The Redwoods, A Community of Seniors

In the surveyor’s words

From the most serious findings on record at The Redwoods, A Community of Seniors, in the surveyor’s own words.

• Actual harm, isolatedF880Jul 29, 2025

  Based 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; LNs did not place Resident 1 on droplet precautions (measures implemented to prevent the spread of infection when a person who is infected with a pathogen [germs that cause disease] coughs, sneezes, or talks);These failures resulted in Resident 1's… […]

• Actual harm, isolatedF689Jul 12, 2024

  Based 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. […]

• Actual harm, isolatedF689Sep 27, 2023

  Based 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. […]

• Actual harm, isolatedF726May 25, 2023

  Based on observation, interview and record review, the facility failed to provide sufficient nursing staff with appropriate competencies and skills to supervise and adequately care for one of 3 sampled resident ' s (Resident 1), when Resident 1, who had Dementia (memory loss) was reminded by staff to call for assistance with transfers resulting in falls and a fractured right femur (thigh bone). Findings: During a review of Resident 1 ' s Profile Face Sheet, on 3/30/23, Resident 1 ' s Face Sheet, indicated, diagnosis of Dementia. During an interview on 3/30/23 at 2:20 p.m., with DON, she stated, she was aware Resident 1 had fallen and this was Resident 1 ' s second fall within one month. Both falls occurred in the bathroom where Resident 1 was found on the floor calling for help. […]

• Actual harm, isolatedF686Feb 18, 2022

  Based 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. Findings: During a review of Resident 14's medical record, the facility admitted Resident 14 on 12/30/21. […]