Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Redwood Grove Post Acute during CMS and state inspections, most recent first.
Missing Documented Discharge Plan: The facility failed to properly document discharge planning for a resident with sepsis, atherosclerosis of the aorta, and emphysema. The IDTCC included a discharge plan checkbox but did not identify the actual plan, and the CM stated she had not documented one. The DON said the resident was discharged to a motel for two nights, while the ADM noted the facility had tried to connect the resident with county resources that were refused.
A resident with a periprosthetic fracture had a Dulcolax suppository incorrectly administered by an LVN, who inserted it into the resident's private area instead of rectally. The incident was confirmed by a CNA present and was not reported by the LVN. This failure to follow professional standards of practice had the potential to affect the resident's health and psychosocial wellbeing.
The facility failed to ensure proper infection control practices, including sanitizing items between residents' rooms, storing oxygen equipment correctly, and implementing enhanced barrier precautions. A phlebotomist did not sanitize a clipboard between residents, and oxygen tubing was improperly stored. Staff also failed to wear gowns during a resident transfer, despite the presence of an indwelling catheter.
The facility failed to provide the required 80 square feet per resident in 10 multiple-resident rooms, each offering only 71.5 square feet per resident. This was confirmed through a Client Accommodations Analysis and measurements by the Maintenance Supervisor, who acknowledged the rooms' non-compliance with the approved capacity.
A resident with dementia, type 2 diabetes, and hypertension underwent a KUB x-ray for abdominal pain, revealing increased bowel distention. The physician ordered a repeat x-ray, but the order was not documented, and the repeat x-ray was not performed. Interviews confirmed the order was given but not recorded, leading to a potential lapse in necessary follow-up care.
A resident with severe cognitive impairment was inadequately supervised, leading to multiple incidents of entering female residents' rooms and inappropriate behavior. Despite interventions like hourly safety checks and stop signs, the resident continued to wander and engage in inappropriate actions, highlighting insufficient monitoring by the facility.
A resident with a history of angry outbursts and verbal altercations threatened and verbally abused three other residents in the facility. Despite being cognitively intact, the resident refused psychiatric evaluation and medication, leading to repeated incidents of verbal abuse. The facility's interventions, including monitoring and attempts to redirect the resident, were ineffective in preventing further incidents, highlighting a deficiency in protecting residents from verbal abuse.
The facility did not follow its policy for disposing of discontinued medications, affecting two residents. An anonymous tip revealed that medications from the facility were found in a staff member's home. The staff member admitted to accidentally keeping the medications in his car. The Pharmacy Consultant confirmed that the medications should have been destroyed within 90 days, according to the facility's policy.
A resident experienced a verbal altercation with a physical therapist, which was not reported to the state agency as required. Multiple staff members witnessed the incident, but it was not documented or reported promptly. Additionally, the facility failed to provide abuse training to all staff at the required quarterly frequency, as confirmed by the Director of Staff Development.
Missing Documented Discharge Plan
Penalty
Summary
The facility failed to properly perform and document discharge planning for one of six residents when there was no documented discharge plan in the interdisciplinary team meeting notes. Resident 1 was admitted with diagnoses including sepsis, atherosclerosis of the aorta, and emphysema. A review of the electronic record showed that the resident’s IDT Care Conference note dated 7/2/25 included a check box for a discharge plan, but the actual discharge plan was not indicated. During interviews, the CM stated she had not documented a discharge plan for Resident 1, and later stated she was writing progress notes rather than care planning at that time. The DON stated Resident 1 was discharged to a motel for two nights. The ADM stated the facility had attempted to connect the resident with county resources, which the resident had refused, but the IDTCC still did not contain a documented discharge plan. The facility policy required every resident to have an individualized post-discharge plan developed by the care planning/interdisciplinary team with resident and family involvement.
Medication Administration Error by LVN
Penalty
Summary
The facility failed to provide care and service based on professional standards of practice when a Licensed Vocational Nurse (LVN) incorrectly administered a medication to a resident. The resident, who was admitted with a diagnosis of a periprosthetic fracture around an internal prosthetic right hip joint, had an order for a Dulcolax suppository to be administered rectally as needed. However, during the administration, the LVN inserted the suppository into the resident's private area instead of the rectal area, as confirmed by both the resident and a Certified Nursing Assistant (CNA) present during the incident. The incident was not reported by the LVN, and the Director of Nursing (DON) confirmed that the LVN was aware of the error. The facility's policy and procedure for administering medications, which includes verifying the right resident and the right method of administration, was not followed. This failure had the potential to affect the resident's health and psychosocial wellbeing, as the medication was not administered according to the prescriber's orders and professional standards of practice.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by a phlebotomist and other staff members. During an observation, a phlebotomist did not sanitize a clipboard between visiting two residents' rooms, one of whom was on contact isolation due to a multidrug-resistant organism and wound infection. The phlebotomist acknowledged the oversight, citing a lack of available wipes. The facility's administrator confirmed that items should be disinfected between rooms, especially for residents on transmission-based precautions. Additionally, the facility did not adhere to its policy regarding the storage of oxygen equipment. A resident who used supplemental oxygen as needed had their nasal cannula and tubing improperly stored, first under the handle of an oxygen concentrator and later observed on the floor. Staff interviews revealed a lack of awareness about the correct storage procedure, which should have been in a plastic bag when not in use, as confirmed by the facility's administrator. The facility also failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter. During a transfer using a mechanical lift, staff members wore gloves but did not don gowns, contrary to the facility's policy for residents with indwelling medical devices. Both staff members involved acknowledged the error, and the Director of Nursing reiterated the expectation for staff to follow isolation precautions and wear appropriate personal protective equipment.
Deficiency in Room Size for Multiple-Resident Rooms
Penalty
Summary
The facility failed to ensure that multiple-resident rooms provided the required minimum of 80 square feet per resident. Specifically, 10 rooms (Rooms 101, 103, 105, 107, 109, 111, 114, 116, 118, and 119) were identified as having an approved capacity of two residents each, but only provided 143 square feet in total, equating to 71.5 square feet per resident when at full capacity. This deficiency was confirmed through a Client Accommodations Analysis form signed by the Administrator and through direct measurement by the Maintenance Supervisor, who verified that these rooms were indeed 11 feet by 13 feet in size. The Maintenance Supervisor acknowledged that these rooms were approved for two residents despite not meeting the square footage requirement.
Failure to Follow Physician's Order for Repeat X-ray
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident when it did not follow the physician's order. The resident, who had diagnoses including dementia, type 2 diabetes mellitus, and essential hypertension, underwent a KUB x-ray for abdominal pain, which showed increased bowel distention. The physician was informed of the results and ordered a repeat abdominal x-ray to follow up on the findings. However, there was no documentation of the repeat x-ray order in the resident's medical record, nor was there any evidence that the repeat x-ray was performed. Interviews with the physician and a licensed vocational nurse confirmed that the physician had ordered a repeat x-ray, but the order was not recorded in the resident's chart as required by the facility's policy. The nurse acknowledged notifying the physician of the initial x-ray results and receiving the order for a repeat x-ray, but she could not locate any documentation or results of the repeat x-ray. This oversight had the potential to result in the resident not receiving the necessary follow-up care and treatment as ordered by the physician.
Inadequate Supervision of Resident with Cognitive Impairment
Penalty
Summary
The facility failed to adequately monitor and supervise a resident with severe cognitive impairment, leading to multiple incidents where the resident entered female residents' rooms and engaged in inappropriate behavior. The resident, who was admitted with diagnoses including cerebral infarction and abnormalities of gait and mobility, was able to move independently in a wheelchair. Despite being placed on every 1-hour monitoring after initial incidents, the resident continued to enter other residents' rooms. The resident's behavior included inappropriate touching and wandering, as documented in several SBAR forms and IDT Risk Management Meeting Notes. The facility's interventions, such as placing stop signs outside female residents' rooms and conducting hourly safety checks, were insufficient to prevent further incidents. Observations showed the resident moving independently in the hallway, while staff were occupied with other tasks, indicating a lack of effective supervision. Interviews with staff, including CNAs and the DON, revealed that the hourly safety checks were deemed appropriate despite repeated incidents. The facility's policy on resident rights emphasizes the importance of providing a safe environment, yet the actions taken were inadequate to protect the residents involved from the inappropriate behavior of the resident in question.
Verbal Abuse and Threats Among Residents
Penalty
Summary
The report identifies a deficiency in protecting residents from verbal abuse within the facility. Three residents were subjected to verbal threats and abusive language by another resident, who had a history of angry outbursts and verbal altercations. This resident, diagnosed with cerebral infarction and major depressive disorder, was cognitively intact according to his BIMS score. Despite this, he engaged in multiple incidents of verbal abuse, including threatening to shoot and stab other residents. The facility's records and interviews reveal that the abusive resident had a history of making threats and possessing weapons, such as knives, which were confiscated by staff. The facility's interventions, including monitoring and attempts to redirect the resident, were ineffective in preventing further incidents. The resident refused psychiatric evaluation and medication, contributing to the ongoing issue of verbal abuse. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents of verbal abuse. Staff were aware of the resident's behavior, but the measures taken were insufficient to protect other residents from harm. The Director of Nursing acknowledged the ineffectiveness of the interventions, and the Administrator expressed uncertainty about whether the incidents constituted abuse or were merely outbursts.
Failure to Dispose of Discontinued Medications
Penalty
Summary
The facility failed to adhere to its policy and procedure for the disposal of discontinued medications, which affected two residents. An anonymous email alerted the Administrator to medications from the facility being found in the home of a facility staff member. The medications were linked to two residents, one of whom was discharged on an unspecified date and the other on November 29, 2019. During an interview, the Administrator confirmed that the staff member admitted to accidentally keeping the medications in a plastic bag in his car. The Pharmacy Consultant stated that discontinued medications should be destroyed within 90 days, as per the facility's policy dated November 2017.
Failure to Report Abuse and Conduct Regular Training
Penalty
Summary
The facility failed to implement its abuse policy and procedure in two significant ways. Firstly, an incident involving a resident and a physical therapist was not reported to the state agency and other required agencies. The incident occurred when the physical therapist entered the resident's room unannounced and engaged in a verbal altercation with the resident, who repeatedly asked the therapist to leave. Despite multiple staff members witnessing the incident and recognizing it as reportable, it was not documented or reported promptly. The facility's administrator was informed of the incident but did not report it to the necessary agencies, as the resident did not explicitly mention abuse during an interview. Secondly, the facility did not provide abuse training to all staff at the required frequency. The Director of Staff Development confirmed that training sessions conducted in January 2024, January 2023, and July 2023 did not include all necessary staff members, such as the administrator and the Director of Nursing. The facility's policy required abuse training to be conducted at least quarterly, but the training was only provided twice a year. This lack of compliance with the training schedule was acknowledged by the Director of Staff Development, who was unaware of the required frequency. The deficiencies in reporting and training had the potential to delay the investigation of abuse allegations and place residents at risk for further potential abuse. The facility's undated Policy and Procedure on Patient Abuse and Prevention outlined the requirements for reporting and training, which were not adhered to in these instances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Santa Cruz
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Santa Cruz Post Acute | 0.8 mi | ★★★★★ | 8 | 0 |
| Pacific Coast Manor | 1.3 mi | ★★★★★ | 0 | 0 |
| Driftwood Healthcare Center - Santa Cruz | 1.5 mi | ★★★★★ | 18 | 0 |
| Watsonville Nursing Center | 12.5 mi | ★★★★★ | 12 | 0 |
| Watsonville Post Acute Center | 12.5 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.