Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based 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.
Findings:
During an interview on 8/29/23 at 7:15 a.m., with CW 1, CW 1 stated on August 19, 2023, at 08:10 a.m. a
Certified Nursing Assistant (CNA 1) was in Resident 1 room and heard the Resident yell at her to get out of
his room. CNA refused to leave and forced Resident 1 into his wheelchair to take him to the breakfast area.
CW 1 stated CNA 1 then could be heard and seen by everyone verbally agitated and picking on the
resident and stated, You are a nasty mean old man to which he replied, No I'm not, go away. CW 1 stated
Resident 1 asked CNA 1 to go away multiple times and she just stood there and made rude comments. CW
1 observed CNA 1 approach Resident 2, who was already agitated, and she kept giving him a giant,
belittling, mocking/sneer smile to agitate him even more. The nurses attempted to redirect Resident 2, but
CNA 1 continued to follow him and get into his face. CW 1 stated Resident 2 was so upset he used his
walker to try and hit everyone and everything.
During an interview on 8/29/23 at 9:30 a.m., with CW 1, CW 1 stated he did not complete SOC 341 (Report
of Suspected Dependent Adult / Elder Abuse). CW 1 stated he called and reported to his supervisor
regarding the incident on 8/19/23. CW 1 stated he wasn't aware if his supervisor completed form SOC 341.
CW 1 stated he should have followed facility P&P for abuse reporting.
During an interview on 8/29/23 at 9:40 a.m., with Custodian Supervisor (CS 1), CS 1 stated on 8/19/23, he
received a phone call from CW 1. CS 1 stated CW 1 had some concerns regarding inappropriate behavior
from CNA 1 to residents. CS 1 stated he informed CW 1 that if he felt and witnessed elder abuse, he was a
mandated reporter. CS 1 stated he advised CW 1 to talk with Nursing Supervisor and make a call to the
Ombudsman (an independent official person who investigates complaints against the facility). CS 1 stated
he did not instruct CW 1 to complete SOC 341. CS 1 stated he should have instructed CW 1 to complete
SOC 341, but he completely forgot. CS 1 stated they did not follow facility P&P.
During an interview on 8/29/23 at 9:45 a.m., and 11:00 a.m., with Standards Compliance Coordinator (SCC
1), SCC 1 stated CW 1 did not inform her that he felt the residents had been abused or
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555891
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555891
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - Redding
3400 Knighton Road
Redding, CA 96002
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
neglected. SCC 1 stated CW 1 did not inform the Supervising Registered Nurse (SRN), and he should have
followed through to ensure proper reporting was completed. SCC 1 stated CW 1 did not complete SOC 341
which delayed the internal investigation initiation which began on 8/21/23. SCC 1 stated, on 8/19/23 and
during the facility investigation, residents were not protected from potential harm by removing the accused
from any patient contact. SCC 1 stated they did not follow facility abuse P&P. SCC 1 stated CNA 1 was not
removed from patient care on 8/19/23 and during the ensuing investigation. SCC 1 further stated they (the
facility) did not report the abuse allegation to California Department Public Health (CDPH).
During a review of Resident 1's and Resident 2's Investigation Report (IR), dated 8/24/23, the IR indicated,
Custodian [CW 1] sent an email on August 19, 2023 regarding CNA [CNA 1]. [CW 1] alleges that [CNA 1]
refused to leave resident [Resident 1] room when he yelled at her to Get the hell out of my room . [CW 1]
further alleges that CNA [CNA 1] forced resident [Resident 1] into his wheelchair and called him names.
[CW 1] said [Resident 1] looked neglected (hair messy and dirty). [CW 1] went on to talk about a different
incident that CNA [CNA 1] was involved in, [CW 1] alleges that Resident [Resident 2] was already agitated
by CNA [CNA 1] and [CNA 1] kept giving [Resident 2] a giant belittling mocking/sneer smile to agitate him
even more. [Resident 2] went on ramming everyone and everything with his walker .
The facility P&P titled, Elder Abuse, Prevention and Reporting dated 6/4/20 indicated, .Each Resident has
the right be free from abuse, exploitation, mistreatment, neglect, and misappropriation of property . D.
Employee procedure / response for situation, allegations, and suspicions of elder abuse. 1. If employee
witness, suspects, or is told of an incident of abuse, or identifies injury of unknown origin that is of
suspicious nature, the employee will immediately: a. Protect the Resident from harm, including separating
the Resident from the alleged abuser; b. Nursing staff will conduct physical and psychosocial assessments,
as appropriate, and make necessary care plan revision and referrals for follow up; c. Ask for security and /
or supervisor assistance to ensure safety; d. Protect Residents from harm during an investigation; e.
Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress;
f. The home will implement interventions to keep alleged abusers from unsupervised Resident access
during any investigations related to the incident. IV. Reporting. The mandated reporters is required to
complete the Elder Abuse Mandated Reporter form (SOC 341), and report the incident to the Supervisor so
that appropriate protection of the Resident can be initiated. All witnessed /alleged violations will be reported
immediately to the appropriate authorities .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555891
If continuation sheet
Page 2 of 2
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
FAQ · About this visit
Common questions about this visit
What happened during the September 8, 2023 survey of Veterans Home Of California - Redding?
This was a inspection survey of Veterans Home Of California - Redding on September 8, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Veterans Home Of California - Redding on September 8, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.