The Redwoods Post-Acute

In the surveyor’s words

From the most serious findings on record at The Redwoods Post-Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF880Feb 14, 2023

  Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infections as evidenced by: 1. The facility failed to use the proper disinfectant to disinfect shared (used for multiple residents) glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to manufacturer's instructions and accepted professional standards for 41 of 41 residents when: 1a. Licensed Vocational Nurse A (LVN A) failed to properly disinfect a shared glucometer during observation for two of 41 residents (Residents 9 and 25) according to manufacturer's instructions; 1b. […]

• Actual harm, isolatedF689Aug 18, 2021

  Based on interview and record review, the facility failed to implement care plan interventions and failed to provide adequate supervision to prevent an accident for one of three sampled residents (Resident 1) when the one-to-one sitter (1:1 sitter, staff designated to be with the resident at all times to ensure safety) went to the bathroom and did not get another staff member to stay with the resident. This resulted in Resident 1's fall, head injuries, and subsequent death. Findings: Resident 1's clinical record documented she was admitted to the facility on [DATE] and had the diagnoses of [CONDITION(S)] (heart muscle does not pump blood as well as it should), dementia (mental disorder caused by brain disease or injury), [CONDITION(S)] (condition that causes loss of vision), abnormalities… […]

• No harm, potential for more than minimal, widespreadF888Mar 18, 2022

  Based on observation, interview, and record review, the facility failed to compliant to the staff COVID-19 (Coronavirus 2019, a new strain of virus that can cause mild to severe respiratory illness) vaccination requirements when: 1. Facility's did not follow the Centers for Medicare & Medicaid Services (CMS) Federal regulation to include the required components for its staff COVID-19 vaccination policy and procedure. 2. Unvacciniated Registered Nurse A's (RN A) medical exemption from COVID-19 vaccination did not have a licensed practitioner's name, title or signature. 3. The facility did not have a policy and procedure regarding the process by which the staff 's exemption from COVID-19. 4. […]

• No harm, potential for more than minimal, patternF880Jul 28, 2026

  Based on observation, interview, and record review, the facility failed to ensure to maintain infection prevention and control practices to prevent the spread of infection when:Certified nursing assistant (CNA) staff failed to wear a gown (to cover staff's clothing and skin to prevent the spread of infection [part of the personal protective equipment, PPE]) when they transferred a resident with enhanced barrier precautions (EBP, an infection control strategy used with residents with high risk infections or devices in place to prevent the spread of infections or to protect from infections); and,Occupational Therapist (OT, a healthcare expert who helps residents do everyday tasks and gain independence) failed to discard gloves appropriately after removed.These failures had the potential for… […]

• No harm, potential for more than minimal, patternF758Jan 17, 2025

  Based on interview and record review, the facility failed to ensure three out of 31 sampled residents (Residents 92, 307, and 400) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 92 received four psychotropic medications without documented evidence of attempted or contra-indicated non-pharmacological (non-drug) interventions prior to initiating or increasing these medications. Also, there was no monitoring for side effects of aripiprazole (Abilify, an antipsychotic medication to treat mental illnesses) since July 2024; 2. […]