Other·September 4, 2019

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 Abbreviated Standard Survey for the investigation of a facility reported incident number: CA00631439. Representing the California Department of Public Health: 16553, Health Facilities Evaluator Nurse (HFEN). The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for facility reported incident visit: CA00631439.

F602 SS=E Free from Misappropriation/Exploitation CFR(s): 483.12

F602 08/29/2019 §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 medical symptoms. This REQUIREMENT is not met as evidenced by: Based on staff interview, record review, and review of facility policies, the facility failed to prevent fiduciary abuse/misappropriation of Resident 1's property when missing funds and a credit card, belonging to Resident 1, were reported missing. This failure had the potential 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: EIZ811 Facility ID: 630014895 If continuation sheet 1 of 4 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 08/15/2019 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 for Resident 1 to suffer mental/psychological distress that could potentially impact Resident 1's level of functioning. Findings: Resident 1's record was reviewed on 5/22/19. Resident 1 was a 92-year-old individual admitted to the Skilled Nursing Facility on 2/8/19. Resident 1's diagnoses included, but were not limited to, muscle weakness, atrial fibrillation, and dysphagia. The IDT (Interdisciplinary Team) note, dated 5/21/19, indicated Resident 1 scored 14/15 on the BIMS (Brief Interview for Mental Status/cognitive test), which indicated little to no cognitive impairment. Social services staff, Staff A, was interviewed on 4/3/19 at 10:00 a.m. Staff A stated on 3/28/19, Resident 1 reported that he was missing an envelope that contained $700.00-$800.00. Resident 1 stated that he could not remember the last time he saw the money and he was not sure how long it had been missing. The following day, Resident 1 reported that he was also missing a credit card from his wallet. Staff A stated that she and Resident 1 contacted the bank and canceled the credit card. Staff A stated that it appeared that the credit card was used for fraudulent charges at a grocery store, for gas, and for food. Staff A further stated that Resident 1 had not left the building. Staff A stated that a family member also reported that he (the family member) brought an envelope, containing the cash, from RCFE (Residential Care for the Elderly) to Klamath (Skilled Nursing Unit) when Resident 1 was transferred there. The envelope was placed in a large folder in Resident 1's room. Staff A stated that the folder was there but the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EIZ811 Facility ID: 630014895 If continuation sheet 2 of 4 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 08/15/2019 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 envelope was not. The family member said that the envelope contained $600.00-$700.00. Additionally, Staff A stated that a family member put a $100.00 bill in Resident 1's wallet and this money was also missing. Subsequent facility documentation, dated 5/15/19, indicated the CHP (California Highway Patrol) located footage of one of the facility's staff members using Resident 1's credit card. This staff was identified, to the surveyor, as CNA (Certified Nursing Assistant) C. Staff A was interviewed on 5/22/19 at 9:25 a.m. and was asked about the status of the missing money. Staff A stated that there had been no closure about the missing funds, it was an undetermined amount, and the police were aware of it. On 6/25/19 at 3:20 p.m., the surveyor requested to interview Resident 1. Administrative staff, Staff B, attempted to arrange an interview with Resident 1 but Resident 1 told Staff B that it happened long ago and it was over and done with. He requested the surveyor speak with Staff A, social services staff. The policy for "Elder Abuse, Prevention and Reporting," last reviewed 3/19/19, contained the following entry: "Each Resident has the right to be free from abuse, exploitation, mistreatment, neglect, and misappropriation of property." Misappropriation of Resident property was defined as: "The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a Resident's belongings or money without the Resident's consent." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EIZ811 Facility ID: 630014895 If continuation sheet 3 of 4 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 08/15/2019 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 Event ID: EIZ811 ID PREFIX TAG 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 4 of 4