Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Redwood Terrace Health Center during CMS and state inspections, most recent first.
A resident with dementia and a urinary catheter was ordered to wear bilateral hand mittens, and nursing staff documented the mittens as in place on the TAR. However, staff did not complete an assessment or ongoing evaluation to determine whether the mittens were still needed, and there were no related weekly progress notes. Interviews showed the resident was confused but was not pulling at the catheter during the stay, and the DON acknowledged the mittens should have been reevaluated.
Failure to Provide Written Bed Hold Notice: A resident with metabolic encephalopathy was transferred to the hospital after his wife requested it for difficulty breathing, and the MDS indicated he was expected to return. An LN stated bed hold was not discussed with the resident or RP and no written notice was given. The DSD and DON confirmed no bed hold was offered, despite facility policy requiring residents and/or representatives to be informed in writing of bed hold policies.
Failure to Assess and Document Hand Mitten Use: A resident with dementia and a urinary catheter was ordered bilateral mittens, and nursing staff signed off the TAR as if the mittens were in use. However, staff interviews and record review showed there was no pre-use assessment, no documented evaluation of whether the mittens were still needed, and no progress notes addressing the mittens. Observations also showed the resident at times without mittens, while staff reported he had not been pulling at his catheter during the facility stay.
A LN administered Amantadine to a resident without offering food, despite the physician’s order that it be given with breakfast and lunch and the medication pack instruction to give it with food. The resident had severely impaired cognition, and the DON stated licensed nurses are expected to follow medication orders and instructions to prevent side effects and complications such as gastric upset.
Food Service Staff Incorrectly Calibrated Thermometer: CK 1 incorrectly demonstrated how to calibrate a food thermometer during an observation with the RD, FSD, and EC present. CK 1 placed ice in a metal bin, added a small amount of sink water, and touched the probe to the bottom of the bin, stating this was how they had been trained. The FSD and RD stated the correct method was to use a cup or small container with ice and water to the top, per facility policy.
Failure to Wear Hair Restraint During Kitchen Food Handling: A Dietary Aide was observed sorting food utensils and folding papers in the clean area of the food cart without a hair net. Another Dietary Aide prompted her to put one on, and she later stated she forgot to wear it while handling food-related items. The RD confirmed that kitchen staff were expected to wear hair nets at all times, and the facility policy required approved hair restraints for all associates working with food.
Failure to follow EBP occurred when an LPN administered medication to a resident with a stage 3 sacral pressure ulcer without wearing PPE and without performing hand hygiene before or after care. The resident’s room had an EBP sign posted, and the LPN acknowledged not using gown and gloves during the medication pass. The DON stated staff should perform hand hygiene before and after resident care and use PPE to help prevent spread of infection.
The facility did not send the results of an abuse investigation involving a resident with dementia to the state agency within the required five working days. Instead, the results were sent after seven working days, contrary to facility policy and state requirements.
Failure to Re-evaluate Hand Mittens Used as a Physical Restraint
Penalty
Summary
The facility failed to ensure a physical restraint was re-evaluated for one resident who had bilateral hand mittens ordered to protect him from scratching and unaware wounding of his face. The resident was admitted with dementia with mood disturbance and had a urinary catheter. His MDS dated 7/10/25 coded him with limb restraints, and his care plan noted that hand mittens were present upon admission. The physician order dated 7/7/25 directed that he wear bilateral mittens at all times except during hygiene, and the July 2025 TAR showed nursing staff signed off the mittens as being in place from 7/7/25 through 7/25/25. During observation, the resident was seen lying in bed and later was observed without hand mittens. A CNA stated the resident was confused but did not pull at his urinary catheter during his stay at the facility. An LN stated the resident came to the facility with hand mittens at the family member’s request to prevent catheter pulling. The MDS nurse stated there was only a statement in the admission notes, no assessment was done for the mittens, there were no weekly nursing progress notes related to the mittens, and there was no evaluation of whether the resident still needed them. The DON stated the mittens should have been reevaluated, and education should have been provided to the family member to prevent unnecessary use of restraint.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident and his RP when the resident was transferred to the hospital. Resident 4 was admitted with diagnoses including metabolic encephalopathy, which can cause confusion, memory loss, and loss of consciousness. The admission record listed the resident’s wife as the RP, and the resident was transferred to the hospital due to difficulty breathing after the wife requested the transfer. A subsequent MDS indicated the resident was sent to an acute hospital and was anticipated to return to the facility. During interviews, an LN stated bed hold was not discussed with the resident or the RP and that a written bed hold notice was not given. The LN stated there should have been a bed hold notice to inform the resident and RP that there was an available bed when the resident returned from the acute hospital. The DSD and DON both stated there was no bed hold offered to the resident and RP, and the DON stated the facility expectation was for bed hold to be offered when residents were sent to the acute hospital. The facility policy titled Bed-Holds and Returns stated residents and/or representatives are informed in writing of the facility and state bed hold policies, including holding or reserving a resident’s bed during hospitalization.
Failure to Assess and Document Hand Mitten Use
Penalty
Summary
The facility failed to assess and document the use of hand mittens for one resident who was admitted with dementia with mood disturbance and a urinary catheter. The resident’s MDS coded a limb restraint, and the care plan stated that hand mittens were present upon admission. A physician order dated 7/7/25 directed the resident to wear bilateral mittens at all times except during hygiene to protect him from scratching and unaware wounding of his face, and the July 2025 TAR showed nursing staff signed off that the mittens were implemented from 7/7/25 to 7/25/25. During observation, the resident was found lying in bed with eyes closed; on a later observation, his upper extremities were exposed and no hand mittens were noted. A CNA stated the resident was confused and had initially had mittens because he had been grabbing his urinary catheter in the hospital, but did not exhibit that behavior during his stay at the facility. An LN stated there was no assessment done prior to the use of hand mittens, and the MDS nurse stated there was only a statement in the admission notes, no assessment before use, and no assessment of whether the resident still needed the mittens. The DON stated the expectation was for nursing staff to assess the resident’s need for mittens and identify less restrictive options before use.
Medication Given Without Ordered Food
Penalty
Summary
A Licensed Nurse failed to follow a physician’s order during medication administration for Resident 38. Resident 38 was admitted with diagnoses that included gastroesophageal reflux disease, and the MDS dated 8/4/25 showed a BIMS score of 3, indicating severely impaired cognition. During an observation on 8/13/25 at 8:46 A.M., LN 11 administered Amantadine to Resident 38 without offering food, even though the medication pack indicated it was to be given with food. The physician’s order dated 7/31/25 directed that Amantadine be given by mouth with breakfast and lunch. During the observation, LN 11 stated she should have given Resident 38 food such as applesauce with the medication as ordered by the physician. Resident 38 later stated she was not sure if she had eaten breakfast and that she took her medication from the nurse. The DON stated licensed nurses are expected to follow physician’s orders and medication instructions to prevent possible side effects and complications such as gastric upset with medications that must be given with meals.
Food Service Staff Incorrectly Calibrated Thermometer
Penalty
Summary
Food and nutrition services staff were not knowledgeable to safely and effectively carry out department functions when CK 1 incorrectly demonstrated how to calibrate a food thermometer. During an observation with the RD, FSD, and EC present, CK 1 placed ice in a metal bin, added a small amount of sink water, and immersed the thermometer with the probe touching the bottom of the bin. CK 1 stated this was how they had been trained to calibrate the thermometer. During interviews, the FSD stated that per facility policy, CK 1 should have used a small cup or container with ice, added water to the top of the container, and then submerged the thermometer. The FSD stated it was important to calibrate the food thermometer correctly to get the right temperature. The RD also stated the proper technique was to fill a cup with ice and water to the top, and that calibration was important to obtain the right food temperature and ensure the food was safe to consume. The facility policy titled Thermometers and Measuring Temperature, dated 10/1/22, stated that thermometer calibration should be verified by filling a cup or small container with ice, adding cold water to the top of the container, and inserting the thermometer probe into the ice water.
Failure to Wear Hair Restraint During Kitchen Food Handling
Penalty
Summary
The facility failed to ensure safe and sanitary measures were followed in the kitchen during dietary operations when a Dietary Aide was observed sorting food utensils and folding papers in the clean area of the food cart without wearing a hair net. During the observation, another Dietary Aide gestured to the staff member to put on a hair net. The observing Dietary Aide stated that kitchen staff were expected to wear a hair net when entering the kitchen to prevent hair from contaminating food. During an interview later that morning, the Dietary Aide stated she had been folding paper and placing food utensils in the food cart and had forgotten to wear a hair net. She stated it was important to wear a hair net at all times in the kitchen because hair could get into the food and contaminate it. The Registered Dietitian later stated that kitchen staff were expected to wear a hair net in the kitchen at all times so hair would be covered to prevent food contamination. The facility policy titled Uniform Dress Code stated that associates working with food must wear the approved hair restraint when on duty regardless of length or presence of hair.
Failure to Follow EBP During Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when a licensed nurse did not follow the facility’s guidance for Enhanced Barrier Precautions during medication administration. Resident 66 was admitted with diagnoses that included a stage 3 pressure ulcer of the sacral region and had a sign posted in the room indicating EBP. During observation of medication administration, the nurse prepared the resident’s medication and entered the room without PPE, then administered enoxaparin by subcutaneous injection. The nurse exited the room without performing hand hygiene before or after the medication administration. During interview, the nurse stated the resident was on EBP and acknowledged not wearing PPE such as gown and gloves while administering medication, and stated PPE was important to prevent the spread of infection to other residents. The DON stated it was important for staff to perform hand hygiene before and after resident care and to put on PPE to prevent the spread of infection to all residents. The facility’s guidance on enhanced barrier precaution indicated EBP should be followed when performing close physical contact and that hand hygiene is recommended before and after resident contact.
Failure to Timely Report Abuse Investigation Results to State Agency
Penalty
Summary
The facility failed to send the results of an investigation into an alleged staff-to-resident abuse incident to the California Department of Public Health (CDPH) within the required five working days. The incident involved a resident with dementia who was admitted to the facility and was the subject of an abuse allegation involving a staff member. The facility became aware of the alleged abuse on 4/15/25 and initiated an investigation on the same day. According to interviews and record reviews, the investigation was completed and the results were sent to CDPH seven working days after the facility became aware of the incident, exceeding the five working day requirement. The facility's own policy, revised in 10/2023, specifies that the results of all abuse investigations must be reported to the state survey and certification agency within five working days. The administrator confirmed that the results were not sent within the required timeframe.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Ocean View Post Acute | 0.6 mi | ★★★★★ | 0 | 0 |
| Valley Vista Post Acute | 0.7 mi | ★★★★★ | 24 | 0 |
| Palomar Vista Healthcare Center | 1.4 mi | ★★★★★ | 32 | 0 |
| Escondido Post Acute | 1.7 mi | ★★★★★ | 2 | 0 |
| Palomar Heights Post Acute | 1.9 mi | ★★★★★ | 4 | 0 |
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