Veterans Home Of California - Redding
Veterans Home Of California - Redding in REDDING, CA — inspection on August 20, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of the P&P titled, Fall Risk Assessment and Prevention Program, dated 3/20/23, the P&P indicated, A Registered Nurse (RN), will complete the fall risk assessment on all Residents . 3.
After each fall . II.
Result/Scores . B.
Based upon the Fall Risk Assessment, if the Resident is assessed as a high risk, the Supervising Registered Nurse (SRN) or designee will: 1.
Develop and implement a plan of care for falls based upon the identified risks. 2.
Communicate the plan of care to direct care staff via verbal or written instruction.
555891 08/20/2025
Veterans Home of California - Redding 3400 Knighton Road Redding, CA 96002
During a review of the facility's policy and procedure titled, Medication Administration, General Guidelines (SNF), dated 4/21/25, the P&P indicated, Medications are administered only by nursing . 1. As Ordered: Medications are administered in accordance with and with orders of the prescriber.
During a concurrent interview and record review on 8/20/25 at 10:23 AM with the LVN 1, the physician order for Oxycodone (narcotic pain medication usually prescribed for severe pain) 5 milligrams (mg) immediate release was reviewed.
The physician order indicated, Take one tablet by mouth every 4 hours, as needed for lower back pain. LVN 1 stated she did not administer the Oxycodone as prescribed and she should have called the physician to obtain a medication order for Resident 1's generalized pain.
During a concurrent interview and record review on 8/20/25 at 10:32 AM with the Director of Nursing (DON), Resident 1's Medication Record, dated July 2025, was reviewed.
The Medication Record indicated the pain medication Oxycodone 5 mg immediate release was administered on 10 occasions by multiple nurses for the incorrect indication as follows: 1. 7/16/25 at 3:35 PM - Increased generalized pain2. 7/18/25 at 3 PM - Body pain 3. 7/25/25 at 7 PM - Generalized pain 4. 7/26/25 at 7 AM - Generalized/facial/neck 5. 7/26/25 at 12 PM - Neck pain6. 7/26/25 at 9 PM - Neck pain 7. 7/27/25 at 4:40 AM - Face and Neck pain 8. 7/28/25 at 7 AM - Face Pain9. 7/29/25 at 1 PM - Face and Neck pain 10. 7/31/25 at 8 AM - Neck pain The DON stated the nurses should have obtained a physician order for Resident 1's general pain.
During an interview on 8/20/25 at 1:40 PM with Medical Doctor 1 (MD 1), MD 1 stated the nurses can administer Resident 1's pain medication Oxycodone 5 mg immediate release as needed for other pain indications even though the indication on his physician order stated for lower back pain.
During an interview on 8/20/25 at 1:46 PM with Pharmacist 1 (Pharm 1), Pharm 1 stated it was okay for nurses to administer Resident 1's pain medication Oxycodone 5 mg immediate release as needed for other pain reasons other than the indication stated on the physician's order.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.