Veterans Home Of California - Redding: Fall Prevention Failures - CA
The August 3 fall occurred two days after nurses had discontinued frequent safety rounds without putting any replacement interventions in place, according to federal inspection records from August 20.
Resident 2's troubles began in late July when his daughter requested removal of SMART alarms that detect when patients get out of bed or chairs. The devices were keeping her father awake and exhausted, she told staff on July 28.
Both the resident and his daughter appeared relieved after the alarms were removed that same day, nursing notes show.
But staff failed to replace the discontinued alarm system with adequate safety measures. The facility had initiated frequent rounding checks on July 25 for one week, ending August 1. When those checks concluded, nurses left the veteran without any documented fall prevention interventions for two critical days.
The Director of Nursing acknowledged the breakdown during an interview with federal inspectors. She stated nurses should have reassessed the resident's risk factors and updated his care plan to continue frequent rounding indefinitely after the family refused alarm use on July 28.
Instead, the DON was unable to provide any documented evidence showing fall prevention interventions were implemented between August 1, when frequent rounding ended, and August 3, when the veteran fell.
The facility's own Fall Risk Assessment and Prevention Program policy, dated March 20, 2023, requires registered nurses to complete fall risk assessments after each fall and develop care plans based on identified risks. The policy mandates that supervising nurses communicate these plans to direct care staff through verbal or written instruction.
Resident 2's fall history reveals a pattern of inadequate response. His Fall Prevention Care Plan, initiated June 24, was updated after each incident with temporary measures. Frequent rounding started July 25 for one week after a previous fall. SMART alarms were added July 26 but removed July 28 at the family's request. After his August 3 fall with significant injuries, staff again initiated frequent rounding for two weeks.
The DON could not provide a policy and procedure for the frequent rounding intervention itself, despite the facility's repeated use of this safety measure.
Federal inspectors found the facility violated regulations requiring adequate fall prevention measures for residents at risk. The deficiency affected few residents but caused actual harm, according to the inspection report.
The veteran's case illustrates how communication breakdowns between families and staff can create dangerous gaps in care. When the daughter requested alarm removal due to sleep disruption, staff accommodated the request but failed to implement the continuous monitoring the facility's own policies required.
The timing proved critical. The veteran went without documented fall prevention interventions for exactly two days before suffering his unwitnessed fall with significant injuries on August 3.
Nursing documentation shows staff recognized the resident's high fall risk. His care plan included multiple interventions updated after each incident. But the facility's response remained reactive rather than proactive, implementing temporary measures that expired without replacement.
The Director of Nursing's admission that frequent rounding should have continued indefinitely after the alarm refusal highlights the facility's failure to follow its own assessment protocols. The DON acknowledged nurses should have reassessed risk factors and updated the care plan accordingly.
Federal regulations require nursing homes to ensure each resident receives adequate supervision and assistance devices to prevent accidents. The Veterans Home of California - Redding failed to meet this standard when it left Resident 2 without fall prevention measures during a critical period.
The facility's inability to produce policies for frequent rounding checks suggests broader problems with safety protocols. Staff repeatedly used this intervention without documented procedures governing its implementation or duration.
Resident 2's unwitnessed fall on August 3 resulted in significant injuries that could have been prevented with proper safety measures. The veteran's case demonstrates how administrative failures and communication gaps can have serious consequences for vulnerable residents who depend on nursing home staff for their safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Veterans Home of California - Redding from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Veterans Home Of California - Redding in REDDING, CA was cited for violations during a health inspection on August 20, 2025.
Resident 2's troubles began in late July when his daughter requested removal of SMART alarms that detect when patients get out of bed or chairs.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.