Redwood Grove Post Acute

In the surveyor’s words

From the most serious findings on record at Redwood Grove Post Acute, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Feb 23, 2022

  Based 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. […]

• Actual harm, isolatedF689Jul 9, 2026

  Based 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).Findings: 1. […]

• No harm, potential for more than minimal, widespreadF801Feb 23, 2022

  Based 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. […]

• No harm, potential for more than minimal, widespreadF813Feb 23, 2022

  Based 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. Findings: On 2/14/22 at 9:05 a.m., an observation of the inside of a reach-in refrigerator located in the kitchen, showed a plastic, store bought container was filled with a dark substance. The plastic container was labeled pork blood. The container outside surface was sticky. […]

• No harm, potential for more than minimal, widespreadF814Feb 23, 2022

  Based 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. Findings: According to the 2017 Federal Food Code, outside receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue shall be designed and constructed to have tight-fitting lids, doors, or covers. […]