Redwood Healthcare Center LLC

In the surveyor’s words

From the most serious findings on record at Redwood Healthcare Center LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Aug 23, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Aug 11, 2022

  Based 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. Findings: During the initial tour of the kitchen on 8/8/22 at 10:15 a.m. with Dietary Manager 1, (DM 1), the following was observed: 1. […]

• No harm, potential for more than minimal, patternF689Apr 21, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF684Mar 16, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF677Aug 23, 2024

  Based 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. FINDINGS: 1a. During a review of Resident 30's Face Sheet, dated August 2024, the Face Sheet indicated, Resident 30 was admitted on [DATE] with diagnosis that includes Hemiplegia (the loss of muscle function on one side of the body) and Hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) and Diabetes (a long-term chronic disease in which the body cannot regulate the amount… […]