Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Redwood Health & Rehab during CMS and state inspections, most recent first.
Improper food storage and handling were observed in the kitchen. Dented cans were found in dry storage for use, a cardboard box of pound cakes in the walk-in freezer was dark and covered in frozen condensation, and six divided plates were stacked wet in the dishwashing area. The Dietary Manager stated staff sometimes forgot correct kitchen practices and that the box had been placed in the wrong spot on the shelf under the freezer fan.
A resident with MS, paraplegia, and a manual wheelchair spilled hot noodles on himself and reported burns and severe pain to a medication aide and later to an RN, but neither staff member assessed the injury, notified the MD/NP, or documented the event that evening. The resident was not evaluated until the next morning, when the burns on his abdomen and thigh were found and treated; the NP later described them as stage 2 thermal burns.
Failure to Notify Hospice Before EMS Transfer: A resident on hospice care fell, became lethargic with very low O2 sats, and was sent to the ED after EMS was called. Nurse staff did not notify the hospice on-call provider or the NP before the transfer, and hospice later confirmed it had not been contacted about the event. Interviews with the RP, hospice staff, and facility staff showed the resident did not want aggressive treatment or hospitalization, but the facility still arranged the hospital transfer without hospice coordination.
A facility failed to ensure working call lights were available for three moderately cognitively impaired residents. During observation, each resident’s call light did not activate the hallway indicator, and no hand bell was present in the rooms for two of the residents; staff, including an RN, NA, Maintenance, DON, and Administrator, stated they were not aware of the problem before it was identified.
An opened bottle of antacid was left unattended in a resident's room without physician order or self-administration assessment, and three unopened bottles of Latanoprost eye drops were improperly stored at room temperature instead of being refrigerated as required by the manufacturer. Nursing staff did not notice or report the unattended medication, and the improperly stored eye drops were found during a medication cart audit.
A resident who was hospitalized returned to find several personal belongings, including an iPad Pro and a prosthetic leg, missing after facility staff had packed and stored the items. Despite staff assertions that the boxes were securely sealed and no evidence of tampering, the items were not recovered, and the facility was unable to account for the loss, resulting in a failure to protect the resident's property.
A dependent, bedbound resident with severe cognitive impairment was unable to access the light switch in her room due to a broken cord, leaving her reliant on staff for assistance. The issue was not identified by the maintenance or nursing staff during routine checks, and the resident expressed frustration at the lack of control over her environment.
A resident's advance directive status was inconsistently documented, with the care plan listing full code while both the physician's order and the advance directive binder indicated DNR. Nursing staff and the MDS Coordinator acknowledged the oversight, and the discrepancy was attributed to a missed update in the care plan.
A resident with diabetes and peripheral vascular disease was found to have long, painful toenails after missing a scheduled podiatry clinic due to hospitalization. Despite reporting discomfort to staff, her foot care needs were not addressed in a timely manner, and she remained on the list for the next podiatry clinic without alternative arrangements being made.
A dietary manager with a beard assisted with plating food in the kitchen without wearing a required facial hair covering. Although he stated he typically wore one, he had not planned to stay at the facility but was asked to remain and help with food service. Both the Culinary Director and Administrator confirmed that facial hair coverings are always required for staff with facial hair in the kitchen.
A resident with opioid dependence received PRN Percocet for pain, but two doses administered by a nurse were not documented in the eMAR, although they were recorded on the controlled substance declining sheet. Nursing progress notes also lacked documentation of the resident's need for the medication on those days. Both the DON and Administrator confirmed that all controlled substances should be consistently documented in both records.
Two nurse aides provided incontinence care to a resident with a physician order for contact precautions due to a multidrug-resistant organism, but only wore gloves and did not use gowns as required. The correct signage for contact precautions was not posted on the resident's door, leading to staff being unaware of the need for additional PPE. Facility leadership confirmed that the required contact precaution sign was missing and that staff should have used both gown and gloves.
Improper Food Storage and Handling
Penalty
Summary
Food was not stored, prepared, and handled in accordance with professional standards in the kitchen areas observed. During an initial tour of the main kitchen, a 108 oz. can of applesauce with a large dent on the rim and side, a 6.62 lb. can of mandarin oranges with a small dent on the rim, and a 7 lb. can of vanilla pudding with a small dent on the rim were found stored in the dry storage area for use. In the walk-in freezer, a cardboard box containing 12-pound cakes was stored under the main cooling fan; the box was dark in appearance and covered in frozen condensation. In the dishwasher area, six divided plates were stacked while still wet. The Dietary Manager stated she had in-serviced kitchen staff on proper drying of dining supplies, inspecting cans for dents, and proper storage in the freezer. She also stated staff sometimes did not pay attention and forgot correct kitchen practices. Regarding the cardboard box in the freezer, she stated it belonged to the Activities department and had been placed in the incorrect spot on the shelf, allowing condensation to drip on it. She stated dented cans were intended to be pulled from rotation and sent back to the distributer for credit. The Administrator stated he expected staff to properly store items in the walk-in freezer and to store divided plates correctly, and he indicated kitchen staff who assist with unloading the food distribution truck would be educated on proper can storage in the dry storage area.
Failure to Assess and Treat Resident Burn Injury Promptly
Penalty
Summary
The facility failed to provide clinical assessment and treatment when a cognitively intact resident accidentally spilled a cup of hot noodles on himself and reported that he had been burned. The resident had diagnoses including multiple sclerosis, paraplegia, muscle weakness, and lower-extremity contractures, and he used a manual wheelchair. He stated that after the spill he cleaned himself up, changed clothes, and later told a medication aide that he had burned himself and was having pain rated 8 out of 10. The medication aide gave him his PRN hydrocodone, but no assessment or treatment of the burn was provided at that time. The resident also stated that he later told the second-shift nurse about the burn, but she did not assess the injury, provide treatment, or contact the physician. The medication aide confirmed that the resident reported the burn to her, that she gave the PRN pain medication, and that she did not assess or treat the burns that evening. The second-shift nurse stated she did not recall being told about the burn and did not assess the resident or notify the physician. The resident was not physically assessed for the injury until the following morning when the first-shift nurse was informed. When the first-shift nurse assessed the resident the next morning, the burns were documented on the right lower abdomen and right upper thigh, and the nurse notified the NP and wound nurse. The NP later described the injuries as stage 2 thermal burns. The NP stated he was not notified on the evening the incident occurred and would have wanted to be notified so an initial assessment could have been made. The DON and Administrator both stated that staff should have immediately reported the incident, assessed the resident, notified the physician, and documented the event, and they agreed that the medication aide and second-shift nurse did not do so.
Failure to Notify Hospice Before Hospital Transfer
Penalty
Summary
The facility failed to ensure effective communication and coordination of care with the hospice provider for a resident receiving hospice services. The resident was admitted under hospice with diagnoses including protein-calorie malnutrition and ascorbic acid deficiency, and his care plan and physician orders directed staff to notify hospice of changes in condition or concerns. The hospice agreement also required the facility to notify hospice immediately of significant changes in the resident’s status, clinical complications, a need to transfer, or death. On the night of the event, the resident fell in his room and was assessed by Nurse #1, who documented that he appeared lethargic, was assisted back to bed, and then became restless and repeatedly stated he was having difficulty breathing. A pulse oximetry reading was obtained and was noted to be in the low 60s, after which oxygen was applied. EMS was contacted and the resident was transported to the hospital for further evaluation and treatment. The record did not show physician orders to send the resident to the ED on that date, and the hospice on-call provider was not notified before EMS was called. Interviews confirmed that hospice was not contacted about the fall or transfer. Nurse #1 stated she did not call hospice or the NP, and the former weekend supervisor stated he did not make any calls to hospice, the NP on-call service, or the RP regarding the resident. Hospice staff stated they were not contacted and learned of the hospitalization the next day when the RP called. The RP stated the resident did not want hospital treatment and that hospice was not called for orders or evaluation before the transfer. Hospital records later showed the resident had a fractured rib, pneumonia, and osteomyelitis, and hospice was contacted by hospital staff regarding comfort measures.
Nonfunctioning Call Lights for Three Residents
Penalty
Summary
The facility failed to ensure a working call light system was available for three residents who required assistance with activities of daily living. Resident #5, who was moderately cognitively impaired, had a room call light that did not activate the hallway light when pressed during observation, and the resident stated he was not aware it was not working and might have to yell for help if needed. No manual hand bell was present in the room, and the Unit Manager stated she was not aware of the problem until it was observed. Resident #19, who was also moderately cognitively impaired, had a call light that did not light the hallway indicator when tested, and no hand bell was present in the room. Resident #48, who was moderately cognitively impaired, also had a call light that did not activate the hallway light when pressed, and no hand bell was present in the room. Staff interviewed, including a nurse, a nurse aide, the Maintenance Director, the Maintenance Assistant, the DON, and the Administrator, stated they were not aware of the nonfunctioning call lights before they were identified during the survey observations.
Failure to Secure and Properly Store Medications
Penalty
Summary
The facility failed to ensure proper storage and security of medications for residents. An opened bottle of liquid Pepto Bismol was found left unattended on top of a resident's bedside table, despite the resident not being assessed or approved for self-administration of medication and lacking a physician's order for the medication. The resident, who had moderately impaired cognition, stated that his wife brought the medication into the facility and left it in his room, and he had not used it. Both the nurse and nurse aide who provided care that morning did not notice the medication in the room, and neither reported it. Additionally, during a medication storage audit, three unopened bottles of Latanoprost eye drops were found stored at room temperature in a medication cart, contrary to the manufacturer's instructions that require refrigeration until opened. The bottles were unopened, with intact seals, but had been labeled with opening dates. The nurse present confirmed the improper storage and was unaware of who placed the medications in the cart. Both the DON and the Administrator stated that staff are expected to follow proper medication storage protocols and keep the facility free of unattended medications.
Failure to Protect Resident Property During Hospital Transfer
Penalty
Summary
A resident with a history of right above-the-knee amputation and brain neoplasm, who was cognitively intact, was sent to the hospital from the facility. During the resident's hospital stay, the facility packed up and removed the resident's belongings from his room. Upon return, the resident discovered that several personal items, including an Apple iPad Pro, a new bag of sleeveless t-shirts, some pants, and a right leg prosthesis, were missing from the two boxes returned to him. The resident reported the missing items to nursing staff and later filed a grievance regarding the loss of his iPad Pro. The resident expressed concern and disappointment over the missing property, particularly the iPad Pro. Facility staff interviews revealed inconsistencies and lack of clarity regarding the handling and documentation of the resident's belongings. The housekeeping manager stated he packed the items, including a tablet and prosthetic leg, and sealed the boxes with strong tape, asserting that tampering was unlikely. Nursing staff reported not having seen the missing items and indicated that housekeeping was responsible for packing. The administrator stated that valuables should be taken by residents or left with the social worker during hospital transfers, but acknowledged the resident's report of the missing items and did not know what happened to them. The facility failed to ensure reasonable care and protection of the resident's property from loss or theft during the resident's absence.
Failure to Ensure Resident Access to Light Switch Due to Broken Cord
Penalty
Summary
A deficiency occurred when a dependent resident with severely impaired cognition and recent stroke, who was bedbound, was unable to access the light switch in her room. The light switch was located behind the bed, approximately five feet from the floor and six feet from the bed, with a broken cord that was only three inches long. The resident reported she could not control the light and had to rely on staff for assistance, expressing frustration at repeatedly having to ask for help. She could not recall when the cord was broken. Observations confirmed the switch cord remained inaccessible, and both the Maintenance Director and a nurse acknowledged the issue. The Maintenance Director stated he conducted weekly walkthroughs and relied on staff to report repair needs, but did not notice the broken cord. The nurse providing care also did not notice the issue. The DON and Administrator both stated that staff were expected to be attentive to residents' environments and report repair needs promptly, but this did not occur in this instance.
Failure to Maintain Consistent Advance Directive Documentation
Penalty
Summary
The facility failed to maintain accuracy and consistency of a resident's advance directive throughout the medical record. One resident was admitted with an advance directive indicating full code status in the care plan, with interventions including the administration of CPR. However, a physician's order and the advance directive binder at the nurses' station both indicated the resident was designated as Do Not Resuscitate (DNR). This inconsistency was present across different documentation sources within the facility. During interviews, nursing staff and the MDS Coordinator acknowledged the discrepancy, noting that the care plan had not been updated to reflect the current DNR status. The MDS Coordinator, responsible for updating the care plan, stated that routine audits are conducted but was unable to explain why this resident's care plan was missed, attributing it to an oversight. The Director of Nursing and the Administrator both confirmed their expectation that the care plan should be updated in a timely manner to match any changes in code status.
Failure to Provide Timely Podiatry Care for Diabetic Resident
Penalty
Summary
A resident with diagnoses including type II diabetes mellitus, lymphedema, and peripheral vascular disease was admitted to the facility and had a care plan intervention for referral to a podiatrist or foot care nurse to monitor and document foot care needs, including cutting long nails. The resident was cognitively intact and required substantial to maximal assistance with personal hygiene. During an observation, the resident was found in bed with toenails that were jagged, pointed, and varied in length, with some measuring up to one inch. The resident reported pain from her long toenails, which prevented her from covering her feet with a sheet, and stated she had missed the most recent podiatry clinic due to hospitalization. She was unsure when she would next be seen by the podiatrist, despite having communicated her concerns to nursing staff. Review of the podiatry schedule confirmed the resident had not been seen at the last clinic due to hospitalization and was scheduled for the next clinic several weeks later. Staff interviews revealed that the resident's complaints about painful toenails were reported to a nurse, but the nurse was unaware of the pain and had not observed the toenails' condition. The DON was also unaware of the resident's pain following the missed clinic. The facility failed to provide timely podiatry care or alternative arrangements for foot care after the resident missed the scheduled clinic, resulting in prolonged discomfort and unaddressed foot care needs.
Dietary Staff Failed to Use Required Facial Hair Covering During Food Service
Penalty
Summary
During a follow-up kitchen tour, a dietary manager was observed assisting with plating food at the steam table while having a short, neatly trimmed beard that was not covered by a facial hair covering. The dietary manager stated he usually wore a facial hair covering but had not planned to stay at the facility, as he was originally there to pick up chemicals. However, after a phone call with the Culinary Director, he was asked to remain until her arrival and subsequently participated in food service without the required facial hair covering. Both the Culinary Director and the Administrator confirmed that facial hair coverings are always required for staff with facial hair in the kitchen, and acknowledged that the dietary manager should have been wearing one during food service.
Failure to Accurately Document PRN Controlled Substance Administration in eMAR
Penalty
Summary
The facility failed to maintain accurate and consistent documentation in the electronic medication administration record (eMAR) for a resident with a diagnosis of opioid dependence who had a physician's order for PRN Percocet for pain management. On two consecutive days, the eMAR did not reflect all administrations of Percocet, as two doses given around 10 PM each night were documented on the controlled substance declining sheet but not entered into the eMAR. The nurse responsible for administering these doses confirmed during an interview that he had provided the medication and signed it out on the controlled substance declining sheet, but failed to document the administration in the eMAR due to distractions. Further review of nursing progress notes revealed no documentation regarding the resident's need for PRN Percocet on the days in question. Both the Director of Nursing and the Administrator acknowledged that all controlled substances should be documented accurately and consistently in both the controlled substance declining sheet and the eMAR. The resident also confirmed receiving the medication at the times in question, corroborating the findings of incomplete documentation.
Failure to Implement Contact Precautions for Resident on Transmission-Based Precautions
Penalty
Summary
Two nurse aides failed to implement required Transmission-Based Precautions (TBP) while providing incontinence care to a resident with a physician order for contact precautions due to Enterobacter cloacae complex in her urine. During the observed care, both aides wore only gloves and did not use gowns, despite the facility's policy requiring both gloves and gowns for interactions involving contact with the resident or their environment under contact precautions. The signage on the resident's door indicated Enhanced Barrier Precautions (EBP) rather than the specific contact precautions required by the physician order. Interviews with the nurse aides revealed they were unaware the resident was on TBP, and the Director of Nursing confirmed that appropriate signage indicating the need for gown and gloves was not posted. The Assistant Director of Nursing acknowledged that he did not add a contact precaution sign because an EBP sign was already present for the roommate, not realizing this would not communicate the specific requirements for the resident in question. The administrator also confirmed that a contact precaution sign should have been posted per the physician order.
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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 Charlotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wilora Lake Healthcare | 0.7 mi | ★★★★★ | 4 | 0 |
| White Oak Manor - Charlotte | 2.1 mi | ★★★★★ | 10 | 2 |
| Asbury Health And Rehabilitation Center | 2.4 mi | ★★★★★ | 5 | 0 |
| Peak Resources - Charlotte | 2.5 mi | ★★★★★ | 0 | 0 |
| Shamrock Nursing Center | 3.1 mi | ★★★★★ | 0 | 0 |
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