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 Resident 2's Interdisciplinary Progress Note - Nursing, dated 8/4/25 at 8 AM, the note indicated a late entry for 7/28/25 when Resident 2's daughter requested the alarms (SMART alarms [devices that use sensors to detect when a patient or resident gets out of bed or a chair, alerting a caregiver wirelessly to help prevent a fall]) to be removed because the alarms were Keeping him awake and exhausted.
The note also indicated that both the resident and his daughter appeared relieved after the alarms were removed.
During a concurrent interview and record review on 8/20/25 at 2:08 PM with the Director of Nursing (DON), Resident 2's Fall Prevention Care Plan initiated on 6/24/25 was reviewed.
The care plan was updated after each fall with the following interventions: a.
Frequent rounding was initiated on 7/25/25 for one week (end date 8/1/25). b.
Initiate SMART alarms on 7/26/25 and were discontinued on 7/28/25. c.
Frequent rounding for two weeks was initiated on 8/3/25 (date of most current fall- after Resident 2 fell).The DON stated Resident 2's frequent rounding that was initiated on 7/25/25 concluded on 8/1/25.
The DON also stated the nurses should have reassessed Resident 2 risk factors and updated the care plan to continue frequent rounding indefinitely since Resident 2 and his family refused the use of alarms on 7/28/25.
The DON was unable to provide documented evidence to show there were fall prevention interventions implemented after the frequent rounding intervention was discontinued on 8/1/25, two days prior to Resident 2's unwitnessed fall with significant injuries on 8/3/25. In addition, the DON was unable to provide a policy and procedure (P&P) for the frequent rounding checks intervention.
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - Redding
3400 Knighton Road Redding, CA 96002
SUMMARY STATEMENT OF DEFICIENCIES
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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