joint from partial dislocation cause by caused by paralysis or injury in the shoulder joint capsule), and no weekly skin assessment was done. This failure resulted in Resident 14 developing a wound inside her right armpit with infection, and there was no current wound assessment and wound care order from the Physician.

Inspectors wroteA review of Resident 26's face-sheet indicated, Resident 26 was admitted with a diagnosis that included Parkinson's disease (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), history of Falling, and unsteadiness on feet. During an interview on 2/16/2022 at 1:35 p.m., Resident 26's daughter stated she is worried about her father's increased number of falls. The daughter stated her father just returned two days (2/12/22) ago from (name) (acute care) hospital because of a fall. The staff told her, the CNA (Certified Nursing Assistant) could not watch her father all the time and suggested that she might consider getting a 1:1 (one-on one) sitter (one person who will only monitor one resident), but we would have to pay out of pocket for that care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents and staff knew the complaint and grievance process and posted grievance and complaint information in a manner accessible to all residents. This failure did not ensure residents rights to file a grievance and had the potential to delay the facility's identification and response to residents needs or complaints.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan for 5 out of 13 sampled residents (Resident 229, Resident 129, Resident 130, Resident 132, Resident 133) when: 1. Resident 229 had no baseline care plan for Percutaneous Endoscopic Gastrostomy (PEG-a device that allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus) Care Plan. This failure had the potential for Resident 229 not receiving adequate care because of staff not knowing what care to provide. 2. New admissions to the facility, Resident 129, Resident 130, Resident 132, and Resident 133, were all receiving skilled nursing care without an assessment of their care needs. This failure had to potential for needs to go unmet, continued health decline, and a lower quality of care for these residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for 3 sampled residents (Resident 14, Resident 20, and Resident 28) that were individualized and updated to show residents specific care related to their medical needs when: a. Resident 20 did not have a care plan for urinary catheterization. b. Resident 28 did not have a care plan for monitoring of antipsychotic medications and dementia behaviors c. Resident 14 did not have a Care Plan for Anti-Subluxation brace/sling (a medical device intended to protect the shoulder joint from partial dislocation cause by caused by paralysis or injury in the shoulder joint capsule). These failures possibly resulted in residents decline in health, harm, and negatively impact the residents' quality of care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide medications as ordered by the physician to one of six residents sampled for medication administration (Resident 129). This delayed acquisition resulted in Resident 129 to not receive 11 doses and increased his potential to develop complications.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive action plans for identification, analysis, correction, and evaluation of systemic care issues, including high-risk, high-volume concerns, and repeat survey deficiencies. This failure had the potential to precent timely recognition and improvement of care services that do not meet standards for quality for all 31 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate was lower than 5% when staff made five medication errors out of 27 opportunities. This failure resulted in a medication error rate of 18.5%, which had the potential of unsafe provision of medications to residents.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement clinical criteria protocols, infection surveillance protocols, and antibiotic use protocols that promoted antibiotic stewardship. These failures had the potential for inconsistent and ineffective antibiotic stewardship (a coordinated program that promotes the appropriate use of antimicrobials [including antibiotics], improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) services for all residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure 3 out of 5 sampled residents (Resident 133 Resident 129 and Resident 28) immunization status was assessed and accurately documented in their medical record. These failures had the potential to result in higher risk for infection due to lack of immunization or side effects from an additional dose of vaccine been given.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assistive devices for vision was provided for one resident (Resident 26). This failure resulted in the resident not having vision assistance to read (an activity the resident enjoys) and could contribute to his increased incidents of falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor, re-evaluate, and document clinical rationale for continued use of a psychotropic drug for one of five sampled residents for medication regimen review (Resident 13) despite the resident not exhibiting behaviors the medication was originally prescribed for. This failure placed Resident 13 at a higher risk for adverse side effects associated with psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage when: 1. Expired medications, including an eye drop belonging to one unsampled resident (Resident 2) were found in medication storage, and 2. Temperature logs were not maintained in the medication refrigerator. These failures had the potential for contamination and altered integrity of stored medications.