Redwood Health & Rehab

In the surveyor’s words

From the most serious findings on record at Redwood Health & Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 20, 2021

  Based on observations, an interview with the legal guardian, the physician, interviews with staff, and record review, the facility failed to implement elopement interventions to prevent Resident #2's unauthorized and unsupervised exit from the facility. Resident #2, with an appointed Department of Social Services (DSS) guardian of the person, assessed at risk for elopement and a diagnosis of Alzheimer's disease, exited the facility on 3/21/21 after 8:35 PM in her wheelchair with a wander guard management bracelet (WG) on her wheelchair that did not sound to alert staff and the facility exit door automatic lock system did not engage to prevent egress. […]

• No harm, potential for more than minimal, widespreadF851Jan 17, 2024

  Based on staff interview and record review, the facility failed to electronically submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for quarter 1 of fiscal year (FY) 2023 (October - December 2023). The failure occurred for 1 of 5 quarters reviewed. The findings included: A review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility failed to submit the required PBJ Staffing Data for the first quarter of FY 2023. […]

• No harm, potential for more than minimal, patternF812May 11, 2026

  Based on observations and staff interviews, the facility failed to discard dented canned goods stored for use, failed to dry divided plates prior to stacking, and failed to discard a wet cardboard box of pound cakes covered in frozen condensation. These practices occurred in 1 of 1 walk-in freezer, 1 of 1 dishwashing area, and 1 of 1 dry storage area and had the potential to affect food served to residents. The findings included:An initial tour of the main kitchen occurred on 5/4/26 at 9:58 AM with the Dietary Manager. The following concerns were identified:-A 108 ounce (oz.) can of applesauce with a large dent on the rim and side, a 6.62 pound (lb.) can of mandarin oranges with a small dent on rim, and a 7 lb. […]

• No harm, potential for more than minimal, patternF761Apr 24, 2025

  Based on observation, record review, and staff interviews, the facility failed to secure an opened bottle of antacid for 1 of 1 Resident (Resident #90) and failed to store 3 unopened eye drops at the proper temperature per manufacturer's instructions for 1 of 4 medication cart (100 halls medication cart) review for medication storage. The findings included: a. Resident #90 was admitted to the facility on [DATE]. A review of Resident #90's medication records revealed he had never been assessed nor approved for self-administration of medication since admission. […]

• No harm, potential for more than minimal, patternF835Jan 17, 2024

  Based on interviews with staff and record review, the facility administration failed to provide effective leadership and oversight when the facility failed to enact their emergency operations plan to notify law enforcement of a missing resident. Resident #86 left the facility for a planned leave of absence but did not return to the facility as planned and did not communicate to the facility the Resident's whereabouts for 12 days. This failure occurred for 1 of 1 sampled residents reviewed. […]