Redwood Grove Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, infection control prevention was maintained, to one of twenty-nine residents affected with coronavirus disease 2019 (COVID-19, contagious disease caused by the severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2), (Resident 1), when Resident 1 was allowed to go to his medical appointment without informing the receiving healthcare facility in advance that Resident 1 had a pending COVID-19 testing result. This failure affected the way the receiving healthcare facility handled Resident 1 who eventually tested positive for COVID-19, and this could potentially spread to the staffs and patients of the receiving healthcare facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards for two of three sampled residents (Residents 1 and 2) when staff did not:1. accurately assess for fall risk and implement interventions to prevent further fall on 6/20/26 for Resident 1; and,2. implement interventions to prevent further falls for Resident 2. These failures led to Resident 1's unwitnessed fall on 6/20/26 which resulted in a left humerus fracture (broken upper arm bone) and Resident 2's unwitnessed fall on 6/29/26 which resulted in a cervical spine fracture (broken neck bone).

Inspectors wroteBased on interview, and record review, the facility failed to ensure to develop and implement comprehensive (thorough) person -centered care plan (individual care, treatments, and goals to resident's cultural, personal values, and lifestyle) for discharge that included discharge target, measurable objectives, and interventions for three of three sampled residents (Resident 1, 2, and 3). Above failure had the potential for lack of opportunity for resident/ resident representative (RP, a legally assigned person, authorized to make day to day decisions on behalf of the resident) right to participate in develop and implement person-centered plan of care decisions for discharge for Resident 1,2, and 3.

Inspectors wroteBased on interview and record review the facility failed to ensure pre-admission screening and resident review (PASRR- screening for residents with mental disorders and residents with intellectual disability) Level 1 screening was completed and submitted to state mental health authority for review for one of three sample resident (Resident 1) with significant change in mental illness (MI-a wide range of conditions that affect resident's mood, thinking, and behavior) and treatment plan. This failure had the potential for mentally ill Resident 1 not to received benefit from specialized health care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four residents (Resident 1) was treated with respect and dignity, when the occupational therapy assistant (OTA) made inappropriate gestures towards Resident 1. This failure had the potential to negatively affect Resident 1's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to properly perform and document discharge planning for one of six residents (Resident 1), when there was no documented discharge plan on the interdisciplinary team ( IDT, a group of healthcare professionals from different fields that work together towards common goal for a patient) meeting notes. This failure resulted in Resident 1 being discharged without a definitive plan documented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to render care and service based on professional standards of practice for one of four residents (Resident 1) when the Licensed Vocational Nurse (LVN) incorrectly administered a medication. This failure had the potential to affect the resident's health and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure a phlebotomist sanitized items between residents' rooms for 2 (Resident #325 and Resident #326) of 9 residents reviewed as part of the infection control task, failed to ensure oxygen tubing and a nasal cannula was stored in a manner to prevent potential contamination when not in use for 1 (Resident #118) of 9 residents reviewed as part of the infection control task, and failed to ensure staff implemented enhanced barrier precautions (EBP) when providing care to 1 (Resident #1) of 4 residents reviewed for transmission-based precautions.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure multiple-resident rooms provided at least 80 square feet per resident for 10 (Rooms 101, 103, 105, 107, 109, 111, 114, 116, 118, and 119) of 70 resident rooms. Specifically, each of these 10 rooms had an approved capacity of two residents and provided a total of 143 square feet, or 71.5 square feet per resident when at full capacity.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when the facility did not follow the physician's order for Resident 1. This failure had the potential to result in Resident 1 not receiving needed care and treatment, as ordered by the physician.

Inspectors wroteBased on the observation, interview, and record review, the facility failed to adequately monitor and supervise one of three sampled residents (Resident 1) to prevent him from entering other female residents' rooms. This failure resulted to Resident 1 entering Residen 2 and Resident 3's room and could compromised the residents' rights to a safe environment in the facility.

Inspectors wroteBased on observation, interview, and record review, three of four sampled residents (Resident 2, 3 and 4) were not free from verbal abuse when Resident 1 cursed and threathened to harm Residents 2, 3, and 4. This failure had the potential to negatively impact the physical and mental well-being of all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their own policy and procedure for disposal of discontinued and/or medications left in the nursing care center for two of three residents (Resident 1 and Resident 2). This failure had the potential to result in the diversion of medications compromising resident's health and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy and procedure (P&P) when: 1. For Resident 1, staff did not report an incident of potential abuse to the state agency and other required agencies; and 2. The facility did not provide abuse training to all staff at least quarterly. These failures had the potential to delay the investigation of abuse allegations and place residents at risk for further potential abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe food handling practices when: 1. A refrigerator used to store residents' food brought in by visitors, which included TCS foods (foods that require time/temperature control to prevent bacterial growth) had recorded temperatures above 41 degrees F that were unaddressed by staff. Formerly known as Potentially Hazardous foods); and the facility did not ensure staff followed directions to label food items with an open date, the name of the resident and room number. An Immediate Jeopardy (IJ, a situation in which recipient(s) of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health safety requirements) was called on 2/14/22, at 5:07 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. The Registered Dietitian comprehensively evaluated the effectiveness of food service operations as evidenced by lapses in the delivery of services associated with meal palatability and nutritional value (cross-reference F804) food safety (cross-reference F812); and 2. A competent staff was in the position of the Director of Food and Nutrition services to oversee the day-to-day operations of Food and Nutrition Services, when the Registered Dietitian (RD) did not have full time work status. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored in a safe and sanitary manner, when food brought in by staff was not separate or easily distinguishable from resident food brought in by family members and/or other visitors. This failure had the potential for the contamination of resident food and/or residents receiving contaminated food, for 87 residents who ate food by mouth out of a facility census of 89.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that wastes were properly contained in garbage dumpsters when two out of three garbage dumpsters were overfilled with garbage, so lids were not closed, and three out of three garbage dumpsters had lids that would not lay flat when lowered. These failures had the potential to attract pests to the facility and expose residents to pest related disease for 89 residents out of a facility census of 89.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a sanitary environment in the staff breakroom where resident foods were stored when used beverage containers were located directly under the sink cabinet of the cabinet's black matter covered floor base. These failures had the potential to affect the health and safety of the staff and 89 residents at the facility by exposure to disease carrying pests.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently monitor temperatures for two out of three medication refrigerators. This failure had the potential to result in residents receiving medications with decreased potency or efficacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure palatability and nutritive value of cooked foods were maintained when: 1. The recipe for making pureed foods were not followed and 2. Pureed foods were held in the heated oven for an extended time. These failures had the potential to result in decreased palatability leading to decrease in food consumed by residents; and, food held in the heated oven for extended time periods could lose nutritive value, leading to a decreased nutrient intake for 8 residents with a Puree diet order out of a facility census of 89.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices and precautions when: 1. Facility staff did not follow the infection control policy when moving Resident 15 from the red zone (area for residents that tested positive for SARS-CoV-2, a virus that can cause COVID-19, a mild to severe respiratory illness) to the green zone (area for residents that tested negative for SARS-CoV-2) ; 2. Housekeeper supervisor (HS) and visitor did not wear appropriate PPE (personal protective equipment; N-95 (type of particulate filtering facepiece respirator mask), gloves, gown and faceshield) while in the yellow zone (area designated for residents who have had a known exposure to coronavirus 2019), room; 3. Registered Nurse L (RN L) did not wear a complete PPE upon entering a yellow zone room; 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was available, completed, and accurate for 4 of 18 sampled residents (Residents 12, 25, 29, and 42). These failures had the potential to result in the facility omitting, providing unnecessary or inappropriate medical treatment and services that was against the resident's goals and wishes. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards for one of 18 residents (32) when social service assistant P (SSA P) pasted Resident 32's name, date of birth , and date of admission on Resident 87's A1C (a blood test that measures the average blood sugar level over the past 3 months) test result to produce Resident 32's A1C test result, and the director of nursing (DON) agreed and signed this produced A1C test result that he faxed to the physician. This failure resulted in inaccurate A1C test result for Resident 32 and could have adverse effects on Resident 32's treatment and well-being.

Inspectors wrote2. Review of Resident 23's medical record indicated he was admitted on [DATE] and had the diagnosis of epilepsy (a disorder that causes seizures). Review of Resident 23's medication administration record (MAR) indicated he had an order, dated 4/9/2020, for Tegretol (medication used to treat seizures) 500 milligrams (mg, unit of dose measurement) by mouth every morning and at bedtime. The MAR further indicated Resident 23's morning dose of Tegretol was scheduled to be administered at 9:00 a.m. During an observation on 2/16/2022 at 9:19 a.m., licensed vocational nurse I (LVN I) administered medications to Resident 23. As LVN I was preparing the medications, she was unable to find Resident 23's Tegretol in the medication cart. She finished preparing the rest of the medications and administered them to Resident 23. LVN I did not administer Tegretol to Resident 23 during the observation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment free of accident hazards for two of 18 sampled residents (Residents 54 and 347) when: 1. Facility staff did not complete quarterly smoking assessments for Resident 54; and 2. Facility staff gave coffee to Resident 347, who was not supposed to receive any food or fluids by mouth. These failures placed the residents at risk for accidents and subsequent harm.

Inspectors wrote2. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted with multiple diagnoses including end stage renal disease (ESRD, kidneys no longer work as they should to meet your body's needs), dependence on renal dialysis (a treatment for people whose kidneys are failing), and type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar). During a review of Resident 25's Minimum Data Set (MDS, anassessment tool), dated 1/24/22, it indicated he had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates the resident is cognitively intact). During a review of Residents 25's Medication Administration Record (MAR), for 2/22, the MAR indicated levothyroxine sodium tablet give on an empty stomach or 30 minutes before food. Order dated 7/15/21 scheduled at 6:30 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 11 residents (32, 75, and 88) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 32 did not have informed consent (the process in which a health care provider educates a resident about the risks, benefits, and alternatives of a given procedure or intervention) for Abilify (used to treat certain mental/mood disorders) 10 milligrams (mg, a metric unit of mass), and his A1C (a blood test that measures the average blood sugar levels over the past 3 months) and lipid panel (a blood test that measures fats and fatty substances used as a source of energy by the body) tests were not done as ordered by the physician; 2. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure multiple resident rooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents received.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the policy regarding use of emergency medication kit was implemented when used emergency medication kits were not returned to pharmacy and items removed from the emergency medication kit were not documented. These deficient practices have the potential to compromise the health and safety of the residents due to lack of emergency medication kit accountability which may lead to improper drug use. During a medication storage audit with the director of nursing (DON) on 7/15/19 at 8:49 a.m., the following were observed: 1. Pharmacy emergency kit was found inside a medication cabinet with following labels: a. IV (intravenous) supply emergency kit with a green plastic zip tie. b. IV medication emergency kit with a green plastic zip tie. c. Oral emergency kit with a green plastic zip tie. d. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation requirements were met as evidenced by: 1. Gas stove was covered with dark substance 2. Back of gas stove was found with dirt and other debris 3. Milk temperature was not within acceptable range 4. Three compartment sink has no observable air gap 5. Rust was found on the ceiling of the walk in refridgetor 6. A pan of ground beef was cooked 8 hours early prior to serving These failures had the potential to result in cross contamination and can cause food borne illnesses in a medically vulnerable population of residents who consumed food from kitchen.

Inspectors wroteBased on interview and record review, the facility failed to follow it's policy for one of one sampled resident (Resident 88) when Resident 88's legal representative was not notified Resident 88 refused to use the splint. This failure had violated the right of the resident and his legal representative to choose treatment alternative or choose other options that resident prefer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the policy on self-administration of medication for two of two sampled residents (Residents 87 and 86) when medications were kept at Residents 87 and 86 room unattended. These failures had the potential for unsafe and improper administration of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for one of 23 (Resident 90) when the interdisciplinary team (IDT, a team of different professional disciplines that work together to provide the greatest benefit for the resident) did not assess Resident 90 to accommodate his food preferences. This failure had the potential for a decline in quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for one of one sampled resident (Resident 52), when registered nurse (RN) did not give apple juice and glucagon (hormone) as ordered during hypoglycemic episodes (blood sugar below reference ranges). These failures had the potential to result to life-threatening complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an oversight to prevent fall for two of six sampled residents (Residents 34 and 101), when Resident 34 and Resident 101 had a fall incident and sustained an injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 88) with behavioral problem would be adequately monitored and would received the necessary care and services. This failure had the potential for residents not attaining their highest well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate monitoring for efficacy of Nuedexta (used to treat uncontrollable laughter or crying) for one of one sampled resident (Resident 38). These medication had the potential to cause medication adverse effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 81) was assessed when, Valium (anti-anxiety and sedative) PRN (as needed) order for Resident 81 has no physician justification for the continued PRN use order after 14 days. This failure had the potential to exposed the resident in the use of unnecessary drugs.

Inspectors wroteBased on observation, interview and record review, the facility had 15.38 percent medication error rate when four medication errors out of 26 opportunities were observed during medication pass for two out of six residents (38 and 24). These failures had the potential to compromise the resident's medical health.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were stored/labeled when: 1 .Refrigerator was out of temperature requirements. 2. One insulin pen with no pharmacy label 3. Two bottles of eye drop medications improperly stored and a bottle of insulin with no open date. 4. Two eye drop medications expired and three insulins improperly stored. These failures could potentially compromise the health and safety of the resident.

Inspectors wroteBased on observation, interview and record review the facility failed to provide two of three residents (Residents 90 and 26) with adaptive assistive device during meals when Residents 90 and 26 were not given nosey cut cups (a cup with a nose cut out that allows with proper head positioning, avoid neck extension and spillage). This failure could potentially compromise residents' head and neck positioning while drinking and limit the degree of independence of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention practices were followed for five of five sampled residents (Residents 93, 88, 38, 54, and 24) when: 1. Resident 93, his indwelling catheter (a thin, sterile tube inserted into the bladder to drain urine bag) did not have a privacy bag and was placed on the floor 2. Resident 88, he was observed chewing on his treatment dressing 3. Resident 38, a licensed nurse did not use gloves while giving medication via injection 4. Resident 54, a licensed nurse did not clean a rubber cup of insulin vial prior to injecting needle, and 5. Resident 24, a licensed nurse did not perform hand hygiene in between glove changes

Inspectors wroteBased on observation and interview, the facility failed to ensure multiple resident rooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents received.