Health inspection·August 20, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to reassess fall risk factors and update the care plan interventions for 1 of 3 sampled residents (Resident 2), who was identified as being at high risk for falls. This failure resulted in Resident 2's unwitnessed fall, transfer to the acute care hospital for evaluation and treatment, and subsequent admission due to several broken ribs and a broken right collarbone on 8/3/25 (refer to Intake 2581256).Findings: During a concurrent observation and interview on 8/20/25 at 11:35 AM with Resident 2 in his room, Resident 2 was observed with multiple purplish black discolorations on the right side of his trunk, right side of his head/face, and some small, scattered purplish black discoloration on his right arm. Resident 2 was alert and oriented to person, place, and time. However, Resident 2 got short of breath easily and was drowsy during the interview. Resident 2 stated he did not recall what happened on 8/3/25 when he fell and sustained his injuries. During an interview on 8/19/25 at 11:45 AM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Resident 2 was independent with his activities of daily living but was considered a high fall risk. CNA 1 stated Resident 2 was on frequent rounding checks for a little bit until it was discontinued. CNA 1 stated frequent rounding was checking on the residents every 15 to 30 minutes sometimes hourly depending on the resident's need and noting what was seen, addressing the 4Ps (pain, potty [bathroom needs], positioning, and possessions [or proximity of personal items]), and ensuring alarms were in place and working. During a review of Resident 2's face sheet, the face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a progressive respiratory disease, causing shortness of breath), heart failure, and progressive joint disease resulting in joint pain. Resident 2 had a history of falls. During a review of Resident 2's Case Manager's Note, dated 7/3/25, the note indicated his Brief Interview for Mental Status (BIMS) score was 13/15 (intact cognition). The note also indicated Resident 2 fell on 5/30/25, prior to his admission to the facility and he used a four-wheel walker to ambulate. During a review of Resident 2's Interdisciplinary Progress Note - Nursing, dated 8/3/25 at 10:30 PM, the note indicated Resident 2 had an unwitnessed fall while toileting and was found on the floor with his four-wheel walker behind him on 8/3/25 at 8:30 PM. During a review of Resident 2's Interdisciplinary Progress Note - Nursing, dated 8/4/25 at 4:10 AM, the note indicated Resident 2 was admitted to the acute care hospital with several broken ribs and broken right collarbone on 8/3/25. During a review of Resident 2's Interdisciplinary Resident Fall Investigation and Intervention, the notes indicated Resident 2 had unwitnessed falls on the following dates: a. 7/25/25 at 3:28 PM - due to inability to gauge sleepiness and exhaustion and retire to bedb. 7/26/25 at 1:20 AM - due to impaired balance and overestimated ability. During a review of Resident 2's Fall Risk Assessment Forms (total score of 10 or above represents HIGH RISK), indicated Resident 2 scores were as follows:a. 6/24/25 (on admission), scored 16. b. 7/25/25 (post-fall), scored 15. c. 7/26/25 (post-fall), scored (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 3 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 08/20/2025 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)