Veterans Home of California - Redding

Inspectors wroteBased on observation, interview, and record review the facility failed to store and label pasteurized eggs in accordance with professional standards for food service safety, and facility policy, when an unlabeled tray containing 18 pasteurized eggs was found in the walk-in refrigerator outside of its marked container. This failure had the potential to expose medically fragile residents to food contamination, increasing the risk of foodborne illness for all 39 residents who eat meals prepared in the kitchen. During an observation on 4/20/26 at 2:20 p.m. in the Main Kitchen's walk-in refrigerator a tray containing 18 pasteurized eggs was observed left outside of its marked container. The tray did not have a label indicating the received-on date or the use by date. During an interview on 4/20/26 at 2:31 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain proper grooming by ensuring fingernail care for one of twelve sampled residents (Resident 7), in accordance with the facility policy titled, Activities of Daily Living. This failure had the potential to increase the risk of infection for Resident 7. During a review of Resident 7's admission Record, dated 12/16/25, the admission Record, indicated Resident 7 was admitted to the facility with diagnoses of osteoarthritis (breakdown of cartilage) and tremor (involuntary shaking). During a concurrent observation and interview on 4/20/26 at 2:31 p.m. with Resident 7, in the facility hallway, Resident 7 was seated in his wheelchair with his fingernails exposed. Resident 7's fingernails were long. Resident 7 stated he wanted his nails trimmed and staff did not consistently perform nail trimming. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medication was not available for use when two vials of Lidocaine HCL (used to rapidly numb specific body areas for medical procedures by blocking nerve pain signals) were stored in the emergency kit beyond their expiration date. This failure had the potential to place residents at risk of receiving expired medication, which may lead to harmful side effects or reduced effectiveness. During a concurrent observation and interview on [DATE] at 9:10 a.m. with the Director of Nursing (DON) inside the medication room, the emergency kit contained two vials of Lidocaine HCL which had an expiration date of 3/2026. The DON confirmed the medication vials were expired. The DON stated that pharmacy and nursing staff should check the emergency kit for expired medication. During an interview on [DATE] at 10:24 a.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective infection control program when one of twelve sampled residents (Resident 20) indwelling catheter (a tube placed in the body to drain and collect urine from the bladder) bag was touching the floor. This failure had the potential to cause cross contamination and increase the risk of infection for Resident 20. During a concurrent observation and interview on 4/20/26 at 5:55 p.m., with Registered Nurse (RN) 1 in the facility hallway, Resident 20 was observed seated in a wheelchair self-propelling in the hallway. A urinary catheter drainage bag was secured to the lower portion of the wheelchair however, the catheter tubing was touching the floor. RN 1 confirmed the observation and stated the tubing should not be in contact with the floor due to infection control concerns. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reassess fall risk factors and update the care plan interventions for 1 of 3 sampled residents (Resident 2), who was identified as being at high risk for falls. This failure resulted in Resident 2's unwitnessed fall, transfer to the acute care hospital for evaluation and treatment, and subsequent admission due to several broken ribs and a broken right collarbone on 8/3/25 (refer to Intake 2581256).

Inspectors wroteBased on interview and record review, the facility failed to ensure the pain medication was administered as prescribed for Resident 1. This failure had the potential to result in uncontrolled pain management and adverse outcomes for Resident 1 (refer to Intake 2573274).

Inspectors wroteBased on observations, dietary and leadership staff interview and departmental document review the facility failed to ensure food handling practices were consistently carried out in accordance with food safety standards when: 1. There were lapses in cooldown monitoring of foods associated with foodborne illness and 2. One staff member was chewing gum during food production activities. These failures had the potential to result in foodborne illness and cross-contamination for the facility's residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that internal and external medications were stored separately for 2 of 2 medication storage areas observed. This failure had the potential to cause cross-contamination and medication administration errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 17 sampled residents (Resident 9 and Resident 19) were free of unnecessary psychotropic medications (drugs that affect brain function, mood, thoughts, or behaviors) when: 1. Staff did not implement non-pharmacological interventions (treatments that do not involve medication prior to administering psychotropic medications) for Resident 19. 2. Staff failed to implement behavioral monitoring related to the use of psychotropic medications for Resident 9. These failures had the potential to result in unecessary drug administration for Residents 9 and 19.

Inspectors wroteBased on observation, interview, and record review, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, three medication errors were observed out of twenty-eight opportunities, resulting in an error rate of 10%, and involved two separate insulin administrations and one nasal spray medication for Resident 3. These deviations from proper technique posed a risk for suboptimal therapeutic outcomes. The failure to adhere to manufacturers' instructions for insulin and nasal spray administration not only violates professional standards of practice but also increases the risk of therapeutic failure and resident harm.

Inspectors wroteBased on observation, leadership interview and dietary department document review the facility failed to ensure sufficient staff were employed as evidenced by the lack of a full-time qualified position to supervise and manage the day-to-day operations of the skilled nursing dietetic services. Failure to ensure sufficiently qualified staff may result in dietetic services that are inconsistent with professional standards of practice placing 35 residents at risk for potential food related medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a complete and accurate medical record when consent for the use of psychotropic medication (drugs that affect brain function, mood, thoughts, or behaviors) was not documented in the medical record for one of 12 sampled residents (Resident 19). This failure had the potential for Resident 19 to receive psychotropic medication that the resident did not consent to leading to unwarranted side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect 1 of 3 sampled residents (Resident 1) right to personal privacy when Resident 1's bank account statement was opened and viewed by facility staff. This failure resulted in unauthorized access to Resident 1's personal privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions in the food service department when: 1. Equipment was not replaced when considered unsafe, 2. Foods were found uncovered in the storage area, 3. Foods were not labeled appropriately, 4. Unsafe food was not discarded. These failures had the potential to expose residents to food contamination and foodborne illnesses (sickness by consuming contaminated food or drinks) for a population of forty-one residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that two out of eight dumpsters were covered for the main and the satellite kitchens. This failure had the potential to attract pests, rodents and spreading bacteria and leading to food contamination for a population of forty-one residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for two of four sampled residents (Resident 21 and 26) when: 1. A non-crushable medication, pantoprazole (medication to reduce acid production in the stomach), was crushed and administered to Resident 26 despite manufacturer's guidelines not to crush medication due to delayed release. 2. A non-crushable medication, finasteride (medication to treat enlarged prostate), was crushed and administered to Resident 26 despite facility's guidelines regarding handling of finasteride. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the plan of care for two of 12 sampled residents (Resident 18 and Resident 25) when: 1. For Resident 18, the care plan intervention Call don't fall signs were not posted, and assistive devices were not within reach. 2. For Resident 25, the care plan intervention Call don't fall signs were not posted, and discontinued assistive devices with signage were present in room. These failures had the potential to result in subsequent falls and serious injuries for Residents 18 and 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe monitoring of pharmaceutical medical supplies when four expired filter needles (a needle designed to remove particles, like glass, that might contaminate medication) were found in the injectable Emergency Drug Kit (E-Kit, small supply of medications for emergency situations). This failure had the potential to result in expired and ineffective medical supplies being used for residents and had the potential to result in contaminated medications being injected into residents.

Inspectors wroteBased on interview and record review, the facility failed to protect Resident 1 from verbal abuse when CNA 1 (certified nurse ' s assistant 1) called Resident 1, you d**k, after Resident 1 punched CNA 1 on the chest. This failure resulted in verbal abuse to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged abuse incident to law enforcement officials when Resident 1 reported a sexual assault incident in the Skilled Nursing Facility. This failure did not allow for law enforcement officials to conduct an investigation.

Inspectors wroteBased on interview and record review, the facility failed to follow their Policy and Procedures (P&P) on abuse reporting for two of two sampled residents (Resident 1 and Resident 2), when an abuse allegation was made by a Custodian Worker (CW 1). This failure had the potential of putting residents at risk for harm by not following proper procedures including removing the alleged abuser from patient care, failing to complete proper documentation, and notifying the appropriate agencies.