Redwood Cove Healthcare Center

In the surveyor’s words

From the most serious findings on record at Redwood Cove Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Dec 2, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF882Dec 2, 2025

  Based 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. Findings:During an interview on 09/24/2025 at 5:23 PM, the Director of Nursing confirmed the facility did not have a designated certified IP for approximately one month. The DON stated he and the interim IP were currently assuming the IP position but neither of them were certified. […]

• No harm, potential for more than minimal, widespreadF921Dec 2, 2025

  Based 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.Findings:During an initial tour of the kitchen on 09/22/25 at 12:24 p.m., the kitchen had several cracked and broken floor tiles. Photos were taken to document the finding.During a concurrent review of photos of the kitchen floor and interview with the Dietary Manager (DM) on 09/22/25, at 12:36 a.m., the DM confirmed the kitchen had several cracked and broken floor tiles.A review of Title 42 of the Code of Federal Regulations section 483.90(i), Other Environmental… […]

• No harm, potential for more than minimal, widespreadF925Dec 2, 2025

  Based 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.Findings:During the initial tour of the kitchen on 9/22/25 at 12:21 p.m. insects that looked like cockroaches were observed crawling under the dishwashing sink. A video was taken of the observation.During an interview on 09/22/2025 at 2:08 p.m., Unlicensed Staff A reported seeing a large cockroach in the hallway near the shower room the previous week. She also acknowledged being aware of cockroach activity in the kitchen. […]

• No harm, potential for more than minimal, widespreadF801May 3, 2024

  Based 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. […]