Other·November 21, 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 the investigation of a complaint. Complaint Number: CA00547361 Representing the California Department of Public Health: Health Facilities Evaluator Nurse: 37341 Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for Complaint Number: CA00547361 THE DEPARTMENT WAS ABLE TO SUBSTANTIATE A VIOLATION OF THE REGULATIONS

F224 SS=G PROHIBIT

F224 MISTREATMENT/NEGLECT/MISAPPROPRIA TN CFR(s): 483.12(b)(1)-(3) §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. 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: 2UBD11 Facility ID: 630014895 If continuation sheet 1 of 8 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 10/25/2017 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 483.12(b) The facility must develop and implement written policies and procedures that: (b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (b)(2) Establish policies and procedures to investigate any such allegations, and (b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to prevent 1 of 3 sampled residents from neglect when licensed staff (RN 3) failed to assess a resident (Resident A) during a change of condition (change in health status), failed to offer medication for nausea and vomiting, and failed to provide wound care. Unlicensed staff notified RN 3 that the Resident A was not feeling well and complained of symptoms that could have been cardiac related. The assigned licensed staff nurse (RN 3) failed to assess Resident A following notification of the change of condition and Resident A was subsequently discovered deceased during change of the shift. Findings: On 7/28/17, an investigation was initiated regarding a complaint that Certified Nursing Assistants (CNA 5, CNA 6) had notified a registered nurse (RN 3) that Resident A needed attention. The resident was described FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UBD11 Facility ID: 630014895 If continuation sheet 2 of 8 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 10/25/2017 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 as displaying symptoms, which could have been related to his known cardiac condition. The complainant reported that although RN 3 was notified, RN 3 did not assess the resident, have another RN assess the resident, did not provide wound care as ordered, or provide any other interventions. Resident A was found by staff deceased in his room at 6:35 a.m. on 6/18/17. Resident A's medical record was reviewed on 8/29/17. The June 2017 Treatment-Wound Administration record for Resident A, dated 6/1/17 through 6/30/17 indicated the resident had four wounds, one skin tear above the left knee, one on the back of the left hand, a right wrist skin tear, and left gluteal fold (between leg and buttock) wound. Wound care treatment orders showed treatments were to be performed daily on the night (NOC) shift. Further review of Resident A's medical record on 9/6/17, included the History and Physical (H&P), dated 1/4/17. The H&P indicated Resident A, age 81, had primary diagnoses including Coronary Artery Disease (reduce blood flow through the cardiac arteries), Cardiac Artery Bypass Surgery (Surgery performed to bypass occluded arteries), Gastro Esophageal Reflux Disease (Stomach contents leak backwards into the throat), Atrial Fibrillation (rapid, irregular beating of the upper chamber of the heart) and severe Peripheral Neuropathy (degeneration of nerves in extremities). Resident A's mental and behavioral status was documented as alert and "agreeable." On 8/9/2017 at 2:30 p.m., when asked about the night of 6/17/17, CNA 8 stated a supervising registered nurse (SRN) had been working on the staff schedule for the 6/17/17 night shift. CNA 8 was taking Resident A's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UBD11 Facility ID: 630014895 If continuation sheet 3 of 8 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 10/25/2017 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 blood pressure when Resident A overheard the SRN mention that for the 6/17/17 night shift, RN 3 was to be assigned to care for Resident A. Resident A specifically told the SRN he did not want RN 3 to take care of him. During interview with a supervising registered nurse (SRN 1), on 8/10/17 at 9:00 a.m., SRN 1 stated that although he had not worked the night of the event, he was aware Resident A and RN 3 had a relationship with conflict. SRN 1 characterized Resident A as having been very alert and an advocate for other residents at the facility. According to SRN 1, Resident A had asked for a change of nurses 3-4 weeks previously, not wanting RN 3 to provide care to him. SRN 1 had looked into making the change and informed Resident A that he would try to accommodate the resident's request. SRN 1 stated to accommodate the request, a resource nurse (a nurse available to assist with assessments, treatments and administration of medications) could do that resident's dressing changes or give his medications. SRN 1 stated during the 6/17/17 night shift, RN 3 should have traded assignments with a resource nurse to accommodate Resident A's request not to be cared for by RN3. During interview with CNA 6, on 8/9/17, at 1:50 p.m., CNA 6 indicated she worked the 6/17/17 night shift (from 10 p.m. to 6:30 a.m.) and helped CNA 5 during the shift, assisting with the call lights and covering her for breaks that night. CNA 6 stated Resident A, complained of dry heaves, nausea, and did not feel well. CNA 6 stated Resident A was not the "same," with slow movements and speech. CNA 6 notified RN 3 several times during that night shift, that Resident A wanted medications for nausea. RN 3 stated, outside of Resident A's room, "He doesn't like my face; I can't go into that room." RN 3 did not go into the room per CNA 6. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UBD11 Facility ID: 630014895 If continuation sheet 4 of 8 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 10/25/2017 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 According to CNA 6, this event occurred around 4:00 a.m. or 5:00 a.m., toward the end of the shift. During an interview on 8/10/17 at 10:00 a.m., CNA 5 stated she worked the 6/17/17 night (NOC) shift, as the direct care provider for Resident A. Resident A put on the call light and informed her that he wanted the head of the bed up and had "dry heaves." CNA 5 reported to RN 3 between 3-4 a.m., that Resident A looked sick and had dry heaves while she was getting a basin for the resident. CNA 5 stated she had not observed RN 3 check on Resident A and CNA 5 did not witness any refusal of care by the resident. During an interview with RN 3 on 8/11/17 at 2:36 p.m., RN 3 stated she was notified of Resident A's condition at 1:00 a.m. and checked on him at that time. Resident A was watching TV, and refused wound care treatment. RN 3 stated Resident A did not like her. RN 3 stated she was "off the clock when patient was found dead." Review of Resident A's Medication Administration Record (MAR) on 8/23/17, dated 6/1/2017 through 6/30/17, showed an order for Ondansetron HC (used for nausea and vomiting) 4 mg. (milligrams) - take 1 tab by mouth every 6 hours as needed. There was no documentation on the MAR showing that medication for nausea had been given, nor was there any documentation of refusal of antiemetic (to prevent/relieve nausea) medication on 6/17/17 or 6/18/17. During an interview with RN 4, on 8/23/2017, at 3:28 p.m., RN 4 stated when she arrived to work on the a.m. shift, 6/18/2017, Resident A was found unresponsive by a CNA on day shift. There was no report from RN 3 regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UBD11 Facility ID: 630014895 If continuation sheet 5 of 8 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 10/25/2017 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 Resident A's change of condition, complaints or status, nothing mentioned during the change of shift report. The patient expired at 6:35 a.m. on 6/18/17. During an interview with RN 7, on 8/29/17 at 10:10 a.m., RN 7 stated she had been a resource nurse on the 6/17/17 NOC shift. She indicated she worked the NOC shift on 6/17/17 on another unit, which was next to the unit where RN 3 was assigned. RN 7 stated she was aware of the relationship between Resident A and RN 3. The RN stated a resource nurse could work both units. If there was friction between the patient and the RN 3, RN 7 could have provided care to Resident A. RN 7 stated that RN 3 did not ask RN 7 to give Resident A's medication or provide wound care treatment to the resident that night. On 8/29/2017, record review showed no written evidence that wound care had been provided on the 6/17/17 NOC shift. The TreatmentWound Administration record for Resident A, dated 6/1/17 through 6/30/17 indicated the resident had four wounds with wound care treatment orders to be performed on the NOC shift. On the record where a signature would have indicated the treatment had been done, instead there was RN 3's signature circled, indicating the treatment was not performed. On the back of the wound care record, RN 3 documented, "All tx's (treatments) for NOC'S done by resource nurse." The resource nurse, during the 8/29/17, 10:10 a.m. interview, stated she did not provide wound care to Resident A and had not been asked to. The medical record included a Gastric Care Plan, dated 3/21/16. Within the plan were instructions to notify a physician if the resident had signs/symptoms of GI distress. No record of physician notification was in the record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UBD11 Facility ID: 630014895 If continuation sheet 6 of 8 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 10/25/2017 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 Review of the vital signs record for Resident A for 6/17/17 or 6/18/17, indicated that there were no vital signs done for Resident A. Review of the facility policy and procedure titled, "Notification of Physician, Resident, and Representative, dated 3/1/17, stated licensed staff of the Skilled Nursing Facility (SNF) must notify the resident, physician, and representative of significant or changes in the condition in the residents' condition." During medical record review, the Interdisciplinary Progress notes for Resident A, showed no documentation for 6/17/17 NOC shift on that resident until after he was found deceased. During an interview at 11:30 a.m. on 8/9/17, the Director of Nursing (DON) stated wound care was usually done on NOC shift. The DON stated if a resident had a request the facility was unable to accommodate, it should investigate the problem, and switch with another staff person to provide care for a resident if it was a staff-client conflict. She stated she knew of the relationship with Resident A and RN 3. The DON said the standard policy, if there was a change in condition of a resident, if reported, was that an assessment should be done, a physician called if needed, and vital signs should be reported to oncoming nurses. During an interview with the Skilled Nursing Facility administrator, on 8/9/17, at 3:10 p.m., the administrator stated when there was a conflict between staff and residents, the procedure was to provide conflict resolution, assess the situation and resolve the issues. A resource nurse would provide care if a patient refused treatment from the main nurse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UBD11 Facility ID: 630014895 If continuation sheet 7 of 8 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 10/25/2017 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 The Certificate of Death for Resident A was reviewed on 9/1/17. The indicated time of death was 6/17/17 at 6:35 a.m. The immediate cause of death was Coronary Artery Disease and Atherosclerotic Cardiovascular Disease. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UBD11 Facility ID: 630014895 If continuation sheet 8 of 8