Other·June 22, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an entity reported incident visit. Entity Reported Incident number CA00496026 Inspection was limited to the specific incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, 5008 THE DEPARTMENT SUBSTANTIATED THE FOLLOWING VIOLATION OF THE REGULATIONS.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GPR711 Facility ID: 630014895 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555891 (X3) DATE SURVEY COMPLETED 03/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - REDDING 3400 Knighton Rd Redding, CA 96002 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: AMENDED 2567-3/29/17 Based on interviews, record review and facility document review, the facility failed to ensure one of three residents (Resident 1) remained free of accidents as possible, when facility policy was not followed and the resident fell out of his wheelchair breaking his arm and the resident's plan of care failed to identify use of the wheelchair and associated risk for the resident. This failure resulted in actual harm to Resident 1 who sustained a fractured right arm. Findings: The facility reported incident indicated that on 6/29/16 at 11:05 a.m., Resident 1, while being pushed in his wheelchair, by a volunteer, fell out of the wheelchair and sustained a broken FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GPR711 Facility ID: 630014895 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555891 (X3) DATE SURVEY COMPLETED 03/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - REDDING 3400 Knighton Rd Redding, CA 96002 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE arm. The facility incident report indicated while Resident 1 was being pushed over yellow safety bumps on a sidewalk ramp, "the wheelchair stumbled," and the jarring caused the resident to fall out of the wheelchair. The volunteer yelled for help and two passersby picked up the resident and transferred him back to the wheelchair. The volunteer stated she heard a "pop during the lift." The volunteer had separated from the group and brought the resident to a distant restaurant across the mall parking lot at the resident's request. After the fall the volunteer pushed the resident back across the mall parking lot to the mall where the remainder of the group was gathered. The resident was asked if he wanted to go to the hospital or return to the facility. The resident stated he preferred to return to the facility. After an assessment by the nurse practitioner at the facility, the resident was transferred to a community hospital where he was diagnosed and treated for a right arm fracture. The record indicated that Resident 1 was wheelchair bound due to severe Parkinson's disease. The Minimum Data Set (MDS) quarterly assessment dated 6/3/16 indicated Resident 1 had limitation of both upper extremities, was not able to walk and required extensive assistance by another person to weight bear, transfer and move about in a wheelchair. A wheelchair was identified as the assistive device used. During an interview, on 1/30/17 at 1:30 p.m., the Administrator and Director of Nursing (DON) stated that the resident did not have footrests in place on this outing. The resident was not wearing a safety belt during the outing although the Administrator and DON stated there had not been a reason to assess the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GPR711 Facility ID: 630014895 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555891 (X3) DATE SURVEY COMPLETED 03/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - REDDING 3400 Knighton Rd Redding, CA 96002 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE need for one. During an interview, on 1/30/17 at 3 p.m., the Recreation Therapist (R.T.) stated that nursing staff only accompany residents during an outing if residents will be eating. The R.T. stated that the volunteer did not notify her that she and Resident 1 were leaving the mall, which she should have done. The volunteer should not have left the mall alone with Resident 1. Regarding the resident's fall out of the wheelchair, the R.T. stated that the resident was would jump when startled. She could imagine him being jostled out of the wheelchair when going over those yellow bumps. During an interview, on 2/7/17 at 3:15 p.m., the volunteer accompanying Resident 1 stated she verbally prepared the resident before going over the bumps. The volunteer stated the resident tended to lean forward in the wheelchair and with the bumping he fell to the ground. She stated she yelled for help. The resident was very uncomfortable as it was a hot day and the resident was on the pavement. Two passersby lifted the resident back into the wheelchair. The volunteer stated she heard a pop when the resident was transferred back to the wheelchair. The volunteer then pushed the resident back across the parking lot to the mall. The resident reported to the Recreation Therapist he thought he broke his arm. The Recreation Therapist contacted the facility. The resident did not have footrests on the wheelchair for the outing. Regarding the lack of footrests, the volunteer stated that she could not put footrests on the wheelchair, only nursing. The resident's plan of care updated 6/25/16 for "Activities of Daily Living" and for the problem of "Potential for Fall and/or injury" failed to identify the resident's use of a wheelchair. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GPR711 Facility ID: 630014895 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555891 (X3) DATE SURVEY COMPLETED 03/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - REDDING 3400 Knighton Rd Redding, CA 96002 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care plan did not indicate the resident had the tendency to lean forward when in the wheelchair. Review of facility policy titled: "Therapeutic Activities, Community Outing (SNF)" under the section "staffing" 6. "Nursing staff will provide assistance with Resident transfers, toileting, and provide escort services as indicated to ensure the care and safety of the attending Residents." Review of wheelchair procedures from the facility's "Volunteer Services Handbook" revised May 2016, indicated the following section: "IMPORTANT! THIS IS A "NO LIFTING" FACILITY. If a resident falls do not help them up ask them to lie still and go to the nearest staff and ask them to page the nurse. If you are with another volunteer or if someone is walking by ask them to go to security for you and stay with the resident. Medical personnel must evaluate each fall. The handbook under the section wheelchair procedures also indicated "After a resident is seated, put foot pedals down..." Another document titled: "Wheelchair Assist" indicated to make sure the resident's feet are on the footrests to prevent dragging and possible injury. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GPR711 Facility ID: 630014895 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555891 (X3) DATE SURVEY COMPLETED 03/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - REDDING 3400 Knighton Rd Redding, CA 96002 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: GPR711 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: 630014895 (X5) COMPLETE DATE If continuation sheet 6 of 6