Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Redwood Healthcare Center Llc during CMS and state inspections, most recent first.
Missed Pain Medications and Uncontrolled Pain: A resident with a spinal cord injury and recent cervical spinal fusion did not receive ordered Dilaudid and Lidocaine patch doses for multiple days because the meds were unavailable. MARs and PN showed repeated missed doses, the LVN said Tylenol was used PRN but did not control the pain, and the DON confirmed the missed administrations. The resident was transferred to the hospital for pain management.
A resident admitted after cervical spinal fusion and with a spinal cord injury did not receive ordered skilled PT five times per week during the first three weeks of admission. Therapy records showed fewer sessions than ordered, and the DOR stated therapist availability might have contributed to the missed sessions, while the DON stated the facility was responsible for providing therapy per the physician order.
The facility failed to consistently monitor the functioning of wander guard devices for three cognitively impaired residents with histories of wandering or elopement. One resident with vascular dementia and a prior elopement had care plan and physician orders requiring every-shift checks of wander guard functioning and placement, yet MARs over several months showed documentation only for placement and skin checks, with no evidence of functioning checks. A second resident with moderate cognitive impairment and an elopement history had a care plan requiring every-shift monitoring of wander guard functioning, but MAR review revealed a 13-day gap with no documented functioning checks, and this resident was later observed attempting to leave through the front exit. A third resident with dementia and documented wandering risk had multiple days and shifts with missing MAR signatures for wander guard functioning, placement, and skin monitoring, and was observed near a back exit door when the wander alarm sounded. The DON and other staff confirmed that these monitoring tasks were not consistently performed or documented, and leadership acknowledged there was no specific wander guard policy in place.
A resident with moderate cognitive impairment, cognitive communication deficits, psychoactive substance dependence, and a documented history of elopement had an MDS assessment coded to show no wander/elopement alarm in use, despite the care plan identifying exit-seeking behavior and directing staff to monitor a wander guard on the resident’s left wrist each shift. During interview and record review, the DON confirmed the resident was wearing a wander guard on the assessment date and that the MDS coding completed by the MDSC was inaccurate, contrary to facility policies requiring accurate assessments to support comprehensive, person-centered care planning.
The facility failed to ensure fall-risk care plan interventions were implemented when two residents at risk for falls did not have their call lights within reach. One resident with a vertebral compression fracture and history of repeated falls was observed ambulating unassisted to the bathroom and appeared unsteady; her call light was later found on the floor behind a distant nightstand, despite a care plan intervention requiring it to be within reach. Another resident with seizures, benign prostatic hyperplasia, and right-sided weakness, who had a prior unwitnessed fall while self-transferring, was found in bed with the call light on the floor, and the CNA acknowledged not checking its placement during the last round. Staff, including a CNA, an LVN, and the DON, stated that call lights should be within arm’s reach, and facility policies require providing residents with a means to call staff and implementing interventions to prevent falls.
The facility did not comply with Federal regulations for food service operations by failing to employ a full-time dietitian or a qualified full-time dietetic services supervisor. The part-time dietitian worked only 8 hours a week, and the dietary supervisor lacked the necessary certification, potentially leading to unsafe food practices for 43 residents.
The facility failed to maintain proper nail hygiene for three residents, including those with diabetes and cognitive impairments. Observations revealed long and dirty fingernails, despite care plans indicating dependency on staff for personal hygiene. Staff interviews confirmed the expectation for regular nail care, which was not met, leading to potential infection risks.
The facility failed to ensure safe storage of medications and biologicals, with expired items found in the medication room and a discontinued medication improperly labeled in a medication cart. Additionally, non-medication items were stored in the cart, contrary to facility policy.
The facility failed to provide adequate living space for 27 residents in Rooms A through I, with each room containing three beds and offering less than the required 80 square feet per resident. Despite this deficiency, observations indicated sufficient space for care provision, and no complaints or safety concerns were reported.
Missed Pain Medications and Uncontrolled Pain
Penalty
Summary
The facility failed to ensure that a resident with a spinal cord injury who had undergone cervical spinal fusion received scheduled pain medications as ordered. The resident’s MAR showed physician orders for Hydromorphone (Dilaudid) 2 mg, three tablets by mouth three times daily, and Lidocaine Patch 4% applied once daily in the morning and removed in the evening. The MAR and progress notes showed the resident did not receive Dilaudid from the afternoon dose on 3/24/26 through 3/29/26, and did not receive the Lidocaine patch on multiple days from 3/21/26 through 3/29/26. Progress notes documented that Dilaudid and the Lidocaine patch were unavailable during these periods. The resident’s records showed the resident was transferred back to the hospital on 3/29/26 for pain management. During interview, an LVN stated the pharmacy supplied Dilaudid for three days, then the facility contacted UCSF Hospital for a triplicate refill order but did not receive a response, and Tylenol was given as needed but did not adequately control the resident’s pain. The DON confirmed the missed doses and stated the facility was responsible for clarifying orders, coordinating with the physician and pharmacy, and ensuring the prescribed medications were administered. The facility policy stated medications are to be administered in a safe and timely manner, and as prescribed.
Missed Ordered PT Sessions
Penalty
Summary
The facility failed to ensure that one sampled resident was provided physician-ordered skilled PT five times per week during the first three weeks of admission. Resident 1 was admitted with a diagnosis of spinal cord injury and had undergone a cervical spinal fusion. The order listing report showed an order for skilled PT five times a week for four weeks to address muscle weakness through therapeutic exercises, therapeutic activities, neuromuscular education, wheelchair mobility training, and patient/caregiver education. Review of the therapy records showed that Resident 1 received PT four times during the first week, two times during the second week, and four times during the third week, rather than the ordered five sessions per week. During interview, the DOR stated that lack of therapist availability might have contributed to missed scheduled sessions but could not confirm that definitively. The DON stated it was the facility's responsibility to provide therapy according to the physician order.
Failure to Consistently Monitor Wander Guard Functioning for Residents at Risk of Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring of wander guard devices for three residents identified as at risk for elopement. All three residents had documented cognitive impairment and histories of wandering or elopement or attempted elopement. For one resident with vascular dementia and a prior elopement from the facility, the care plan and physician orders required monitoring of wander guard functioning and placement every shift. The resident had previously eloped from the facility and was returned by police after being found at a gas station, at which time the wander guard was found on the bed and not on the resident. Although the care plan and earlier orders included monitoring of wander guard functioning, the Medication Administration Records (MARs) from mid-December through mid-April showed documentation only for placement and skin checks, with no documented evidence that the functioning of the wander guard was monitored every shift during that period. The DON confirmed that the wander guard functioning was not monitored every shift for approximately four months and stated that if it was not documented, it was not done. A second resident, with moderate cognitive impairment and a history of elopement or attempted leaving the facility without informing staff, also had a care plan that included monitoring the functioning and placement of a wander guard every shift. The elopement evaluation identified this resident as having such a history, and the care plan goal was for the resident to have no episodes of attempting to leave. During an observation, this resident was seen at the front exit door attempting to leave, and staff had to run after and redirect the resident, who remained at the exit area despite redirection. Review of the MAR for this resident showed no documentation of monitoring the wander guard’s functioning for a 13-day period. The DON confirmed that there was no monitoring of the wander guard functioning during those days and stated that monitoring was important to ensure the device was working well for resident safety. A third resident, with dementia, memory problems, and a history of elopement or attempted leaving the facility without informing staff, had a care plan that included monitoring wander guard functioning, placement, and skin condition every shift. During observation, this resident was seen standing close to a back exit door looking outside, and staff responded when the wander alarm beeped. Review of the MARs for August and September showed multiple days and shifts where staff did not sign for monitoring the functioning of the wander guard, its placement, or the skin around the device. Specific missing documentation included several day, evening, and night shifts where no checkmarks or initials were present for these tasks. The DON acknowledged that it appeared staff did not perform the monitoring and could not find any alternative documentation in progress notes. Additionally, the Regional Nursing Home Administrator stated that the facility did not have a specific wander guard policy and that wander guards were treated as an added measure under the general wandering and elopement policy, despite manufacturer instructions indicating that staff can and should use a detector to verify tag battery status.
Inaccurate MDS Coding for Wander Guard Use
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident when the use of a wander/elopement alarm was not correctly coded. The resident was admitted with diagnoses including cognitive communication deficits and psychoactive substance dependence, and an MDS dated in March showed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. In that same MDS, Section P was coded "0" for wander/elopement alarm, indicating that such an alarm was not used. However, the resident’s elopement evaluation documented a history of elopement or attempts to leave the facility without informing staff, and the comprehensive care plan initiated and later revised identified exit-seeking or elopement behavior. The care plan directed staff to monitor the functioning and placement of a wander guard on the resident’s left wrist every shift. During a telephone interview and concurrent record review, the DON confirmed that the MDS coding was inaccurate, stated that the MDS coordinator had coded the assessment, and verified that the resident was wearing a wander guard on the date of the MDS. Facility policies on resident assessments and comprehensive person-centered care plans required appropriate assessments and development of care plans based on resident needs, which were not accurately reflected in the MDS for this resident.
Failure to Maintain Accessible Call Lights for Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement fall-risk care plan interventions by not ensuring that call lights were within reach for two residents identified as at risk for falls. Resident 1, who had diagnoses including a vertebral compression fracture and repeated falls, was observed standing from her bed, using a walker, and ambulating to the bathroom unassisted, appearing unsteady. A CNA stated that this resident required staff assistance to the bathroom due to fall risk and was supposed to call for help. When asked for the call light, the resident, who was hard of hearing, did not understand, and the CNA found the call light on the floor behind a nightstand that was not close to the bed. The CNA then attached the call light to the bed and instructed the resident on its use. Resident 1’s care plan for fall risk included an intervention to ensure the call light was within reach and to encourage the resident to use it for assistance as needed. Resident 2, with diagnoses including seizures and benign prostatic hyperplasia with lower urinary tract symptoms, was also identified as a fall risk with a weak right side. During observation, this resident was lying in bed asleep, and a CNA reported the resident had not called that day. When asked about the call light, the CNA located it on the floor, then attached it to the resident’s pillow, acknowledging it should not have been on the floor and should be reachable. The CNA admitted that during the last round, she did not check whether the call light was within reach. Resident 2 had a prior unwitnessed fall while self-transferring from bed to wheelchair, and the care plan documented a risk for injury due to a fall with a goal of no further falls. Facility staff, including a LVN and the DON, stated that call lights should always be within arm’s reach of residents, consistent with facility policies on the call system and fall risk management, which require providing residents a means to call staff and identifying interventions to prevent falls.
Non-compliance with Dietary Staffing Regulations
Penalty
Summary
The facility failed to comply with Federal regulations regarding the oversight of food service operations by not employing a full-time dietitian or a qualified full-time dietetic services supervisor. According to the California Code, Health, and Safety Code - HSC S 1265.4, a health facility that employs a registered dietitian less than full-time must also employ a full-time dietetic services supervisor who meets specific educational and certification requirements. The facility's dietary supervisor, who had been in the role for a year, did not possess the necessary Dietary Manager Certification and was still in the process of obtaining it. This lack of a qualified, full-time supervisor for the Food and Nutrition Services Department had the potential to result in unsafe food practices and foodborne illness for the 43 residents consuming facility-prepared foods. Interviews conducted with the Dietary Supervisor and the Registered Dietitian Nutritionist revealed that the dietitian worked part-time, only once a week for 8 hours, and the dietary supervisor was not certified as required. The facility's job description for the Dietary Supervisor, revised in March 2021, indicated responsibilities for planning, organizing, developing, and directing the overall operation of the Dietary Department in accordance with applicable standards and regulations. However, the current dietary supervisor did not meet the qualifications outlined in the California Code, which contributed to the deficiency identified during the survey.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to provide adequate personal hygiene care for three residents, specifically in trimming and cleaning their fingernails. Resident 30, who was admitted with hemiplegia, hemiparesis, and diabetes, was observed with long and dirty fingernails. Despite being cognitively intact and dependent on staff for personal hygiene, Resident 30 reported that no staff assisted her with nail care. Both a CNA and an RN acknowledged the condition of Resident 30's nails and confirmed that licensed nurses were responsible for trimming the nails of diabetic residents. Resident 32, with a diagnosis of spinal cord disease and moderate cognitive impairment, also had long and dirty fingernails. The resident's care plan indicated a dependency on staff for personal hygiene. Observations confirmed the poor condition of Resident 32's nails, and staff interviews revealed an expectation for daily cleaning and trimming as needed. However, this care was not provided, as evidenced by the state of the resident's nails during the survey. Resident 33, who had severe cognitive impairment and required maximum assistance with personal hygiene, was similarly found with long and dirty fingernails. The care plan for Resident 33 also indicated a need for daily grooming and assistance with ADLs. Staff interviews, including with the DON, highlighted an expectation for CNAs and LNs to check and maintain residents' nail hygiene during morning rounds. The facility's policy emphasized the importance of regular nail care to prevent infections, yet this was not adhered to, resulting in the observed deficiencies.
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to ensure the safe storage of drugs and biologicals, as observed during a survey. In the medication room, outdated or expired items such as tube feeding formula, COVID-19 test kits, specimen collection kits, first aid kits, dextrose injection bags, and normal saline pre-filled flush syringes were found. These items had expiration dates ranging from early 2022 to early 2024, indicating that they should have been discarded or placed in a designated discard box. The Infection Preventionist acknowledged that these items should not have been stored in the medication room. Additionally, a medication cart was found to contain a discontinued medication and food items. An opened cough syrup bottle, which was no longer used for a resident, lacked proper labeling, including the open date, resident's name, and room number. This could lead to potential medication errors. Furthermore, non-medication items such as a yogurt cup and a pudding cup were improperly stored in the medication cart. The Registered Nurse present confirmed that these items should not have been kept in the cart and should have been discarded. The facility's policy and procedures require that all drugs and biologicals be stored safely and securely, with proper labeling and disposal of discontinued or outdated items.
Inadequate Living Space for Residents
Penalty
Summary
The facility failed to provide adequate living space for 27 out of 43 residents in Rooms A through I, as required by regulations. Each of these rooms contained three beds, but the square footage per resident was below the mandated 80 square feet. Specifically, the space per resident ranged from 71.42 to 73.65 square feet, which is insufficient according to the standards. This deficiency was identified through a record review of the Client Accommodations Analysis dated August 19, 2024. Despite the deficiency in room size, observations conducted from August 19 to August 22, 2024, indicated that there was sufficient space for the provision of care, and no heavy equipment was present that could interfere with resident care. Residents reportedly had adequate personal space and privacy, and there were no complaints regarding insufficient space for personal belongings. Additionally, there were no negative consequences or safety concerns noted as a result of the decreased space in these rooms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Excell Health Care Center | 0 mi | ★★★★★ | 1 | 0 |
| Princeton Manor Healthcare Center, Llc | 1 mi | ★★★★★ | 21 | 0 |
| Mercy Retirement & Care Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Bellaken Skilled Nursing Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Bay Marina Post Acute | 1.2 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.