Inspection·April 11, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few Findings: A review of Resident 1 ' s admission record indicated she was admitted on [DATE], and her medical diagnoses included acute osteomyelitis (infection of the bones), right tibia and fibula (two long bones of the lower leg) and Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterium resistant to many antibiotics) infection. A review of Resident 1 ' s order summary report dated April 2025 indicated an active order for a PICC line on the right brachial vein (a deep vein in the upper arm that accompanies the brachial artery, draining blood from the arm's deep tissues back to the heart). This report also indicated an order written on 3/28/2025 which specified, Monitor site RUA [right upper arm] for signs and symptoms of infection including redness, drainage, pain at insertion site every shift for monitor until 4/13/2025 at 11:59 p.m. Alert MD [physician] if signs of infection are noted. A review of Resident 1 ' s IV Administration Record, dated 3/28/25 to 4/11/25, indicated the PICC line had not been documented as monitored for signs and symptoms of infection by a licensed nurse. During an interview on 4/11/25 at 12:05 p.m., the Director of Nursing (DON) stated the documentation for Resident 1 ' s PICC line monitoring had not been completed because it was located on the IV Administration Record and not the Medication Administration Record (MAR). The DON stated the monitoring should have been placed on the MAR so the licensed nurses could see it. During an interview on 4/11/25 at 1 p.m., the Infection Preventionist (IP) nurse stated nurses were expected to monitor the IV insertion site daily and it should be documented. The IP nurse stated if the monitoring was not done, there would be a potential of infection to resident. A review of a facility policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections dated 2001 indicated, Nursing Practice Guidelines to Prevent Catheter-Related Infections .Observe the insertion site .on every shift, on admission, and with dressing changes .If signs and symptoms of catheter-related infection are present, contact the Physician .The following (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 3 Event ID: 055853 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 055853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redwood Cove Healthcare Center 1162 S Dora St. Ukiah, CA 95482 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)