Redwood Terrace Health Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF761Dec 15, 2022

  Based on observation, interview, and record review, the facility failed to ensure LN removed an expired medication from the medication cart for one of two medication carts observed. In addition, LN left medications unattended in residents room and allowing residents to self-administer without proper assessment and qualification for two of 13 sampled residents (27 and 88), and five unsampled residents (16, 30, 32, 194 and 200). As a result, there was a potential for staff to administer expired medication. In addition, staff would not have been able to verify the appropriate dose taken by the residents. Findings: 1. On 12/15/22 at 10:21 A.M., an observation of a medication cart was conducted with LN 2. […]

• No harm, potential for more than minimal, isolatedF604Aug 14, 2025

  Based on observation, interview, and record review, the facility failed to ensure a restraint was re-evaluated for one of one sampled resident (Resident 5) reviewed for physical restraint. This failure had the potential for Resident 5 to be restrained unnecessarily. Cross Reference F 636.Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses which included dementia (impaired memory and thinking skills) with mood disturbance and a urinary catheter (a device that drains urine from the urinary bladder into a collection bag), per the facility's admission Record. On 8/11/25, a record review of Resident 5's minimum data set (MDS - a federally mandated resident assessment tool) dated, 7/10/25 was conducted. Per the MDS, Resident 5 had limb restraints. […]

• No harm, potential for more than minimal, isolatedF628Aug 14, 2025

  Based on interview and record review, the facility failed to provide a written bed hold notice to the resident and or resident's Responsible Party (RP - an individual authorized by the resident to act as an official representative) upon transfer to the hospital for one of two residents (Resident 4) reviewed for hospitalization. This failure had the potential for Resident 4 and his RP being unaware of the bed hold duration and his right to return to the facility after hospitalization. Findings: A review of resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (can cause confusion, memory loss and loss of consciousness). The admission Record listed Resident 4's wife as the RP. […]

• No harm, potential for more than minimal, isolatedF636Aug 14, 2025

  Based on observation, interview, and record review, the facility failed to assess and document the use of hand mittens for one of one sampled resident (Resident 5) reviewed for physical restraint. This failure had the potential for Resident 5 to be restrained unnecessarily. Cross Reference F 604.Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses which included dementia with mood disturbance (impaired memory and thinking skills) and a urinary catheter (a device that drains urine from the urinary bladder into a collection bag), per the facility's Face Sheet. On 8/11/25, a record review of Resident 5's minimum data set (MDS - a federally mandated resident assessment tool) was conducted. Per the MDS dated [DATE], Resident 5's had limb restraint. […]

• No harm, potential for more than minimal, isolatedF658Aug 14, 2025

  Based on observation, interview, and record review, the facility failed to follow standards of practice when a Licensed Nurse (LN) did not follow physician's order/instructions during medication administration observation. This failure had the potential to cause side effects for Resident 38's health condition. Findings: Per the facility's admission Record, Resident 38 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease (a condition wherein stomach contents leak backwards). A review of Resident 38's minimum data set (MDS- a federally mandated assessment tool) dated 8/4/25 indicated, Resident 38's brief interview for mental status (BIMS) was 3 which meant Resident 38's cognition (thought process) was severely impaired. […]