Deficiency Records for The Redwoods, A Community of Seniors
Updated as of March 01, 2024
A list of the most recent deficiencies for The Redwoods, A Community of Seniors. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-27 | 2023-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-27 | 2023-11-17 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-05-25 | 2023-06-25 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-18 | 2022-05-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-18 | 2022-05-05 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-18 | 2022-04-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-18 | 2022-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-18 | 2022-04-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-02-18 | 2022-04-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-18 | 2022-04-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-18 | 2022-04-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-18 | 2022-04-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-18 | 2022-04-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-18 | 2022-04-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-02-18 | 2022-04-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-18 | 2022-04-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-18 | 2022-04-14 | Y |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-03-03 | 2022-04-04 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-03-03 | 2022-04-04 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-03-03 | 2022-04-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-03 | 2022-04-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-03 | 2022-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-03 | 2022-04-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-03 | 2022-04-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-03 | 2022-04-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-03 | 2022-04-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-03 | 2022-04-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-03 | 2022-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-13 | 2021-07-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Use approved construction type or materials. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-25 | 2020-01-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-25 | 2020-01-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-25 | 2020-01-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-25 | 2020-01-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-25 | 2020-01-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-25 | 2020-01-13 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-04-02 | 2019-04-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-02 | 2019-04-16 | N |
| Use approved construction type or materials. | Fire Safety | 2019-04-02 | 2019-04-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-02 | 2019-04-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-04-02 | 2019-04-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-02 | 2019-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-02 | 2019-04-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-02 | 2019-04-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-12-19 | 2019-03-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-19 | 2019-03-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-19 | 2019-03-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-19 | 2019-03-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-12-19 | 2019-03-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-12-19 | 2019-03-08 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-12-19 | 2019-03-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-19 | 2019-03-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-19 | 2019-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-19 | 2019-03-08 | N |
