Red Bluff Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were incontinent (involuntary loss of control) of bladder were assessed and provided appropriate treatment and services to maintain or improve continence to the extent possible for one of five sampled residents (Residents 1) when:1. Resident 1 did not receive a bowel and bladder assessment as needed (PRN).2. The Interdisciplinary Team (IDT, a group of healthcare disciplines that develop plans of care) did not re-evaluate Resident 1's incontinent status after changes in urinary status and update care plan as indicated. These failures had the potential to contribute to residents' decline or lack of improvement in urinary continence and or loss of bladder control and function.

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled residents (Resident 1), had a behavioral health evaluation and services to meet psychiatric behavioral needs. This had the potential for Resident 1 to be at risk for worsening psychiatric symptoms, decline in their physical, emotional, and psychosocial well-being and unmet mental health needs.

Inspectors wroteBased on interview, and record review, the facility's Administrator (ADMIN) failed to ensure resident rights were honored during care when:1. Four out of seven residents reported that Certified Nursing Assistant (CNA A) did not treat them with respect, did not consider their self-determination, and individuality when she provided care. 2. Nursing administrative staff did not provide oversight and provide education/feedback to CNA A after multiple resident complaints. Refer to F550. This resulted in a violation of four residents' rights to receive individualized respectful care and put all residents at risk for not receiving dignified care. Refer to F550.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA A) provided residents with dignity and respect during direct resident care for four of seven sampled residents (Resident 1, 2, 3 and 4) when:1. CNA A was rough when providing care to Resident 1.2. CNA A ignored Resident 2's verbal request to be careful with her shoulder during care.3. CNA A did not listen to or provide individualized care to Resident 3.4. CNA A's behavior during care was not respectful toward Resident 4. This failure resulted in a violation of four residents' rights to receive individualized respectful and dignified care.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain the facility in a clean, safe and comfortable home-like environment when:1. The sliding glass door in room [ROOM NUMBER] did not lock properly.2. room [ROOM NUMBER] had buckled, worn brown flooring that was on the right side of the sliding glass door, which made this door hard to slide.3. There was a hole in the bathroom door in room [ROOM NUMBER].4. The bathrooms on the south hall, rooms 14 through 25 needed repair and paint.5. The sliding glass doors were hard to open and slide and unclean in 10 resident rooms on the south hall.6. The nurses' station had chipped and worn areas around the sink and the molding and flooring.7. The Brio water fountain in the front lobby had a stained, unclean drain for the resident and community use. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that seven of eight sampled residents knew the correct procedure to file a grievance with the facility (Resident 1, Resident 19, Resident 22, Resident 23, Resident 25, Resident 39, Resident 45), three of the eight sampled residents were not informed of the findings of the investigations or any corrective actions that were taken for their grievances, (Resident 1, Resident 19, Resident 22), and three of the eight sampled residents stated that they were fearful of retaliation if they filed a grievance (Resident 22, Resident 39, and resident 45). [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to report allegations of mistreatment, made by five of eight sampled residents (Resident 1, Resident 19, Resident 22, Resident 25, and Resident 39) to the appropriate local, state, and federal agencies nor were the residents informed of the progress of an investigation. This failure caused resident complaints/concerns of mistreatment by staff to go unreported with the potential of continued mistreatment, physical and/or psychosocial harm to residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen equipment was stored and dated per policy for two out of three sampled residents (Resident 1 and Resident 31) when the oxygen tubing for Resident 1 and Resident 31 was lying on their wheelchairs, uncovered and not dated. This failure had the potential to contaminate the oxygen tubing and cause an infection to the residents which could spread to other residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to complete annual performance evaluations for four of five sampled Certified Nursing Assistants (CNAs - CNA C, F, G and H). This failure had the potential for direct care staff not to provide quality of care and meet the needs of the residents. During a record review of facility policy titled Performance Evaluations dated 2001 MED-PASS indicated, A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually, thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the food preparation and service areas in a clean and sanitary condition, when the following was identified:A visibly dirty dishwasher. Visibly soiled fans, including an air-conditioning fan located in the pantry. Dirty hanging light fixtures with visible debris. Visibly soiled ceiling above cooking area. An open container of cheese without proper covering. Resident Refrigerator visibly soiled and holding expired items. This had the potential to contaminate food and place residents at risk for foodborne illness. 1. During a concurrent interview and record review on 1/23/26 at 10:20 a.m. with the Nutritional Services Director (NSD), the facility's policy and procedure titled Dishwashing Machine Operation, dated 2020, was reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation of psychiatric (mental health) diagnosis in the medical records for one out of 30 sampled residents (Resident 6) based on standards of practice. This failure could lead to inaccurate treatment and monitoring of Resident 6's psychotropic (medications that affect mood or behavior) medication use. Review of Resident 6's medical record, titled Order Summary Report (a list of all doctor orders and medical conditions), dated 1/2026, the record indicated Resident 6 was on a medication called Seroquel (or quetiapine, a medication used to treat the mood and mental health issues) for bipolar disorder (a chronic mental illness that fluctuated between depression and anxiety) as follow: SEROquel Tablet 25 MG (quetiapine; MG means milligram, a unit of measure); [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure accurate documentation and ongoing pain assessment for one of five residents reviewed for unnecessary medication use (Resident 31). This failure had the potential for unsafe mediation use and risk of adverse effects from opioid use including difficulty breathing and mental confusion.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe use and accountability of narcotic controlled medication (opioid drugs of abuse) use when: Resident 46's Norco (a combination opioid pain medication) was removed from the Controlled Drug Record (CDR - an accountability sheet that tracked narcotic removal with nurse initial, date, and time) without the corresponding documentation in the Medication Administration Record (MAR - a legal document where nursing staff documented medications given to residents). This failure had the potential to contribute to unsafe drug handling, poor pain control, and risk of drug diversion (drug loss).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe storage of medication and supplies with a census of 52 residents when:Medication room refrigerator stored expired and discontinued medications, and the refrigerator temperature was not monitored twice daily for vaccine storage. Medication cart stored undated and expired medications. These failures had the potential to contribute to unsafe medication use and risk of ineffective medications reaching vulnerable residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure compliance with infection prevention practices with census of 52 residents when:1. Blood Pressure (or BP, the force of blood pushing against the walls of arteries as the heart pumps it around the body) device cuff was not cleaned after Resident 46 use.2. The pill cutter stored in the medication cart had white powder like residues inside the device. These failed practices could contribute to unsafe care and spread of infection in the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, safe, comfortable, and homelike environment for seven of 18 sampled residents (Residents 12, 18, 19, 31, 34, 42, and Resident 153) when: 1. Four of Four stand up mechanical lifts were unclean. 2. Patio doors to multiple resident rooms were unkept and unclean with cumulative dust and dark and brown debris. 3. Cumulative food and debris was on the floor and under the wooden side table in room [ROOM NUMBER] A. 4. A side table was unkept, faded, with visible chips in the wood in room [ROOM NUMBER] A. 5. Tile was missing on the floor in room [ROOM NUMBER] A. 6. A foot board was unkept, damaged, and had visible chips in the wood in room [ROOM NUMBER] A. 7. Resident privacy curtains had visible red and brown colored stains. 8. The curtains and tracks of the sliding glass doors in the resident rooms were unclean. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Resident 19 was administered an inhaler without following manufacturer's instructions to meet Professional Standards of Care. This failure resulted in and had the potential for the medication to be ineffective for all residents that were ordered an inhaler routinely or as needed (prn).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen equipment was monitored, changed, and dated as ordered for two out of five sampled residents (Resident 1 and Resident 34) when: 1. The oxygen tubing for Resident 1 was dated 12/25/24 during an observation on 1/7/25. 2. The oxygen bottle for Resident 34 was empty, not full of bubbling water and dated 12/1/24, and the oxygen tubing for Resident 34 was dated 12/25/24. This failure had the potential to cause discomfort, and the spread of infection to the residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to document behaviors for an antipsychotic (medication used for moods and behaviors to treat mental illness) medication used for one of three sampled residents (Resident 31). This failure had the potential to not identify an increase in behaviors, identify new interventions needed, and a change in condition that should be reported to the physician for medication management.

Inspectors wroteBased on interview, record review and facility policy review, it was determined that the facility failed to ensure an advance directive was on file for 2 (Resident #26 and Resident #28) of 4 residents reviewed for advance directives.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure that before bed rails were installed, residents were assessed for risk and evaluated for appropriate alternatives and that informed consent for bed rail use was obtained from the resident or their representative for 3 (Residents #42, #35, and #27) of 4 residents reviewed for bed rail use.

Inspectors wroteBased on observations and interviews, the facility failed to offer or provide assistance to residents with hand hygiene prior to meal service. This was observed on two of four days of the survey on two of two halls (East Hall and South Hall) for which meal service was observed.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to develop a baseline care plan that included the minimum healthcare information to properly care for 1 (Resident #195) of 3 residents reviewed for baseline care plans.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure the care and services related to oxygen use were addressed on the comprehensive care plan for 1 (Resident #253) of 3 residents reviewed for respiratory care.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to provide wound treatments as ordered by the physician for 1 (Resident # 26) of 3 sampled residents reviewed for wound treatment.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to follow up on a recommendation from an orthopedic physician for the use of a left-hand splint for 1 (Resident #42) of 1 sampled resident reviewed for range of motion and mobility.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure respiratory equipment was stored properly for 2 (Resident #9 and Resident #195) of 3 residents reviewed for respiratory care.

Inspectors wroteBased on record review, interviews, and facility document review, the facility failed to ensure laboratory testing was provided as ordered for 1 (Resident #42) of 5 sampled residents reviewed for unnecessary medications.