Redwood Cove Healthcare Center

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program to provide a safe environment for all residents of the facility when the facility failed:1.implement and follow enhanced barrier precautions (EBP, an infection control intervention, primarily used in nursing homes, that involves the use of gowns and gloves during high-contact resident care activities to reduce the transmission of Multidrug-Resistant Organisms (MDRO)- microorganisms, primarily bacteria, that are resistant to one or more classes of antimicrobial agents) for Resident 7 and Resident 78, and 2. to review and revise, at least annually, the facility's infection prevention and control (IPC) policy and procedure (P&P). [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to designate at least one qualified infection preventionist (IP), for all residents of the facility, when the those performing the role of the IP had not completed specialized training or obtained certification in infection control and prevention. Lack of a qualified IP could lead to an increased risk of infections spreading among residents and staff.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and sanitary kitchen environment for all 63 residents of the facility, when the kitchen had cracked and broken floor tiles. This failure can increase the risk of trips and falls from the uneven surfaces and create an environment for molds and mildew growth.

Inspectors wroteBased on observation, interview and records review, the facility failed to have an effective pest control system for all 63 residents of the facility, when cockroaches were observed in the kitchen under the dish washing sink. This failure had the potential to cause food contamination and endanger the vulnerable residents of the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one out of 16 sampled residents (Resident 10) was informed in advance of the risks and benefits associated with a proposed treatment, when an informed consent (a voluntary agreement to accept treatment or procedures after receiving education about the associated risks, benefits, and available alternatives) was not obtained prior to the facility administering Resident 10 medication for depression. This failure placed Resident 10 at risk of receiving medication she might have declined had she been fully informed, potentially compromising her right to make informed decisions about her care.

Inspectors wroteBased on interview and record review, the facility failed to provide one of 16 sampled residents (Resident 46) with the opportunity to exercise her right to make a choice when her room was changed without her consent. This failure resulted in Resident 46 feeling upset and as though she didn't have a choice.

Inspectors wroteBased on interviews and record reviews, the facility failed, for three out of 16 sampled residents (Residents 1, 7 and 9), to ensure a written summary of the baseline care plan (BCP, a document created within 48 hours of a resident's admission, outlining the initial care needed, focusing on basic needs and resident-specific information) was provided to the resident and or the responsible party (RP, a person who is designated in making decisions about health care and financial matters) .This failure could compromise residents' safety, hinder effective communication, and could lead to adverse events, especially during the critical initial days of admission.

Inspectors wroteBased on observation, interview and record facility failed to ensure its medication error rate was less than 5 percent (% a unit of measure) when there were two errors out of 33 medication administration opportunities for a 6.06% medication error rate. This failure decreased the facility's potential to safely administer medications per physician's orders and prevent the risk of adverse outcomes.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure medications were stored safely for one out of 16 sampled residents (Resident 6), when Resident 6 was allowed to self-administer aspirin (ASA) and antacid tablets as well as keep the ASA and antacid tablets at her bedside with no assessment or physician's order. These failures put Resident 6 at risk for medication error and misuse.

Inspectors wroteBased on interview and record review, the facility failed to treat one resident (Resident 1) out of three sampled residents with dignity and respect when facility staff entered Resident 1's room without announcing themselves or being invited in. This failure caused Resident 1 to feel anxious and unsafe in his room. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Chronic Venous Hypertension (a condition characterized by high pressure inside the veins, most commonly in the legs) with ulcer (an open sore on the skin) of left lower extremity (leg) and Chronic Post Traumatic Stress Disorder (a mental health condition that can develop after experiencing a terrifying or dangerous event). [...]

Inspectors wroteBased on interviews and document reviews, the facility failed to ensure Certified Nursing Assistants (CNA) possessed a current and active certificate in accordance with applicable State laws when one CNA (CNA A) of a sample of nine CNAs had an expired certificate. This failure decreased the facility's potential to provide safe resident care within CNA A's scope of practice.

Inspectors wroteBased on interview and record review, the facility failed to carry out a physician ' s order for one resident (Resident 1) of two sampled residents when nursing staff did not document they were monitoring Resident 1 ' s Peripherally Inserted Central Catheter (PICC line, a long, thin, flexible tube inserted into a vein in the upper arm and guided to a large vein near the heart used to deliver medication) insertion site every shift from 3/28/25 to 4/11/25. This failure increased the potential for a delay in identification of infection and negatively affect the health of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) of two sampled residents was free from a significant medication error when a dose of intravenous (IV- administered into a vein) antibiotic was not documented as administered on 4/5/25 per the physician's order. This failure had the potential to result in incomplete treatment and increase the risk of antibiotic resistance, making further infections harder to treat.

Inspectors wroteBased on interview and record review, the facility failed to ensure it designated a person to serve as the Director of Food and Nutrition Services who was certified, when the Registered Dietician (RD) was not employed full-time. This failure indicated the facility did not meet the Federal guidelines and did not follow the job description, when hiring a Dietary Manager (DM). During an interview on 4/29/24 at 10:01 a.m., the Dietary Manager (DM) stated she was not a Certified Dietary Manager. The DM stated the Registered Dietician (RD) only came in once every week on Wednesdays. The DM stated she did not receive consistent in-services and training's from the RD. During an interview on 4/30/24 at 3 p.m., the DM stated she was not a Certified DM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Resident Rights of 13 Sampled Residents (Resident 200, Resident 16, Resident 28, Resident 164, Resident 264, Resident 22, Resident 5, Resident 42, Resident 14, Resident 53, Resident 38, Resident 30 and Resident 31) were honored, when: 1. Ten Sampled Residents (Resident 200, Resident 16, Resident 28, Resident 164, Resident 264, Resident 22, Resident 5, Resident 42, Resident 14, and Resident 53) reported call light response times of up to two hours. This failure resulted in delay in care and a loss of dignity, when residents were not assisted with timely brief changes when soiled and had the potential to result in incontinent accidents, falls resulting in broken bones, soft tissue injuries, pressure ulcers, psychosocial harm, feelings of despair and depression. 2. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure a safe and sanitary environment for residents, when hand hygiene was not offered to residents before meals, when the hand hygiene P&P was not followed during medication administration, and cross-contamination risks were observed in linen storage and laundry processing areas.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure: 1. Staff were aware of what a Basic Care Plan (BCP, a plan that promotes continuity of care and communication among nursing home staff which should be completed within 48 hours of resident admission and contain the minimum healthcare information necessary to care for resident safely) was and its completion time frame. 2. The BCP was completed for one out of one sampled resident (Resident 216) and completed timely for seven out of eight sampled residents (Residents 10, 14, 20, 30, 31, 216, and 265). These failures had the potential to put residents' safety at risk and for residents not receiving the care they need.

Inspectors wroteBased on observations, interviews and record reviews, for a resident who had a tube feeding (method of feeding that uses the gastrointestinal (GI) tract to deliver nutrition and calories when you cannot eat or drink safely by mouth), the facility failed to: 1. periodically evaluate the amount of feeding being administered for one out one sampled resident (Resident 265), when staff did not know to calculate how much formula was given and how much formula should be left in the feeding bag in a period of time. 2. monitor Resident 265's input and output (I &O, important to help evaluate a person's fluid and electrolyte balance, to suggest various diagnosis, and allows for prompt intervention to correct the imbalance) to ensure she was receiving the calculated amount of tube feeding consistent with practitioner's orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Follow its Policy and Procedure for Medication Regimen Review. 2. Ensure staff knew what a glycoprotein-colony stimulating factor (G-CSF, used to increase the number of white blood cells in the blood, which helps your immune system fight infections and heal injuries, in patients receiving anticancer drugs) injection was. 3. Ensure the monthly Medication Regimen Review by the Pharmacist for Resident 14 was thorough and accurate, when the medication G-CSF injection was not listed on Resident 14's current medications, and staff did not notify the pharmacist Resident 14 was receiving G-CSF injection weekly. These failures had the potential to: 1. Cause serious physical and/or psychosocial harm when the facility did not forward pharmacy recommendations to any facility physician for five months, September 2023 through March 2024. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure food was palatable, and served at temperatures in accordance with resident preferences, for four out of five sampled residents (Residents 5, 14, 42 and 53), and the food temperature was not taken prior to serving to one out of 5 sampled residents (Resident 47). These failures could result in residents not eating the food served, which could result in weight loss and further compromise their medical status. Not taking the food temperature prior to serving to the resident could result in accidents such as burns.

Inspectors wroteBased on observation and interviews, the facility failed to ensure food items in the refrigerator, freezer and dry pantry area were opened- and discard-dated and expired food items were discarded. These failures led to unsafe and unsanitary storage of food. These failures were also a safety risk that could lead to accidental ingestion of expired food items that could result in food-borne illness (an illness that comes from eating contaminated food).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an effective Infection Control Program when: 1. Dirty and stained carpeting, broken floor surfaces, cracked wheelchair arm rests, exposed wall plaster, rust, and chipped paint were observed in patient care areas. 2. Cross-contamination risks were observed in Laundry Processing and storage areas, Clean Utility Room, and resident Ice Storage Room. 3. Vaccination rates of staff and Residents and Hand Hygiene compliance was not monitored. These failures had the potential for resident infection, potential death from cross-contamination and infection, and psychosocial harm

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the kitchen walls were in good repair, when cracks and holes in the walls were noted during rounds, and the dish washing sink counter was rusty. These failures could result in rodents and pests accessing the kitchen area through these cracks and holes, which could put residents at risk for harmful diseases. The rusty kitchen sink counter created a breeding ground for bacteria as it could not be disinfected and cleaned thoroughly, which could be a safety risk.

Inspectors wroteBased on observation and interviews, the facility failed to maintain an effective pest control program to ensure the facility was free of pests or cockroaches, when a cockroach was seen crawling underneath the dish washing sink. This failure could lead to transfer of harmful bacteria to humans and could cause Salmonella (a group of bacteria that can cause diarrhea-3 or more loose, watery stool in a day, in humans), Leptospirosis (an infectious disease that damages the liver and kidneys), Typhoid Fever (a life-threatening infection that causes diarrhea and fever) and Cholera (an infectious disease that causes severe watery diarrhea). During a concurrent observation and interview on 5/1/24 at 7:23 a.m., a brownish-colored pest was crawling underneath the dishwashing sink area, which the Dietary Manager (DM) identified as a small cockroach. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were aware of and had access to, State Survey Agency contact information. This failure had the potential to interfere with residents' ability to file a complaint with the State Agency and possibly delay an investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the results of the most recent State Survey in a location readily accessible (a place where individuals wishing to examine survey results did not have to ask to see them) to residents, family members, and/or legal representatives of residents. This failure had the potential to prevent access to relevant information that could affect a resident's decision making, quality of care and/or quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the physician was notified for a significant weight loss (5% in 1 month, 10% in 3 months and 7.5 % in 6 months) for one out of one sampled resident (Resident 25). This failure had the potential to further aggravate and compromise her medical status.

Inspectors wroteThe facility did not ensure two sampled Residents (Resident 200, Resident 16) had useable prescription glasses. This failure resulted in the inability of Residents to read, be able to watch television, see what they were eating, or engage in activities that provided them joy. This failure made the Residents feel like they did not matter and were unimportant to the facility.

Inspectors wroteBased on observation and interview, the facility failed to properly label insulin pens (insulin delivery device that comes preloaded with insulin, including premixed insulin's) with resident information, when insulin pens were labeled on the outer plastic storage bag or on the cap of the pen instead of the shaft (the section of the pen that contains the insulin storage container). This failure had the potential to: 1. Expose residents to infectious agents if the insulin pens were used by more than one resident. 2. Cause serious adverse effects if a resident was given a dose and/or type of insulin prescribed for another resident.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the development of a plant-based menu. This failure had the potential for residents to not meet the Recommended Daily Intake (RDI, the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all (97-98 per cent) healthy individuals in a particular life stage and gender group) for certain nutrients like protein or vitamins,which could further compromise their medical status. During a concurrent observation and interview 5/1/24 at 7:23 a.m., the Dietary Manager (DM) stated the facility did not have a plant-based menu. The DM stated she asked their vendor and was told they did not have any plant-based menu being offered at this time, but they would be releasing a plant-based menu soon. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement its policies and procedures on infection prevention and control practices when: 1. An unlicensed staff did not perform hand hygiene and change her gloves between residents did not clean and disinfect the vital signs equipment between residents and after using the equipment. 2. Two staff did not wear proper PPE (Personal Protective Equipment) upon entering two resident rooms that were on transmission-based precautions. 3. Two licensed staff did not cleanse and disinfect vital sign equipment in-between residents and after using equipment. These failures did not ensure a clean physical environment for patient care and services, and had the potential to result in an outbreak of infections and illnesses to all residents of the facility.

Inspectors wroteBased on interviews, and record reviews, the facility failed to offer and document advance directives for 8 of 17 sampled residents (Resident 9, Resident 11, Resident 13, Resident 15, Resident 17, Resident 40, Resident 57, and Resident 163). This failure had the potential to result in facility performing care and services at residents' end-of-life that is inconsistent with the residents' best interests or preferences.

Inspectors wroteBased on observation, and interview, the facility failed to ensure access to telephone communication for residents, family members, staff, and outside affiliates was easily available. This failure denied residents, family members and medical staff consistent communication regarding the medical care for residents and had the potential to result in a delayed or non-delivery of care and services to its residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of the three sampled residents (Resident 50) was provided support with activities of daily living (ADL). This failure resulted in Resident 50 staying in bed throughout the survey, which had the potential to cause development of a pressure injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items in the refrigerator were labeled and dated. This failure had the potential to result in residents eating or drinking expired or contaminated food items, which could cause gastrointestinal illness for the vulnerable residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all areas of the facility were safe, sanitary, of comfortable, when facility staff allowed one resident's (Resident 61) room to become cluttered and odiferous. This failure resulted in added safety risk to Resident 61 related to obstacles in the physical environment that posed a risk to timely evacuation in time of emergency, as well as a strong, foul-smelling odor emitting into the adjacent hallway through the doorway of the resident's room.