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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Redwoods Post-acute during CMS and state inspections, most recent first.
Incomplete Documentation of Ordered Skin Treatments, ADL Assistance, and Meal Intake: A resident with Huntington's disease had physician-ordered skin treatments for cellulitis and a body rash, but the TAR lacked documentation on multiple days that the treatments were provided. The EHR also lacked documentation on many days/shifts for ADL assistance with eating, oral hygiene, and toileting hygiene, and lacked meal intake percentages for many meals. LNs confirmed the missing documentation should have been entered in the record.
The facility failed to ensure residents were free from unnecessary psychotropic medications. A resident received multiple psychotropic drugs without documented non-drug interventions or side effect monitoring. Another resident had a PRN order without a 14-day limit, and a third resident's trazodone use was not monitored for effectiveness. The DON confirmed these deficiencies during record reviews and interviews.
A survey found a medication error rate of 11.11% in an LTC facility. Errors included a nurse failing to administer a 5% lidocaine patch due to unavailability, another nurse not removing a previous day's patch as scheduled, and a nurse administering chewable aspirin instead of the prescribed enteric-coated formulation. These actions did not comply with prescriber orders.
The facility was found deficient in maintaining kitchen sanitation practices when two ceiling exhaust fans above the food preparation area were observed to be dirty and dusty with grey lint. The Maintenance Director confirmed the dust and stated that the kitchen was cleaned monthly. The Registered Dietitian also confirmed the unclean state of the fans, highlighting the need for cleanliness in the food preparation area.
The facility failed to ensure that one of two trash dumpsters had its lid closed completely, potentially attracting pests that could spread diseases to the 150 residents. The Dietary Supervisor and Maintenance Director confirmed the issue, and the Infection Preventionist Nurse emphasized the importance of fully closed lids to prevent animal entry and control infection. Facility policies require tight-fitting lids on garbage containers.
The facility failed to complete advance directives or POLST forms for three residents, leaving sections blank and not indicating if directives were in place. The DON confirmed the forms were incomplete, despite the facility's policy requiring these documents to be reviewed and completed upon admission.
A resident with diagnoses including parkinsonism and schizoaffective disorder consistently refused to participate in activities, yet the facility failed to develop a care plan addressing this behavior. Observations and staff interviews confirmed the lack of a care plan, which was contrary to the facility's policy requiring comprehensive, person-centered care plans.
The facility failed to provide proper care for two residents. One resident did not have a care plan or follow-up for hand contractures, despite expressing the need for therapy. Another resident had blood pressure taken on an arm with an AV fistula, against facility policy. Both issues were acknowledged by the nursing staff.
A resident did not receive three prescribed medications for four days due to a lack of follow-up with the pharmacy. Additionally, two nurses failed to use appropriate PPE when handling hazardous drugs, despite facility policies requiring it. These deficiencies were observed during a survey in the LTC facility.
A facility failed to monitor a resident for signs of bleeding while on apixaban and clopidogrel, medications with increased bleeding risk. The resident, with atrial fibrillation and PCI, had no documented monitoring for adverse effects, despite care plan instructions and facility policy requiring such monitoring. The DON confirmed the lack of monitoring in the MAR.
A resident with a history of diabetes and previous ulcers was admitted with a stage II pressure ulcer, but the facility failed to obtain timely measurements and treatment orders. The treatment nurse did not measure the ulcer upon identification, and a treatment order was delayed by six days. Both the treatment nurse and DON confirmed these deficiencies, which were contrary to the facility's policy on pressure injury risk assessment.
A resident underwent multiple room changes without receiving the required written notice or consent forms, as confirmed by staff interviews and record reviews. Additionally, the facility failed to document behavior or psychosocial monitoring for 72 hours after one of the room changes, contrary to its policy.
A facility failed to accurately complete an MDS for a resident with congestive heart failure, ascites, muscle weakness, and mobility issues. The MDS nurse confirmed that the resident had fallen, but the MDS was incorrectly coded, indicating no fall occurred. This inaccuracy could compromise the facility's ability to address the resident's needs.
A facility failed to document a resident's daily weight and notify the physician of significant abdominal girth increases, as ordered. The resident, with congestive heart failure and ascites, had 29 days of undocumented weights and multiple instances of unreported abdominal girth increases. These omissions were confirmed by an LPN during a record review.
The facility failed to develop a comprehensive person-centered care plan for a resident with onychomycosis, despite the resident's diagnoses of paraplegia, schizoaffective disorder, and tinea unguium. The Director of Nursing confirmed the absence of a care plan during a record review.
Incomplete Documentation of Ordered Skin Treatments, ADL Assistance, and Meal Intake
Penalty
Summary
The facility failed to maintain a complete medical record for one sampled resident with Huntington's disease who was admitted with diagnoses including cellulitis of the left upper extremity and a rash to the entire body. The resident had physician orders for skin care treatments, including cleansing the left upper extremity cellulitis with normal saline, patting dry, applying hydrocortisone 1% cream, and leaving open to air twice daily, as well as cleansing the rash to the entire body with normal saline, patting dry, and applying zinc oxide and hydrocortisone 1% cream twice daily. Review of the treatment administration record showed multiple days with no documentation that the ordered treatments were provided for the left upper extremity cellulitis and the entire body rash. The record also showed missing documentation for the resident's daily care and nutrition. The Documentation Survey Report contained a section for staff to record assistance with eating, oral hygiene, and toileting hygiene, but from 4/1/24 to 4/28/25 there were 63 days and 67 shifts with no documentation that assistance was provided for those ADLs. In addition, the same report had a section for documenting meal intake, but from 4/1/24 to 4/28/25 there were 36 days and 67 meals with no documentation of the percentage of food the resident ate. During interviews, licensed nurses confirmed that skin treatments, ADL assistance, and meal intake should be documented in the EHR/TAR when provided.
Failure to Monitor and Limit Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Resident 92 was administered four psychotropic medications without documented evidence of attempted or contraindicated non-pharmacological interventions prior to initiating or increasing these medications. Additionally, there was no monitoring for side effects of aripiprazole since July 2024. The Director of Nursing (DON) confirmed the lack of monitoring and documentation of non-drug interventions during interviews. Resident 307 received a PRN order for prochlorperazine without a 14-day limit, which is against the facility's policy. The DON confirmed the absence of a 14-day limit for this medication order during a review of the resident's clinical record. This oversight could lead to prolonged and potentially unnecessary use of the medication. Resident 400 was prescribed trazodone for insomnia, but there was no monitoring of the hours of sleep to assess the medication's effectiveness. The DON acknowledged that the staff should have been monitoring the hours of sleep to determine the trazodone's efficacy. The facility's policy requires adequate monitoring for efficacy and adverse consequences of psychotropic medications, which was not adhered to in these cases.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 11.11% during a survey, with three errors occurring out of 27 opportunities. One error involved a Licensed Vocational Nurse (LVN) failing to administer a prescribed 5% lidocaine patch to a resident due to the unavailability of the correct patch strength. The nurse documented the issue and informed the pharmacy, physician, and family, but the resident did not receive the medication as prescribed. Another error involved a resident who had a lidocaine patch applied without the previous day's patch being removed as scheduled. The nurse confirmed the oversight and noted that there was no documentation of the resident refusing the removal of the patch. Additionally, a third error occurred when a nurse administered a chewable aspirin to a resident instead of the prescribed enteric-coated, delayed-release formulation. The facility's policy requires medications to be administered according to prescriber orders, which was not followed in these instances.
Deficiency in Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in the kitchen, as observed during a survey. Two ceiling exhaust fans located above the food preparation area were found to be dirty and covered with grey lint. This was confirmed during an observation and interview with the Maintenance Director, who acknowledged the presence of dust and stated that the kitchen was cleaned monthly. Additionally, the Registered Dietitian confirmed the unclean state of the exhaust fans and emphasized that the food preparation area should be clean. The facility's policy on sanitization, revised in November 2022, requires that all kitchen and dining areas be kept clean and free from debris.
Improper Closure of Trash Dumpster Lids
Penalty
Summary
The facility failed to ensure that one of two trash dumpsters had its lid closed completely, which had the potential to attract pests that could spread diseases and bacteria to the 150 residents residing at the facility. During an observation and interview with the Dietary Supervisor, it was noted that the lid of a trash dumpster behind the kitchen was open and not closed completely flat. The Dietary Supervisor acknowledged that trash container lids should be closed completely. Similarly, the Maintenance Director confirmed that one of the trash dumpster's lids was not completely closed and stated that all facility garbage is disposed of in these dumpsters, which should have their lids closed. The Infection Preventionist Nurse also stated that the trash dumpsters should be fully closed with no space in between the lid to prevent animals from entering and to control infection. A review of the facility's policies and procedures on food-related garbage and refuse disposal indicated that all garbage and refuse containers should have tight-fitting lids and must be kept covered when stored or not in continuous use. Additionally, garbage and refuse containing food wastes should be stored in a manner that is inaccessible to pests.
Incomplete Advance Directives and POLST Forms
Penalty
Summary
The facility failed to ensure that advance directives (AD) or Physician Orders for Life-Sustaining Treatment (POLST) were completed for three residents. Specifically, the POLST forms for Residents 29, 31, and 32 were found to be incomplete. The AD sections of the POLST forms for these residents were left blank, and there was no indication whether an advance directive was in place or unavailable. Additionally, Resident 29's POLST form lacked information regarding choices about artificially administered nutrition, such as feeding tubes. During an interview and concurrent record review, the Director of Nursing (DON) confirmed that the POLST forms for these residents were incomplete. The DON stated that the admission nurse is responsible for reviewing the POLST form with the resident or their responsible party to discuss their medical treatment preferences. The facility's policy on advance directives, revised in September 2022, indicates that residents should be provided with information about their rights to accept or refuse treatment and to formulate an advance directive upon admission. However, this policy was not adhered to, leading to the incomplete documentation.
Failure to Develop Comprehensive Care Plan for Resident Refusal of Activities
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for a resident, identified as Resident 301, who consistently refused to participate in activities offered by the facility. Despite observations and interviews confirming the resident's refusals, there was no care plan addressing this behavior. The resident, who was readmitted to the facility with diagnoses including unspecified parkinsonism, unspecified schizoaffective disorder, and generalized muscle weakness, was observed on multiple occasions lying in bed, calm and verbally responsive, yet refusing to engage in activities. Interviews with facility staff, including an activity assistant, the assistant director of nursing, and the director of nursing, confirmed that the resident's refusal to participate in activities was not care planned, monitored, or followed up. The facility's policy on comprehensive, person-centered care plans, which requires the development and implementation of care plans with measurable objectives and timetables to meet residents' needs, was not adhered to in this case. This oversight had the potential to impact the resident's well-being by not providing necessary interventions and monitoring.
Failure to Provide Proper Care for Hand Contractures and Incorrect BP Monitoring
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents. For Resident 8, there was no care plan, monitoring, or follow-up for her hand contractures. Despite being alert and verbally responsive, Resident 8 expressed that she was not receiving therapy for her contracted hands, which she believed would be beneficial. Her clinical records showed a lack of care planning for her condition, and both the Assistant Director of Nursing and the Director of Nursing acknowledged that the hand contractures should have been addressed to prevent deterioration. For Resident 400, the staff repeatedly took blood pressure measurements on the left arm, where the resident had an AV fistula for dialysis access. This was contrary to the facility's policy, which prohibits blood pressure measurements on the extremity with an access site due to the risk of interfering with blood flow. The Director of Nursing confirmed that the blood pressure readings were incorrectly taken on the left arm, acknowledging the oversight in following the facility's procedures.
Pharmaceutical Service and PPE Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, resulting in three medications being unavailable for administration over a period of four days. The resident, who was admitted with diagnoses including glaucoma and unspecified vision loss, was prescribed three eye medications and levothyroxine for hypothyroidism. However, the medications Vyzulta, Xiidra, and levothyroxine were not administered from January 10 to January 13. The nursing staff noted the medications were in transit but did not follow up with the pharmacy effectively, leading to a delay in medication delivery. The Assistant Director of Nursing confirmed that the facility staff should have followed up daily with the pharmacy, and the medications were not received until the day of the survey. Additionally, the facility failed to ensure that nursing staff used appropriate personal protective equipment (PPE) when handling hazardous drugs. During medication administration observations, two licensed vocational nurses were seen preparing and administering hazardous drugs without wearing gloves or any special PPE. The drugs involved included megestrol and divalproex, both labeled with a hazardous drugs sticker. The nurses were unaware of the special handling procedures required for hazardous drugs, despite the facility's policy and procedures indicating the necessity of wearing appropriate PPE during handling and administration. The Director of Nursing acknowledged that an in-service training had been provided the previous year regarding the handling of hazardous drugs, emphasizing the need for careful handling and the use of gloves. However, the observations revealed a lack of adherence to these procedures, posing a potential risk of exposure to hazardous medications for both staff and residents.
Failure to Monitor Anticoagulant Complications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not monitoring for signs and symptoms of bleeding while the resident was receiving two medications with an increased risk for bleeding: apixaban and clopidogrel. The resident, who was admitted with diagnoses including atrial fibrillation and percutaneous coronary intervention, was prescribed these medications to prevent blood clots and manage heart conditions. However, there was no documentation in the resident's clinical record indicating that the nursing staff was monitoring for adverse effects such as bleeding or bruising, which are potential complications of these medications. The care plan for the resident included instructions to monitor and report signs and symptoms of anticoagulant complications, but this was not reflected in the medication administration record (MAR). During an interview, the Director of Nursing confirmed that there was no monitoring for bleeding and other symptoms related to the use of apixaban and clopidogrel in the MAR. The facility's policy on anticoagulants, revised in 2017, required staff and physicians to monitor for possible complications in individuals receiving anticoagulation therapy, but this was not adhered to in the case of this resident.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care for a resident with a pressure ulcer, as evidenced by the lack of timely measurements and treatment orders. Upon admission, the resident, who had a history of multiple health issues including diabetes and a previous diabetic foot ulcer, was identified with a stage II pressure ulcer on the bilateral buttocks. However, the licensed nurse did not obtain measurements of the pressure ulcer, which are crucial for assessing the wound's progression and effectiveness of treatment. Furthermore, no treatment order was obtained for six days following the identification of the pressure ulcer. Interviews with the treatment nurse and the director of nursing confirmed these deficiencies. The treatment nurse acknowledged that she did not measure the wounds during her initial assessment and that a treatment order should have been obtained immediately upon identifying the pressure ulcer. The director of nursing also confirmed the absence of documented measurements and treatment orders, emphasizing that these should have been recorded and obtained at the time of admission or when the ulcer was first identified. The facility's policy on pressure injury risk assessment supports the need for immediate documentation and treatment planning, which was not adhered to in this case.
Failure to Provide Written Notice and Monitoring After Room Changes
Penalty
Summary
The facility failed to provide written notice prior to multiple room changes for a resident, which compromised the resident's rights. The resident experienced room changes on three occasions, and there was no documentation indicating that the facility completed the required Room Transfer form or consent form before these changes. This lack of documentation was confirmed by both social services staff and a licensed nurse during interviews and record reviews. Additionally, the facility did not document behavior or psychosocial monitoring for 72 hours following one of the room changes. This omission could have affected the facility's ability to identify and address any complications arising from the room change. The facility's policy requires that residents receive advanced written notice before a room change, but this was not adhered to in the case of the resident in question.
Inaccurate MDS Completion for a Resident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) for one of the sampled residents, identified as Resident 1. This deficiency was identified during an interview and record review with MDS nurse A, who confirmed that Resident 1 had experienced a fall, which was not accurately documented in the MDS. Resident 1's clinical record indicated diagnoses of congestive heart failure, ascites, muscle weakness, and abnormalities of gait and mobility. Despite these conditions, the MDS dated [DATE] incorrectly coded section J1800 as 'No,' indicating that Resident 1 did not fall during the specified time frame, when it should have been coded 'Yes.' This inaccuracy had the potential to compromise the facility's ability to develop and implement appropriate interventions to meet the resident's needs.
Failure to Document and Notify Physician of Resident's Weight and Abdominal Girth Changes
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident with congestive heart failure and ascites. The resident had a physician's order for daily weights and to inform the physician if there was a weight gain of two pounds or more in a day. However, from November 1, 2023, to February 29, 2024, there were 29 days where the resident's daily weight was not documented, and there was no indication that the resident refused to be weighed. This lack of documentation was confirmed by a licensed nurse during an interview and record review. Additionally, the resident had a physician's order to measure abdominal girth daily and notify the physician of an increase of more than three centimeters. On several occasions, the resident's abdominal girth increased by more than three centimeters, but there was no documentation that the physician was notified. This was also confirmed by the licensed nurse during the interview and record review. These failures had the potential to negatively affect the resident's health and well-being.
Failure to Develop Comprehensive Care Plan for Onychomycosis
Penalty
Summary
The facility failed to follow their policy and procedure to develop a comprehensive person-centered care plan for a resident to address the management of onychomycosis. The resident had diagnoses of paraplegia, schizoaffective disorder, and tinea unguium. During an interview and concurrent record review with the Director of Nursing, it was confirmed that there was no care plan in place to address the management of the resident's onychomycosis. The facility's policy, revised in March 2022, requires a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs, which was not implemented in this case.
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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 San Jose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Empress Care Center, Llc | 1.1 mi | ★★★★★ | 0 | 0 |
| White Blossom Care Center | 1.2 mi | ★★★★★ | 22 | 0 |
| Herman Health Care Center | 1.4 mi | ★★★★★ | 31 | 0 |
| Lincoln Glen Skilled Nursing | 1.8 mi | ★★★★★ | 0 | 0 |
| A Grace Sub Acute & Skilled Care | 2.2 mi | ★★★★★ | 3 | 0 |
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