Inspection visit
Inspection
13 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 13 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
3. A facility policy titled, Enhanced Standard Precautions, revised 08/2022, indicated, Enhanced barrier
precautions (ESPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to
residents. The policy specified, 2. ESPs employ targeted gown and glove use during high contact resident
care activities when contact precautions do not otherwise apply: a. Gloves and gown are applied prior to
performing the high contact resident care activity (as opposed to before entering the room). The policy
indicated examples of high-contact resident care activities requiring the use of gown and gloves included c.
transferring. The policy further indicated, 5. ESPs are indicated (when contact precautions do not otherwise
apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.
Residents Affected - Some
Resident #1's admission Record revealed the facility admitted the resident on 12/31/2003. According to the
admission Record, the resident had a medical history that included diagnoses of multiple sclerosis,
paraplegia, chronic kidney disease, and neuromuscular dysfunction of the bladder.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/22/2024, revealed
Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had
moderate cognitive impairment. The MDS indicated Resident #1 had an indwelling urinary catheter.
Resident #1's care plan included a focus area, initiated 06/07/2024 and revised 11/10/2024, that indicated
the resident required EBP related to having a suprapubic catheter. An intervention dated 06/07/2024
directed staff to instruct visitors and staff to wear proper personal protective equipment (PPE) when
needed.
During an observation on 02/03/2025 at 9:43 AM, Certified Nursing Assistant (CNA) #3 and Licensed
Vocational Nurse (LVN) #2 entered Resident #1's room with a mechanical lift. CNA #3 and LVN #2 wore
gloves but no gowns while using the mechanical lift to transfer the resident out of their bed.
During an interview on 02/04/2025 at 1:02 PM, LVN #2 stated she did not wear a gown on 02/03/2025
when she assisted with Resident #1's transfer, but she should have.
During an interview on 02/04/2025 at 1:34 PM, CNA #3 stated she did not wear a gown on 02/03/2025
when she and LVN #2 transferred Resident #1. CNA #3 said that because the resident had an indwelling
urinary catheter, she should have worn a gown to prevent the spread of germs.
During an interview on 02/06/2025 at 9:05 AM, the Director of Nursing (DON) stated the expectation was
for staff to follow isolation precautions and wear proper PPE.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
055017
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055017
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Grove Post Acute
2990 Soquel Avenue
Santa Cruz, CA 95062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview on 02/06/2025 at 9:10 AM, the Administrator stated the expectation was for staff to
apply PPE during resident care and understand its purpose, which was to prevent potential spread of
infection.
Based 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.
Findings included:
1. A facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 09/2022,
indicated, 5. Reusable items are cleaned and disinfected or sterilized between residents.
Resident #326's admission Record revealed the facility admitted the resident on 01/24/2025. According to
the admission Record, the resident had a medical history that included diagnoses of osteomyelitis
(inflammation of bone caused by infection), local infection of the skin and subcutaneous tissue, and
resistance to multiple antimicrobial drugs.
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/30/2025,
revealed Resident #326 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the
resident had intact cognition. According to the MDS, the resident had active diagnoses of
multidrug-resistant organism and a wound infection.
Resident #326's care plan included a focus area, initiated on 01/25/2024, that indicated the resident had
pseudomonas (a type of bacteria) cellulitis (bacterial skin infection) of their right foot. An intervention dated
01/25/2025 direct staff to implement contact isolation. Another focus area, initiated on 01/25/2025,
indicated Resident #326 received intravenous antibiotics for osteomyelitis of their right foot.
Resident #325's admission Record revealed the facility admitted the resident on 01/28/2025. According to
the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease,
orthostatic hypotension (low blood pressure due to postural changes), and atrial fibrillation (irregular heart
rhythm).
An admission MDS, with an ARD of 02/02/2025, revealed Resident #325 had a BIMS score of 15, which
indicated the resident had intact cognition.
During an observation on 02/03/2025 at 9:33 AM, Phlebotomist #23 entered Resident #326's room. While
in the room, Phlebotomist #23 placed a clipboard on the resident's bed. Without cleaning or sanitizing the
clipboard she placed on Resident #326's bed, Phlebotomist #23 then entered Resident #325's room and
placed the clipboard on the resident's overbed table.
During an interview on 02/03/2025 at 9:46 AM, Phlebotomist #23 said she should have wiped down her
clipboard between residents' rooms, but she did not have any wipes to do so.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055017
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055017
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Grove Post Acute
2990 Soquel Avenue
Santa Cruz, CA 95062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview on 02/06/2025 at 12:32 PM, the Administrator stated phlebotomists should disinfect
items between rooms of residents on transmission-based precautions and those that were not. In addition,
the Administrator said phlebotomists should save the rooms of residents on transmission-based
precautions for last.
2. A facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection, revised 11/2011,
revealed the section titled, Infection Control Considerations Related to Oxygen Administration specified, 8.
Keep the oxygen cannulae and tubing used PRN [as needed] in a plastic bag when not in use.
Resident #118's admission Record revealed the facility admitted the resident on 01/14/2025.
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2025,
revealed Resident #118 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the
resident had moderate cognitive impairment.
Resident #118's 02/2025 Medication Administration Record (MAR) revealed the transcription of an order
started on 01/31/2025 for supplemental oxygen at a rate of 2 liters per minute via nasal cannula as needed
for shortness of breath and to keep oxygen saturation above 92 percent (%). According to the MAR, the
resident did not receive supplemental oxygen during the timeframe from 02/01/2025 through 02/04/2025.
During a concurrent interview and observation on 02/03/2025 at 10:10 AM, Resident #118 stated they only
used oxygen on an as-needed basis. Resident #118's nasal cannula and tubing were observed wrapped
under the handle of their oxygen concentrator not in a plastic bag.
During an observation on 02/04/2025 at 11:26 AM, Resident #118's nasal cannula and tubing were on the
floor in the resident's room.
During an interview on 02/04/2025 at 11:25 AM, Registered Nurse (RN) #12 said he did not know where
nasal cannulas should be stored when not in use.
During an interview on 02/04/2025 at 11:28 AM, RN #13 stated that oxygen nasal cannulas should be
stored in a plastic bag when not in use.
During an interview on 02/06/2025 at 12:47 PM, the Administrator said oxygen tubing should be stored in a
plastic bag when not in use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055017
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055017
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Grove Post Acute
2990 Soquel Avenue
Santa Cruz, CA 95062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings included:
A Client Accommodations Analysis, form, signed by the Administrator on 02/19/2025, revealed Rooms 101,
103, 105, 107, 109, 111, 114, 116, 118, and 119 each had an approved capacity of two residents. The
Client Accommodations Analysis form indicated each of these rooms measured 11 feet by 13 feet and
provided a total of 143 square feet, or 71.5 square feet per resident when at full capacity.
During a concurrent observation and interview on 02/05/2025 at 2:50 PM, the Maintenance Supervisor
measured room [ROOM NUMBER] and room [ROOM NUMBER] and confirmed they both provided a total
of 143 square feet but were approved for a capacity of two residents. The Maintenance Supervisor said
Rooms 101, 103, 105, 107, 109, 111, 116, and 118 were also the same size and had an approved capacity
of two residents.
Based 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 residendents received.
The following resident rooms's square footage measured as follows:
Room number Number of beds Square footage
100
3 75.1
101
2 71.5
102
3 75.1
103
2 71.5
104
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055017
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055017
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Grove Post Acute
2990 Soquel Avenue
Santa Cruz, CA 95062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
3 75.1
Level of Harm - Potential for
minimal harm
105
2 71.5
Residents Affected - Some
106
3 75.1
107
2 71.5
108
3 75.1
109
2 71.5
110
3 75.1
111
2 71.5
112
3 75.1
113
2 71.5
114
2 71.5
115
3 75.1
116 2 71.5
117
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055017
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055017
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Grove Post Acute
2990 Soquel Avenue
Santa Cruz, CA 95062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
3 75.1
Level of Harm - Potential for
minimal harm
118
2 71.5
Residents Affected - Some
119
2 71.5
120
2 71.5
During the survey, observations and interviews with residents and staff, indicated there were no concerns
regarding the square footage of the rooms. Nursing care and services were not impacted by the shortage of
space.
Room waiver is recommended.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055017
If continuation sheet
Page 6 of 6
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Back to topCitations
13 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0293GeneralS&S Fpotential for harm
Have properly located and lighted "Exit" signs.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F926 - Establish policies, in accordance with applicable Federal, State, and
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- 0032GeneralS&S Fpotential for harm
Provide primary/alternate means for communication.
- 0161GeneralS&S Dpotential for harm
Use approved construction type or materials.
FAQ · About this visit
Common questions about this visit
What happened during the February 6, 2025 survey of REDWOOD GROVE POST ACUTE?
This was a inspection survey of REDWOOD GROVE POST ACUTE on February 6, 2025. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at REDWOOD GROVE POST ACUTE on February 6, 2025?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have properly located and lighted "Exit" signs."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.