Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Veterans Home Of California - Redding during CMS and state inspections, most recent first.
Unlabeled pasteurized eggs were found in the kitchen walk-in refrigerator outside of their original container. A Stock Clerk and a Cook could not identify a use-by date, and the FSM stated the eggs should have remained in the original container or been relabeled with the original container information. Facility policy required refrigerated foods to be labeled with the food item name and expiration date.
Failure to provide fingernail care for a resident who needed assistance with ADLs. The resident, who had osteoarthritis and tremor, was observed in a wheelchair with long, exposed fingernails and said staff did not consistently trim his nails. A CNA confirmed the nails were long and should have been trimmed, and the DON stated licensed nurses should provide hygiene care, including nail trimming.
Expired Lidocaine HCL was found in the emergency kit during an observation with the DON in the medication room. The DON confirmed the vials were expired and stated that pharmacy and nursing staff should check the emergency kit for expired medication. Facility policy states the pharmacist checking the emergency drug kit must note the earliest expiration date and the contract production pharmacy is responsible for cycling out the e-kits before that date.
Urinary Catheter Tubing Contacted the Floor: A resident with an indwelling urinary catheter was observed self-propelling in a wheelchair with the catheter tubing touching the floor. An RN confirmed the tubing should not contact the floor due to infection control concerns, and the IP stated catheter tubing must be kept off the floor to reduce infection risk. Facility policy and in-service materials also stated that catheter tubing and bag should be secured and kept off the floor.
Surveyors found that the facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents.
A resident with multiple serious diagnoses received Oxycodone for pain indications not specified in the physician's order, such as generalized and neck pain, rather than only for lower back pain as prescribed. Nursing staff administered the medication for these other pain complaints without obtaining a new physician order, contrary to facility policy, and the DON confirmed that an updated order should have been secured.
Surveyors found that staff did not consistently monitor the cooldown of potentially hazardous foods, such as cooked entrees and tuna salad, and failed to document required temperature checks. Additionally, a food service worker was observed chewing gum during food preparation, contrary to facility policy. These actions were confirmed through observation, staff interviews, and review of facility records.
Surveyors found that internal and external medications were stored together without separation in two medication storage areas, contrary to facility policy. Oral medications were placed next to external-use products such as eye drops and enemas, and staff acknowledged this improper practice had likely been ongoing and unrecognized.
A nurse was observed making three medication administration errors involving insulin and nasal spray for a resident with dysphagia and muscle weakness. The nurse did not follow manufacturer instructions for holding the insulin pen needle in the skin and failed to instruct the resident to blow their nose before nasal spray administration, resulting in a medication error rate above 5%.
The facility did not employ a full-time qualified supervisor dedicated to managing the day-to-day operations of dietetic services in the SNF. Leadership positions were vacant or shared between the SNF and RCFE, and the staff responsible for food and nutrition services did not meet regulatory requirements for full-time supervision, resulting in insufficient oversight of dietetic services.
A resident with heart failure and atrial fibrillation was administered psychotropic medications without documented informed consent in the medical record. Physician orders and the MAR confirmed administration of Temazepam and Trazodone, but neither the DON nor nursing staff could provide evidence of a signed consent form, as required by facility policy.
A resident's right to privacy was violated when a staff member opened and viewed the resident's bank statement without proper authorization. The resident's son, who held the Durable Power of Attorney, denied giving consent for this action. The facility's policy required mail to be opened only at the resident's request or forwarded to their representative, which was not adhered to in this case.
The facility's kitchen failed to maintain safe and sanitary conditions, with equipment like a chipped can opener and scratched cutting boards not replaced, and foods found uncovered in storage. Labeling issues were noted, with some items difficult to read or lacking labels, and expired food not discarded promptly. These deficiencies were confirmed by staff and violated facility policies and FDA guidelines.
The facility failed to cover two out of eight dumpsters in the main and satellite kitchens, potentially attracting pests and spreading bacteria, risking food contamination for forty-one residents. Observations revealed uncovered dumpsters, confirmed by the Assistant Administrator and Dietetics Assistant Director, who emphasized the need for dumpsters to be closed when not in use. The facility's Waste Management Program policy requires bins to have tightfitting covers and be closed when not being loaded.
A LTC facility exceeded the acceptable medication error rate, reaching 11.11%, due to improper administration of medications to two residents. A resident received crushed pantoprazole and finasteride, despite guidelines against crushing these medications. Another resident was not instructed to rinse his mouth after using an inhaler, contrary to the medication's instructions. The errors were attributed to staff not following medication administration guidelines.
The facility failed to implement care plans for two residents, leading to potential fall risks. One resident's assistive devices were not within reach, and 'Call don't fall' signs were missing. Another resident had outdated assistive devices and signage in their room, contrary to their care plan. These deficiencies were confirmed through observations and staff interviews.
Expired filter needles were found in the Emergency Drug Kit at an LTC facility, with staff unaware of their expiration. The facility's policy required regular review and cycling out of expired items, but the needles remained, posing a risk of using ineffective supplies.
Unlabeled Pasteurized Eggs Stored Improperly
Penalty
Summary
The facility failed to store and label pasteurized eggs in accordance with professional food service standards and facility policy when an unlabeled tray containing 18 pasteurized eggs was found in the Main Kitchen walk-in refrigerator outside of its marked container. During observation, the tray did not have a label showing the received-on date or use-by date. A Stock Clerk and a Cook were unable to identify a use-by date on the tray during interviews. The Food Services Manager stated that the eggs should have remained in the original container, and if stored outside that container, the tray should have been relabeled using the information from the original container. The facility policy on leftover and extra food required refrigerated foods to be labeled with the food item name and expiration date.
Failure to Provide Fingernail Care
Penalty
Summary
The facility failed to maintain proper grooming by ensuring fingernail care for one resident who was unable to perform activities of daily living independently. The resident was admitted with diagnoses of osteoarthritis and tremor. During observation, the resident was seated in a wheelchair in the hallway with exposed, long fingernails and stated that he wanted his nails trimmed and that staff did not consistently perform nail trimming. A CNA later confirmed that the resident's fingernails were long and should have been trimmed. The DON stated that licensed nurses should provide hygiene care, including nail trimming, to reduce the risk of skin injury. The facility policy on Activities of Daily Living stated that nursing staff must assist residents with activities of daily living, including maintaining proper grooming and providing finger and toenail care.
Expired Lidocaine HCL Found in Emergency Kit
Penalty
Summary
The facility failed to ensure expired medication was not available for use when two vials of Lidocaine HCL were found in the emergency kit after their expiration date. During a concurrent observation and interview with the DON in the medication room, the emergency kit contained the two vials of Lidocaine HCL with an expiration date of 3/2026, and the DON confirmed the vials were expired. The DON stated that pharmacy and nursing staff should check the emergency kit for expired medication. During a later interview, the DON stated that medication should not be expired for resident safety and drug efficacy. Review of the facility policy titled Emergency Drug Kit stated that the pharmacist checking the kit will indicate the earliest expiration date on the outside of the container and that the contract production pharmacy is responsible for cycling out the e-kits before the expiration date listed on the exterior of the kit.
Urinary Catheter Tubing Contacted the Floor
Penalty
Summary
The facility failed to maintain an effective infection control program when Resident 20's indwelling urinary catheter tubing was observed touching the floor while the resident was seated in a wheelchair and self-propelling in the hallway. During the observation, RN 1 confirmed that the tubing should not contact the floor because of infection control concerns. Resident 20 had an admission order dated 12/2/25 indicating the need for an indwelling catheter for bladder outlet obstruction. The Infection Preventionist stated that indwelling catheter tubing must not contact the floor to reduce infection risk. The facility policy for urinary catheter use stated that catheter care is provided routinely in accordance with recognized standards, and the in-service lesson plan stated that indwelling catheters should be secured to a wheelchair with tubing and bag kept off the floor and not dragging during mobility.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment or supervision in the specified area was insufficient to prevent potential accidents. No additional details about specific residents, their medical history, or the exact nature of the hazards or supervision lapses are provided in the report.
Pain Medication Administered Outside Prescribed Indication
Penalty
Summary
The facility failed to ensure that pain medication was administered as prescribed for a resident with diagnoses including heart failure, metastatic prostate cancer, and muscle weakness. The physician's order specified that Oxycodone 5 mg immediate release should be given by mouth every four hours as needed for lower back pain. However, review of the medication administration record revealed that the medication was given on ten occasions for indications other than lower back pain, such as generalized pain, body pain, facial pain, and neck pain. Multiple nurses administered the medication for these unapproved indications without obtaining a new physician order to cover the broader pain complaints. Interviews with nursing staff confirmed that the medication was not administered strictly according to the prescriber's order, and the Director of Nursing acknowledged that a physician order should have been obtained for the resident's general pain. Although the physician and pharmacist later stated it was acceptable to administer the medication for other pain indications, the facility's policy required medications to be administered only as ordered by the prescriber. This deviation from the prescribed order resulted in a failure to provide safe and appropriate pain management as required by facility policy.
Failure to Monitor Food Cooldown and Prohibit Gum Chewing in Food Preparation Areas
Penalty
Summary
The facility failed to consistently follow food safety standards in the handling and preparation of potentially hazardous foods (PHFs). Surveyors observed that multiple cooked and frozen food items, such as macaroni and cheese, corned beef, vegetarian meatloaf, and lentil loaf, were stored without proper cooldown temperature monitoring. Additionally, prepared tuna salad made from ingredients stored at room temperature was not monitored for temperature during storage, with staff only checking temperatures shortly before use. Review of the facility's cooldown logs confirmed that these items were not tracked during the cooling process, and the facility's policy did not provide guidance for documenting or monitoring the cooldown of PHFs prepared from room temperature ingredients. During food production observations, a food service worker was seen chewing gum while preparing mechanically altered food items, in direct violation of the facility's policy prohibiting gum chewing in kitchen or serving areas. The worker confirmed having gum in her mouth when questioned. These lapses in food handling and staff conduct were identified through direct observation, staff interviews, and review of departmental documentation.
Failure to Separate Internal and External Medications in Storage Areas
Penalty
Summary
Surveyors observed that internal-use medications, such as oral tablets and capsules, were stored directly adjacent to external-use products, including eye drops and enemas, in two medication storage areas within the facility. There was no physical barrier, labeled bin, or designated shelving to separate medications intended for internal administration from those for external use. This storage practice was noted during a tour of the Clamath and another nursing station, where items like Loperamide tablets, Glucosamine Sulfate capsules, and Calcium Citrate tablets were intermixed with Fleet Saline Enema, GenTeal Tears Lubricant Eye Drops, Refresh Plus Eye Drops, and Major Ear Drops. During an interview at the time of observation, the facility's Quality Assessment Nurse acknowledged the improper storage and indicated that this practice had likely been ongoing and unrecognized by staff. The facility's own policy on medication storage specifically requires that internally administered medications be kept separate from externally used medications, but this policy was not being followed as evidenced by the observed storage conditions.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors observed out of twenty-eight opportunities during a medication pass, resulting in a 10% error rate. Specifically, a Licensed Vocational Nurse (LVN) administered two types of insulin to a resident with dysphagia and muscle weakness but did not follow the manufacturer's instructions for holding the insulin pen needle in the skin for the required duration after pressing the dose button. The LVN admitted to routinely removing the pen immediately after pressing the button, rather than adhering to the specified holding time. Additionally, the same LVN administered a nasal spray to the same resident without instructing the resident to blow their nose beforehand, contrary to standard manufacturer instructions for intranasal sprays. The LVN stated that she was unaware of the need for the resident to clear their nasal passages prior to administration. These observed actions contributed to the facility's medication error rate exceeding the acceptable threshold.
Lack of Full-Time Qualified Supervisor for Dietetic Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to manage the food and nutrition service, specifically lacking a full-time qualified position dedicated to supervising and managing the day-to-day operations of the skilled nursing dietetic services. During the survey, it was observed that the Food Manager (FM) was responsible for both the skilled nursing facility (SNF) and a separately licensed residential care facility for the elderly (RCFE), and his position was not dedicated full-time to the SNF. The Dietetics Assistant Director (DAD), a Registered Dietitian, also had responsibilities split between the SNF and RCFE, and her role was not solely dedicated to the SNF. The organizational chart review confirmed that the Director of Dietetics and a Food Service Supervisor (FSS) II positions were vacant, and there was no full-time qualified Food Service Director dedicated to the SNF. Interviews with facility leadership and staff further revealed that the current structure did not provide a full-time qualified supervisor for the SNF dietetic services. The DAD confirmed that all dietetic services leadership positions were shared between the RCFE and SNF, and the Registered Dietitian assigned to the SNF focused on clinical nutrition care rather than day-to-day management of dietetic services. The FM had not completed the necessary training to become a Certified Dietary Manager, and the facility had not attempted to modify position descriptions or minimum qualifications to address the deficiency. Facility policy and regulatory requirements were reviewed, indicating that if a dietitian is not employed full-time, a full-time Food & Nutrition Services supervisor must be responsible for the operation of the food service. The facility's failure to meet these requirements resulted in a lack of dedicated, qualified supervision for the SNF dietetic services, as evidenced by vacant leadership positions and shared responsibilities among existing staff.
Lack of Documented Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a complete and accurate medical record was maintained for a resident who was prescribed psychotropic medications. Specifically, there was no documentation in the resident's medical record indicating that informed consent was obtained for the administration of Temazepam and Trazodone, both psychotropic medications. The resident's face sheet showed admission with diagnoses including heart failure and unspecified atrial fibrillation. Physician orders for Temazepam and Trazodone were present, and the Medication Administration Record confirmed that these medications were administered on multiple occasions. Interviews with the DON and an RN revealed that the physician was responsible for discussing the treatment and obtaining written consent, and that nursing staff should verify the presence of a signed consent form before administering psychotropic medications. Review of facility policy confirmed that written informed consent must be documented and filed in the resident's health record prior to initiating psychotropic drug therapy. Despite these requirements, no such documentation was found in the resident's record at the time of review.
Unauthorized Access to Resident's Personal Information
Penalty
Summary
The facility failed to respect a resident's right to personal privacy when a staff member opened and viewed the resident's bank account statement without proper authorization. The resident, who was oriented to person and place, had her finances managed by her son and daughter. The resident's son held the Durable Power of Attorney, as indicated in the resident's Face Sheet and the durable power of attorney document dated March 1, 2023. During an interview, the Medical Social Worker (MSW) admitted to opening and viewing the resident's bank account statement for June 2024, claiming that consent was given by the resident's son via telephone. However, the MSW could not provide documented evidence of this consent, and the resident's son later denied giving such consent. The facility's policy stated that mail could only be opened at the resident's request or forwarded to their representative if they had a conservator, power of attorney, or other representative. This policy was not followed, leading to unauthorized access to the resident's personal information.
Food Safety and Sanitation Deficiencies in Facility's Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the food service department, as observed during a survey. Equipment such as a can opener with metal chipped off the cutting tip and discolored cutting boards with deep scratches were not replaced, posing a risk of contamination. Foods were found uncovered in storage areas, including frozen burritos, chicken breasts, and vegetable patties with ice build-up, as well as a bag of pork and uncooked ravioli left open to the air. These conditions were confirmed by the Food Manager and Dietetics Assistant Director, who acknowledged the potential for cross-contamination and food quality degradation. Additionally, the facility did not appropriately label food items, with black pepper and bay leaves having labels that were difficult to read, and ice cream bowls lacking labels entirely. This oversight was confirmed by the Dietetics Assistant Director, who stated that staff were expected to label food items with a use-by date to ensure safety. Furthermore, expired food items, such as apple juice boxes, were not discarded in a timely manner, leading to confusion about product safety. These deficiencies were in violation of the facility's policies and procedures, as well as the 2022 FDA Food Code.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two out of eight dumpsters were covered for the main and satellite kitchens, which had the potential to attract pests, rodents, and spread bacteria, leading to food contamination for a population of forty-one residents. During an observation and interview with the Assistant Administrator, it was noted that one out of four trash dumpsters for the main kitchen was not covered, exposing trash. The Assistant Administrator confirmed that the dumpster should be closed and proceeded to close the two lids. Similarly, an observation in the satellite kitchen revealed that one out of four trash dumpsters was not covered, exposing trash. The Dietetics Assistant Director stated that trash dumpsters need to be closed at all times when not in use to prevent attracting rodents or pests to the facility. A review of the facility's Waste Management Program policy indicated that movable bins used for storing or transporting solid wastes should have tightfitting covers and be closed when not being loaded.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 11.11% error rate. This was due to the improper administration of medications to two residents. Resident 26 was given pantoprazole and finasteride in a crushed form, contrary to guidelines. Pantoprazole, a delayed-release medication, was crushed and mixed with applesauce, despite the manufacturer's instructions against crushing. Similarly, finasteride, which requires special handling, was also crushed and administered in the same manner. The Licensed Vocational Nurse (LVN) involved did not notice the 'Do Not Crush' and 'Caution Special Handling' labels on the medication packaging and was unaware of the implications of these labels. Additionally, Resident 21 was not instructed to rinse his mouth after using an inhaler containing fluticasone furoate, umeclidinium, and vilanterol. This step is crucial to prevent potential side effects such as hoarseness and oropharyngeal candidiasis, as indicated by the medication's packaging and prescribing information. The Registered Nurse (RN) administering the medication failed to provide this instruction, and the resident did not have a history of refusing to rinse his mouth after inhalation. The facility's policies and procedures for medication administration were not adhered to in these instances. The Director of Nursing acknowledged that the medications should not have been crushed and that proper instructions should have been given to Resident 21. The facility's guidelines require that altering the form of a medication, such as crushing, should only be done with a physician's order and that special handling instructions should be followed for certain medications.
Failure to Implement Care Plans for Fall Prevention
Penalty
Summary
The facility failed to implement the care plans for two residents, leading to potential safety risks. For one resident, who had a left below-knee amputation and a right transmetatarsal amputation, the care plan required that assistive devices such as a wheelchair and prosthetic leg be within reach. However, during an observation, these items were found across the room and in the bathroom, respectively, making them inaccessible. Additionally, the care plan included the posting of 'Call don't fall' signs, which were not present in the resident's room. Interviews with the Quality Assurance Registered Nurse and the Occupational Therapist confirmed these oversights. For another resident diagnosed with Alzheimer's Disease and ataxic gait, the care plan specified the use of a manual wheelchair, yet a walker and corresponding signage were still present in the room, contrary to the updated care plan. Furthermore, 'Call don't fall' signs, which were part of the fall prevention strategy, were missing from the resident's room. The Assistant Director of Nursing and a Physical Therapist confirmed that the walker had been discontinued and should have been removed, along with the signage. These deficiencies were identified through observations, interviews, and record reviews, highlighting a failure to adhere to the established care plans.
Expired Filter Needles Found in Emergency Drug Kit
Penalty
Summary
The facility failed to ensure the safe monitoring of pharmaceutical medical supplies when four expired filter needles were found in the injectable Emergency Drug Kit (E-Kit). These filter needles, which are designed to remove particles that might contaminate medication, were found without expiration dates in the Klamath Unit medication room. The Pharmacy Technician initially stated that some filter needles did not have expiration dates, and the most recent expiration date was posted on the E-kit lid for staff to alert the main pharmacy for replacements. However, upon further investigation, it was confirmed by the Manufacturer Representative that the filter needles had expired on January 24, 2022. Interviews with the Director of Nursing and a Registered Nurse revealed uncertainty and lack of awareness regarding the expiration dates of the filter needles. The facility's policy and procedure for the Emergency Drug Kit indicated that the contents should be reviewed by the pharmacy services committee and cycled out before expiration. Despite this policy, the expired filter needles remained in the E-kit, posing a potential risk of using ineffective medical supplies and contaminated medications for residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Redding
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquis Care At Shasta | 3.5 mi | — | 19 | 0 |
| Crestwood Wellness And Recovery Center | 4 mi | — | 2 | 0 |
| Copper Ridge Care Center | 4.4 mi | — | 15 | 0 |
| Oak River Rehab | 4.5 mi | — | 0 | 0 |
| River Valley Healthcare & Wellness Centre, Lp | 5.1 mi | — | 1 | 0 |
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