Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Red Bluff Health Care Center during CMS and state inspections, most recent first.
Failure to Reassess Bladder Status After Catheter Removal: A resident with urinary retention and prior Foley use had his catheter removed, but staff did not complete a new bowel and bladder assessment or track voiding after removal. Nursing notes documented repeated complaints that he could not urinate, bladder fullness, refusal to toilet, and episodes of urinating only after assessment. The resident later required hospitalization and was discharged with septic shock, AKI, CAUTI on admission, and uremic encephalopathy.
Failure to provide behavioral health evaluation and services: A resident with anxiety, depressive episodes, and a personality disorder had a PASRR Level II trigger, psych consult orders, and multiple psychotropic medications, but the record showed no documented mental health referrals or Level II completion. The chart also showed repeated behavioral symptoms, verbal aggression, refusal of care, delusional statements, self-induced vomiting, and statements about wanting to die, while the IDT did not document review of behavioral symptoms or response to medications. The SSD and DON acknowledged missing documentation and that the resident’s behavioral health needs were not fully evaluated.
The facility failed to ensure residents received respectful, individualized care and that CNA performance was adequately overseen. Multiple residents reported that a CNA was rough during care, ignored a resident’s request to be careful with a painful shoulder, did not listen to or individualize care, and behaved disrespectfully. Staff interviews described this CNA as treating residents like toddlers, being rude, abrupt, reckless, and careless, with residents preferring other staff. Despite these complaints, the DON and DSD reported being unaware of multiple allegations, and the CNA’s performance review did not reflect issues. The Admin acknowledged knowing for about a year that the CNA was task-focused and did not listen well to residents, but typically did not document counseling unless he viewed the issue as egregious, resulting in only one counseling memo in the CNA’s file.
Multiple residents with hemiplegia, hemiparesis, muscle weakness, pain, and significant assistance needs reported that a CNA provided rough, dismissive, and unprofessional care, including ignoring a resident’s verbal warning about arthritic shoulder pain, handling another resident’s shoulder roughly causing severe pain, cutting off a resident during communication, raising her voice, and engaging in giggling and flirting with staff instead of focusing on resident care. Other CNAs described this CNA as reckless, careless, abrupt, and treating residents like toddlers, and noted that residents preferred other staff. The DON acknowledged the CNA’s task-oriented, fast work style that could overlook resident needs but was unaware of multiple allegations, and the DSD reported no documented performance issues despite these concerns, resulting in residents not consistently receiving dignified, respectful, and individualized care.
A facility failed to maintain a clean, safe, and homelike environment when a resident room sliding glass door would not lock properly, flooring beside the door was buckled and made it hard to slide, a bathroom door had a hole, and multiple south hall bathrooms had chipped paint, holes, and worn molding. Surveyors also found dust and debris in sliding door tracks in 10 resident rooms, worn and chipped areas at the nurses' station, and a stained, unclean drain at the lobby water fountain used by residents and visitors.
A facility failed to ensure residents knew how to file grievances, that grievances were documented and communicated back to them, and that residents felt free from fear of retaliation. Seven sampled residents said they did not know where grievance forms were, three said they were not told the results of their complaints, and three said they feared retaliation. The Admin used his own personal tracking form instead of the facility grievance process, and staff confirmed complaints were not consistently documented or tracked.
Failure to Report Allegations of Resident Mistreatment: A resident group reported that a CNA was verbally aggressive, rough, and unhelpful, and several residents said they felt uneasy, humiliated, or feared retaliation when raising concerns to Admin. Although staff, including the DON, SS/Admit, and LNs, acknowledged repeated complaints about the CNA’s treatment of residents, the facility did not follow its abuse investigation and reporting process or notify residents of investigation progress. Admin stated he did not consider the complaints to be abuse and did not file SOC 341 reports unless he believed they were necessary.
Improper Oxygen Tubing Storage and Dating: Two residents with oxygen orders had tubing observed lying uncovered on their wheelchairs and not dated, despite facility policy requiring oxygen cannulas and masks to be stored in a plastic bag when not in use and changed when soiled. One resident had acute and chronic respiratory failure, COPD, pneumonia, and dependence on supplemental O2; the other had acute and chronic respiratory failure, COPD, and moderate cognitive impairment. Both had orders to change and date oxygen tubing weekly.
Annual CNA performance evaluations were not completed for four of five sampled CNAs. Record review showed CNA C, F, G, and H lacked 2024 evaluations, despite facility policy requiring evaluations after probation and at least annually thereafter. The Admin and MDS/DSD confirmed the missing evaluations and that the facility did not follow its policy.
Unsanitary kitchen and refrigerator conditions were observed during survey. The dishwasher was visibly soiled with lime scale, fans and light fixtures in food prep areas were dirty, and a bedpan was placed under a leaking ceiling above the stove. Surveyors also observed uncovered sliced cheese in the kitchen refrigerator and a visibly dirty resident food refrigerator containing expired items. The NSD and maintenance staff confirmed several of these conditions were not in compliance with facility policy.
Inaccurate psychiatric diagnosis documentation was found for a resident receiving Seroquel for bipolar disorder. The admission H&P and neuropsychiatric consult did not include bipolar disorder, while the EMR later listed bipolar disorder and the MAR tracked manic behavior without defining the behaviors to monitor. The care plan referenced manic behavior and confabulating stories related to bipolar dx, but staff interviews described the resident as pleasant and non-aggressive, and the MD acknowledged the initial consult did not address the bipolar diagnosis.
A resident with respiratory failure, COPD, diabetes, and chronic pain had opioid orders for morphine and Norco, but nursing staff did not document pain level with each Norco dose and recorded the resident’s pain as 0 every day despite the resident reporting daily pain rated 8 to 10 out of 10. An LPN confirmed pain was not checked when opioids were given, and the DON stated the IDT did not discuss pain management or recurrent falls with opioid use.
Missing MAR Documentation for Controlled Pain Medication: A resident with arthritis, chronic pain, and diabetes had PRN Norco removed from the CDR on multiple occasions, but the MAR had no corresponding documentation for those doses. The DON confirmed the missing MAR entries, and facility policy required staff to initial the MAR after medication administration.
Unsafe medication storage and labeling were observed in the medication room and on a south hall med cart. Expired Vancomycin and an overdated open vial of PPD were found in active storage, vaccine refrigerator temps were logged once daily instead of twice daily, and multiple meds on the cart were stored or dated contrary to manufacturer instructions, including Latanoprost, DuoNeb, Insulin Glargine, and Acidophilus with Pectin.
A nurse did not clean a BP cuff after using it on a resident and returned it to the medication cart with other cuffs. A shared pill cutter on the med cart also had visible white powder residue inside it. The DON stated staff should follow infection prevention practices for shared devices, including cleaning BP cuffs with Sani-wipes after each use and wiping pill cutter dust to prevent cross-contamination.
The facility failed to provide a clean, safe, and homelike environment for residents, with unclean mechanical lifts, dusty patio doors, and stained privacy curtains. Observations revealed cumulative food and debris in rooms, damaged furniture, and missing floor tiles. Staff confirmed the need for deep cleaning and repairs to prevent infection spread and ensure resident comfort.
A resident with COPD was not given proper instructions for using an albuterol inhaler, as a nurse failed to follow the manufacturer's guidelines for administration. This oversight was confirmed by the DON, highlighting a lapse in meeting professional standards of care.
The facility failed to maintain oxygen equipment for two residents, with overdue tubing changes and an empty humidifier bottle, risking infection. Both residents required consistent oxygen therapy due to significant medical conditions, and the oversight was confirmed by the DON and a nurse.
A facility failed to document behaviors for a resident prescribed Seroquel, an antipsychotic medication, as required by their policy. The resident, with multiple diagnoses including Bi-Polar disorder, had only one behavior documented over several months, despite needing moderate assistance with daily activities. This lack of documentation could affect the assessment of the medication's necessity and effectiveness.
Failure to Reassess Bladder Status After Catheter Removal
Penalty
Summary
The facility failed to ensure appropriate bowel and bladder assessment and care for a resident with urinary retention and an indwelling urinary catheter history. The resident was admitted with diagnoses including depression, personality disorder, and anxiety, and the clinical record showed urinary retention related to neurogenic bladder. A bowel and bladder assessment completed on 3/4/26 documented an indwelling urinary catheter and bowel incontinence, with the resident needing assistance to toilet, manage clothing, and clean himself after toileting. The resident’s urinary catheter was removed on 4/8/26 per physician order, and nursing documentation stated he would be monitored to ensure he could urinate. After removal, the record showed no bowel and bladder assessments were completed. Nursing notes documented that the resident repeatedly stated he could not use a urinal, refused multiple times to go to the bathroom, and continued to report difficulty urinating. On 4/11/26, staff documented that he had not urinated since the morning, his bladder felt full on assessment, and he later urinated a large amount. He then requested that his catheter be put back in, but no new order was given. On 4/12/26, he again stated he did not know how to use a urinal and later complained of not being able to urinate, with staff palpating his bladder and observing him start urinating. The resident continued to have urinary complaints and behavioral distress, including statements that he felt unwell, did not trust help, and wanted his catheter back. On 4/17/26, staff documented low blood pressure, dry mouth, and the resident’s refusal of assistance from the MD. He was later monitored for behaviors and made statements that he wanted to die, refused medications, and did not want help from nursing staff or the MD. He was transferred to an acute care hospital on 4/19/26 and was discharged 8 days later with final diagnoses including septic shock, kidney injury caused by septic shock, catheter-associated urinary tract infection on admission, and uremic encephalopathy. The DON stated that once the urinary catheter was discontinued, a new bowel and bladder assessment would be expected and confirmed there was no nursing documentation that staff were monitoring or tracking how often he urinated after catheter removal.
Failure to Provide Behavioral Health Evaluation and Services
Penalty
Summary
The facility failed to ensure that one resident with documented behavioral health needs received a behavioral health evaluation and services to address psychiatric and behavioral symptoms. The resident was admitted with diagnoses including personality disorder, other specified depressive episodes, and anxiety. The admission MDS indicated the resident was cognitively intact, and the PASRR dated 2/24/26 triggered for a Level II assessment, but there was no documentation that the Level II screening was completed. Physician orders dated 2/24/26 included psychology and psychiatric consults with follow-up and treatment as needed, but there was no documentation of referrals for either consultation. The resident’s care plan identified behavior problems including frequent calling out, yelling at staff, refusal of care, ineffective coping related to maladaptive thinking patterns, and potential verbal aggression toward staff and peers. Interventions were listed in the care plan, but the record did not show that the resident’s behavioral symptoms, response to behavioral medications, or outcomes were reviewed in IDT notes. The resident’s medication record showed multiple psychotropic medications prescribed during the stay, including buspirone, bupropion, duloxetine, and doxepin, with monitoring documented for anxiousness and sleeplessness but not for depression or sad statements. The chart also contained multiple behavioral events, including screaming for help, delusional statements, refusal of interventions, verbal aggression toward staff, calling police and the ombudsman, self-induced vomiting, and statements that he wanted to die. During interview, the SSD stated the resident had no behavioral health diagnosis and was not prescribed behavioral health medications, then acknowledged the diagnoses and medications had been overlooked and confirmed there were no mental health referral records. The DON stated the resident declined mental health services but could not find documentation of refusal, and also confirmed the IDT did not evaluate the resident’s behavioral symptoms or response to behavioral medications.
Failure to Ensure Respectful, Individualized Care and Oversight of CNA Performance
Penalty
Summary
The deficiency involves the facility Administrator’s failure to ensure resident rights to individualized, respectful care were honored and to oversee and address a CNA’s performance issues. The Administrator’s position description requires responsibility for day-to-day operations, maintaining employee relations, and ensuring residents’ rights to fair and equitable treatment, self-determination, individuality, and dignity. The CNA position description requires providing daily and restorative care in accordance with the care plan while maintaining the highest degree of dignity. Despite these defined responsibilities, four of seven residents reported that one CNA did not treat them with respect or consider their self-determination and individuality during care. Specific resident complaints included that the CNA was rough when providing care to one resident, ignored another resident’s request to be careful with her shoulder during care, did not listen to or provide individualized care to a third resident, and behaved in a disrespectful manner during a fourth resident’s care. Staff interviews corroborated concerns about the CNA’s conduct. One CNA stated that the CNA in question treated residents like toddlers instead of adults, was not respectful, and had been described by residents as rude and abrupt; this CNA also reported observing the CNA being abrupt when removing a resident’s oxygen. Another CNA reported that coworkers avoided working with the CNA because she was reckless and careless when caring for residents, and that residents preferred other staff instead of this CNA. Nursing administrative staff did not provide effective oversight or timely education/feedback to the CNA despite multiple resident complaints. The DON acknowledged that staff did not like the CNA and that the CNA was task-oriented and worked quickly in a way that could result in resident needs being overlooked, but the DON reported being unaware of multiple resident allegations of disrespectful and unprofessional behavior. The Director of Staff Development, responsible for CNA training and performance evaluations, stated she was unaware of the multiple resident and staff allegations and believed that the social services staff or Administrator handled CNA performance issues; her most recent performance review for the CNA did not identify performance problems. The Administrator stated his role included monitoring CNA performance and investigating resident complaints, and he was aware over the past year of the CNA’s task-focused approach and lack of listening to residents’ needs, but he typically did not document counseling unless he considered the issue egregious. The CNA’s file contained only one counseling memo noting the need for a more person-centered approach and better communication, despite the multiple complaints and ongoing performance concerns.
Failure to Ensure Dignified, Respectful, and Individualized Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a certified nursing assistant (CNA A) provided dignified, respectful, and individualized care to multiple residents during direct care interactions. The facility’s own CNA job description required CNAs to provide routine daily and restorative nursing care in accordance with the resident’s assessment and care plan, and to ensure residents’ needs were met while maintaining the highest degree of dignity. Despite this, four cognitively intact or moderately impaired residents with significant mobility limitations and pain needs reported that CNA A was rough, dismissive of their expressed pain, inattentive to their individual requests, and unprofessional in demeanor during care. One resident with hemiplegia and hemiparesis following a stroke, muscle weakness, gait abnormalities, and frequent moderate to severe pain (rated up to 8/10 on assessment and 9/10 when describing the incident) reported that CNA A was rough when providing care, particularly with her left shoulder, causing a lot of pain. This resident stated that the rough handling made her feel like staff did not care. Another resident with hemiplegia and hemiparesis, gait abnormalities, and a history of moderate pain reported that when CNA A came to get her out of bed, she told CNA A that her right shoulder had arthritis and hurt, but CNA A ignored this verbal request to be careful. The resident stated that it hurt significantly. This same resident also described an incident where her roommate requested crackers from a bedside drawer; CNA A briefly looked and told the roommate there were no crackers, even though the resident knew there were crackers in the drawer, which made her angry. A third resident with muscle weakness, paroxysmal atrial fibrillation, high blood pressure, moderate cognitive impairment, and a need for substantial assistance with transfers reported that CNA A did not have enough patience when explaining things and would cut her off if she tried to say anything, which made the resident feel angry. This resident also reported hearing CNA A raise her voice with other residents. A fourth resident with hemiplegia and hemiparesis after stroke, high blood pressure, and dependence or substantial assistance needs for transfers stated that CNA A “horsed around a lot,” was initially “nasty” to her, and preferred to flirt and giggle with male staff instead of paying attention to residents, which the resident felt was not respectful when CNA A was being paid to take care of residents. Staff interviews further described CNA A’s care as disrespectful and not individualized. One CNA stated that CNA A treated residents like toddlers instead of adults, was not respectful, and that residents had reported CNA A as rude and abrupt. This CNA reported observing CNA A being abrupt when removing another resident’s oxygen. Another CNA described CNA A as reckless and careless when caring for residents and noted that residents preferred other staff instead of CNA A. The DON acknowledged that staff did not like CNA A and that CNA A worked quickly and was task-oriented in a way that could result in resident needs being overlooked, while also stating unawareness of multiple resident allegations that CNA A failed to listen and behaved disrespectfully. The Director of Staff Development similarly reported being unaware of the multiple resident and staff allegations involving CNA A and confirmed that no performance issues had been identified in CNA A’s most recent annual performance review. These actions and inactions resulted in multiple residents experiencing care that they perceived as rough, dismissive of their pain and requests, and lacking in dignity and respect.
Unclean and Damaged Resident Areas
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment in multiple areas of the building. A sliding glass door in one resident room did not lock properly, and the flooring beside that door was buckled and worn, making the door hard to slide. Another resident room had a hole in the bathroom door. The bathrooms on the south hall, including rooms 14 through 25, had holes, chipped paint, chipped molding, and paint marks on the flooring. Surveyors also observed that sliding glass doors in 10 resident rooms on the south hall had cumulative dust and debris in the tracks and were difficult to slide properly. The administrator confirmed the doors and tracks were not clean and that the bathrooms on the hall needed paint and minor repairs. The DON also confirmed the bathrooms needed paint and minor repairs to the molding and flooring around the pipes, and confirmed one bathroom door had a hole and one room had flooring that needed repair. In addition, the nurses' station sink area had cumulative dust and debris, with chipped wood molding and worn flooring. The Brio water fountain in the front lobby, used by residents and the community, had a stained and unclean drain. The maintenance director confirmed the fountain drain was stained and stated it would be scrubbed.
Grievance Process Not Available or Properly Tracked
Penalty
Summary
The facility failed to ensure that residents knew the correct procedure to file grievances, that grievance investigations and outcomes were documented and communicated, and that residents were protected from fear of retaliation when raising concerns. Seven of eight sampled residents stated they did not know how to file a grievance or where grievance forms were located. Three of the eight sampled residents also stated they were not informed of the findings of their grievances or any corrective actions taken, and three residents stated they feared retaliation if they complained. Resident 1 was admitted with acute respiratory failure, COPD, pneumonia, and dependence on supplemental oxygen, and had a BIMS score of 15. Resident 19 was admitted with unspecified dementia, nutritional deficiency, and glaucoma, and had a BIMS score of 05. Resident 22 was admitted with CHF, MI, and gait and mobility abnormalities, and had a BIMS score of 14. Resident 23 was admitted with osteoarthritis of both knees, low back pain, and localized edema, and had a BIMS score of 13. Resident 25 was admitted with muscle weakness, seizures, and hyperlipidemia, and had a BIMS score of 11. Resident 39 was admitted with COPD, primary focal hyperhidrosis, and atrial fibrillation, and had a BIMS score of 13. Resident 45 was admitted with atrial fibrillation, dysphagia, and difficulty walking, and had a BIMS score of 08. During interviews, Resident 1, Resident 19, Resident 22, Resident 23, Resident 25, Resident 39, and Resident 45 each stated they did not know how to file a grievance or where the forms were. Resident 1 and Resident 19 said they went to the Administrator with concerns about CNA H but did not receive feedback on how the concerns were handled. Resident 22 stated he feared retaliation from the DON and CNA H and did not know whether the Administrator did anything with his complaint. Resident 39 stated she felt scared to push her concern further because of fear of retaliation by CNA H and staff, and Resident 45 stated she had concerns she wanted to file but feared retaliation from staff. Facility staff confirmed the grievance process was not being handled according to policy. The Administrator stated the facility did not have grievance forms available for residents to access, used his own personal daily meeting form to track complaints, and did not maintain tracking of complaints, interventions, or effectiveness. SS/Admit stated she had a grievance binder but was unsure who the grievance officer was and was unaware residents were going to the Administrator to complain. The DON confirmed SS/Admit was the grievance officer, confirmed resident concerns and complaints were not documented or tracked, and stated the Administrator should not decide whether a concern warranted a grievance. The Administrator also confirmed the facility had not followed its grievance policy.
Failure to Report Allegations of Resident Mistreatment
Penalty
Summary
The facility failed to report allegations of mistreatment made by five sampled residents to the appropriate local, state, and federal agencies, and the residents were not informed of the progress of any investigation. The report states that residents complained about CNA H being verbally aggressive, rough, disrespectful, and not helping when assistance was requested. Facility leadership, including the Admin, DON, and SS/Admit, acknowledged that residents had repeatedly voiced concerns about CNA H, but the complaints were not handled through the facility’s abuse investigation and reporting process as written in policy. Resident 1 was admitted with acute respiratory failure, COPD, pneumonia, and dependence on supplemental oxygen, and had a BIMS score of 15. Resident 19 was admitted with unspecified dementia, nutritional deficiency, and glaucoma, and had a BIMS score of 5. Resident 22 was admitted with CHF, MI, and gait and mobility abnormalities, and had a BIMS score of 14. Resident 25 was admitted with muscle weakness, seizures, and hyperlipidemia, and had a BIMS score of 11. Resident 39 was admitted with COPD, primary focal hyperhidrosis, and atrial fibrillation, and had a BIMS score of 13. These residents each described concerns about CNA H’s treatment, including being spoken to harshly, feeling uneasy, feeling humiliated, or being left without help. Interviews showed that residents reported their concerns directly to Admin, but they did not receive feedback about how the concerns were handled. Resident 22 stated he feared retaliation from DON and CNA H. Resident 39 stated she felt scared to push the matter further because of fear of retaliation. Resident 45 also stated she had concerns but feared retaliation from staff, especially CNA H. Staff interviews confirmed that CNA H had been the subject of repeated complaints for verbal aggression and rough treatment, and that Admin had given only verbal counseling because he considered CNA H coachable. Admin stated he did not report the concerns because he did not believe they constituted abuse, defining abuse as cuts, bruises, scars, or injuries, and he stated he would not fill out an SOC 341 for every little thing. SS/Admit and DON both confirmed the facility did not follow its reporting policy and should have.
Improper Oxygen Tubing Storage and Dating
Penalty
Summary
Safe and appropriate respiratory care was not provided when oxygen tubing for two residents was found improperly stored and not dated. Resident 1 was admitted with diagnoses including acute and chronic respiratory failure, COPD, pneumonia, dependence on supplemental oxygen, heart disease, diabetes, and neuralgia. Resident 1’s MDS showed a BIMS score of 15 out of 15, indicating the resident had the mental capacity to make medical decisions. Resident 1 had an active order for oxygen at 3 liters via nasal cannula day and night for shortness of breath and/or to maintain oxygen levels greater than or equal to 90%, and an order to change oxygen and/or nebulizer tubing every seven days and date and label all components every Tuesday. During observation, Resident 1’s oxygen tubing was lying on the back of the wheelchair, uncovered and not dated. Resident 31 was admitted with diagnoses including acute and chronic respiratory failure, COPD, diabetes, malaise, neuralgia, depressive episodes, and chronic pain. Resident 31’s MDS showed a BIMS score of 10 out of 15, indicating moderate cognitive impairment. Resident 31 had an active order for oxygen at 2 liters via nasal cannula at bedtime for shortness of breath and/or to maintain oxygen levels greater than or equal to 90%, along with an order to change oxygen and/or nebulizer tubing every seven days and date and label all components every Tuesday. During observation, Resident 31’s oxygen tubing was lying on the wheelchair inside red shoes, uncovered and not dated. The facility policy required oxygen cannulas and masks to be stored in a plastic bag when not in use and changed when soiled.
Annual CNA Performance Evaluations Not Completed
Penalty
Summary
The facility failed to complete annual performance evaluations for four of five sampled Certified Nursing Assistants (CNAs): CNA C, CNA F, CNA G, and CNA H. The report states that the facility policy titled Performance Evaluations required a performance evaluation for each employee at the end of the 90-day probationary period and at least annually thereafter, with the evaluation meeting occurring at the same time as the employee's compensation review. Record review showed CNA C, hired on 9/14/22, did not have a performance evaluation completed for 2024. CNA F, hired on 6/9/22, also did not have a 2024 evaluation. CNA G, hired on 5/5/05, did not have a performance evaluation for 2024, and CNA H, hired on 6/9/22, likewise did not have a 2024 evaluation. During interviews, the Administrator confirmed CNA H should have had a performance evaluation completed for 2024, and the MDS/DSD confirmed that CNA C, F, G, and H did not have performance evaluations for 2024 and that the facility did not follow its policy.
Unsanitary kitchen and refrigerator conditions
Penalty
Summary
The facility failed to maintain the food preparation and service areas in a clean and sanitary condition. During observation with the Nutritional Services Director (NSD), the dishwasher was visibly soiled on the exterior with lime scale stains on the front and sides, and the NSD confirmed it should have been wiped down before food service in accordance with facility policy. The kitchen also contained visibly soiled fans, including an air-conditioning unit cover in the pantry with dust and debris and a standing fan near the dishwasher with food-like debris and dirt present, which the NSD confirmed should not have been visibly soiled. In the cooking area, light fixtures over the stove were observed to be covered with dust. The NSD stated maintenance was responsible for cleaning the fixtures and that they had not been cleaned because of the type of fixture. Maintenance later stated the fluorescent bulbs could not be cleaned and that replacement with LED lighting had not yet been completed, while confirming the fixtures were required to be in compliance with facility policy. In the same area, a bedpan was positioned to collect water leaking from the ceiling above the stove, and a lock and chain were observed over a pipe directly above the cooking range with visible dust on the pipe. The NSD removed the bedpan during the observation and confirmed it should not have been present in the food preparation area. Additional food storage concerns were identified in the kitchen and resident refrigerator areas. An open container of sliced cheese was observed in the kitchen refrigerator without proper covering, and the NSD confirmed it was not stored in accordance with facility policy requiring refrigerated cheese to be tightly packaged. The resident food refrigerator used for items brought in from outside the facility was observed to be visibly dirty, and multiple food items were expired and should have been discarded after three days per facility policy. The Assistant DON confirmed the refrigerator condition was not acceptable and that the expired items should have been discarded.
Inaccurate Psychiatric Diagnosis Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of a psychiatric diagnosis in the medical record for one resident who was receiving Seroquel for bipolar disorder. The resident’s Order Summary Report listed Seroquel 25 mg, 2 tablets at bedtime, for bipolar disorder with manic episodes, with the dose increased on 2/13/26. The record also showed Seroquel had originally been started on 9/13/23, about one month after admission, but the supporting admission History and Physical dated 8/24/23 did not include bipolar disorder. Review of the resident’s neuropsychiatric consultation dated 9/5/23 showed diagnoses of Lewy Body dementia, epilepsy, and parkinsonism, but did not include bipolar disorder. In contrast, the electronic medical record’s Medical Diagnosis section listed Bipolar Disorder, Current Episode manic without Psychotic Feature, Mild, created 9/13/23 during the stay. The MAR for 1/2026 included behavior monitoring for manic episodes, but no manic behaviors were documented during day and evening shifts, and the MAR did not define the specific behaviors staff were expected to monitor. The care plan, written by the facility social worker, identified a behavior problem of manic behavior and confabulating stories related to bipolar diagnosis, with interventions to administer medications as ordered and monitor/document side effects and effectiveness. However, it did not explain what confabulating stories meant in this resident’s case. During interviews, CNA staff described the resident as pleasant, cooperative, and not aggressive, while an LPN stated the resident wanted things her way, resisted change, and often felt abandoned by family. The DON stated the resident had repeatedly expressed wishes to die and was on comfort care, and the MD acknowledged the initial neuropsychiatric consult did not address the bipolar diagnosis.
Inaccurate Pain Documentation and Incomplete Pain Assessment
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services. The facility failed to ensure accurate documentation and ongoing pain assessment for one of five residents reviewed for unnecessary medication use. Resident 31 was admitted with diagnoses including respiratory failure, COPD, diabetes, and chronic pain. The resident had orders for Morphine Sulfate oral solution 20 mg/mL as needed for mild, moderate, or severe pain with instructions to hold for RR<12, and Norco 5-325 mg every 12 hours for chronic pain with the same respiratory hold parameter. The Norco order did not prompt nursing staff to document pain level with each dose administered. A review of the electronic record showed Resident 31’s pain level was documented as 0 every day from 10/24/25 to 1/21/26, while the resident stated during interview that pain occurred every day and could range from 8 to 10 out of 10 in the feet, lower back, and finger. A nurse confirmed that pain level was not checked when opioid pain medication was administered and could not explain the repeated documentation of pain as 0. The DON stated that for scheduled pain medication staff only needed to assess pain once per shift, and confirmed the IDT did not discuss pain management at the last meeting and should have assessed recurrent falls along with opioid medication use. The facility policy stated that a comprehensive pain assessment should be conducted upon admission, at quarterly review, with significant change, and with new or worsening pain.
Missing MAR Documentation for Controlled Pain Medication
Penalty
Summary
Safe use and accountability of narcotic controlled medication were not maintained for a resident receiving Norco for pain management. Resident 46 was admitted with diagnoses including arthritis, chronic pain, and diabetes, and had an order for Norco, one tablet by mouth every four hours as needed, starting 12/11/25. A review of the resident’s Controlled Drug Record for Norco from 12/20/25 to 1/20/26 showed Norco removals for PRN use on 1/7/26 at 1600, 1/9/26 at 2140, and 1/15/26 at 1500. A comparative review of the Controlled Drug Record and the Medication Administration Record showed no MAR documentation for those three Norco removals. During a concurrent interview and record review, the DON confirmed that the Norco documentation was missing from the MAR on those dates and that it should have been documented in the MAR to match the Controlled Drug Record. The facility policy titled Administering Medications stated that when a medication is administered, staff must initial the resident’s MAR on the corresponding line after it is given before giving the next medication.
Unsafe Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure safe storage of medications and supplies in the main medication room and on a south hall medication cart for a census of 52 residents. During observation with the ADON, a bag of Vancomycin was found expired on 1/1/26, and an open vial of Tuberculin PPD was dated 9/11/25 even though the manufacturer label indicated it should be discarded 30 days after opening. The medication refrigerator was storing vaccines, but the temperature monitoring log showed the refrigerator temperature was recorded once daily rather than twice daily. The ADON stated outdated medications should have been removed from active storage and was not aware of the twice-daily monitoring expectation for vaccine storage. During observation of the south hall medication cart with an LN, three unopened bottles of Latanoprost were stored on the cart even though the label indicated refrigeration until opened, one opened bottle of Latanoprost had an open date of 11/6/25 despite a six-week discard instruction, four opened DuoNeb bags had no open date, one Insulin Glargine pen had an open date of 12/8/25 despite a 28-day discard instruction, and one opened bottle of Acidophilus with Pectin was stored in the cart even though the label indicated refrigeration after opening. The DON confirmed the manufacturer instructions for Latanoprost, Insulin, Acidophilus with Pectin, and DuoNeb, and the facility policy stated discontinued, outdated, or deteriorated drugs shall not be used and medications requiring refrigeration must be stored in a refrigerator.
Infection Control Lapses With Shared Care Devices
Penalty
Summary
The facility failed to ensure infection prevention practices were followed during medication administration and use of shared patient care devices. During an observation in the South hall, a Licensed Nurse took a blood pressure cuff into Resident 46’s room, measured the resident’s blood pressure, and then placed the cuff back on the medication cart without cleaning it. In an interview shortly afterward, the nurse stated the cuff should have been cleaned after each use between residents. During a later inspection of the medication cart in the South hall, the shared pill cutter contained a significant amount of white powder and dust inside the device. The nurse stated the pill cutter was shared and used to split pills when needed and that it should have been cleaned after each use. The DON stated staff should have followed infection prevention practices when cleaning shared patient care devices such as BP cuffs and pill cutters, and identified that BP cuffs should be cleaned with Sani-wipes after each use and kept separate from clean cuffs, while pill cutter dust must be wiped to prevent cross-contamination.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment for several residents, as evidenced by multiple observations and interviews. Four mechanical stand-up lifts used for resident transfers were found to be unclean, with visible dried food particles, dust, and debris. This was confirmed by a CNA and the DON, who acknowledged that the equipment should be cleaned and sanitized after each use to prevent the spread of infection. Additionally, the facility's environmental surfaces, including patio doors, sliding glass door tracks, and resident rooms, were observed to be unclean and unkept. The sliding glass doors and tracks in multiple resident rooms had accumulated dust and debris, and the privacy curtains had visible stains. The housekeeping supervisor confirmed the need for deep cleaning, which was not included in the current policy. Specific resident rooms were noted to have issues such as cumulative food and debris on the floor, damaged furniture, and missing floor tiles. These conditions were confirmed by the facility's administrator, who acknowledged the need for repairs and replacements to ensure proper cleaning and maintenance. The report highlights the potential for these deficiencies to negatively impact resident health, safety, and comfort, as well as the risk of spreading bacteria within the facility.
Improper Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure that a resident was administered an inhaler according to the manufacturer's instructions, which did not meet professional standards of care. During an observation, a licensed nurse handed the albuterol inhaler to the resident without providing the necessary instructions for proper breathing techniques as outlined in the manufacturer's guidelines. The guidelines specify that the resident should exhale fully before inhaling the medication, hold their breath for about 10 seconds after inhalation, and then exhale slowly. This omission was confirmed by the Director of Nursing, who acknowledged that the medication was not administered correctly. The resident involved in this deficiency was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), muscle weakness, hypercalcemia, heart disease, and depressive episodes. The resident is capable of making their own medical decisions. The active order for the resident included albuterol sulfate to be administered as needed for wheezing. The failure to provide proper instructions for inhaler use had the potential to render the medication ineffective for the resident and possibly other residents who were prescribed inhalers.
Failure to Maintain Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of oxygen equipment for two residents, leading to potential health risks. For Resident 1, the oxygen tubing was observed to be dated 12/25/24, which was seven days overdue for a change according to the facility's policy and active orders. This oversight was confirmed by the Director of Nursing (DON) during an interview, acknowledging the need for timely changes to prevent potential discomfort and infection. Similarly, Resident 34's oxygen equipment was not maintained as required. The oxygen water humidifier bottle was found empty and dated 12/1/24, and the oxygen tubing was also overdue for a change, dated 12/25/24. Licensed Nurse 4 confirmed that the facility's policy required weekly changes of oxygen equipment, and the DON acknowledged that failure to adhere to these orders could lead to respiratory infections, including pneumonia. Both residents had significant medical conditions requiring consistent oxygen therapy, highlighting the importance of adhering to equipment maintenance protocols.
Failure to Document Behaviors for Antipsychotic Medication Use
Penalty
Summary
The facility failed to document behaviors for a resident who was prescribed an antipsychotic medication, Seroquel, for mood and behavior management. The facility's policy requires that antipsychotic medications be used only when necessary and that staff observe, document, and report the effectiveness of interventions, including medications. However, a review of the resident's medical record showed that only one behavior was documented over a period of several months, despite the requirement to track specific target behaviors and monitor for efficacy and adverse consequences. The resident in question was admitted with multiple diagnoses, including diabetes, high blood pressure, epilepsy, Parkinson's disease, and Bi-Polar disorder. The resident had a mild cognitive deficit and required moderate assistance with activities of daily living. Despite these conditions, the facility did not appropriately document the resident's behaviors on the Medication Administration Records (MARs), which is crucial for assessing the need for continued use of the antipsychotic medication. This lack of documentation could potentially lead to unrecognized changes in the resident's condition that should be reported to the physician for medication management.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 21 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Red Bluff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shasta View Care Center | 1.2 mi | ★★★★★ | 15 | 0 |
| Oak River Rehab | 20.2 mi | ★★★★★ | 0 | 0 |
| Veterans Home Of California - Redding | 24.6 mi | ★★★★★ | 6 | 0 |
| Marquis Care At Shasta | 28 mi | ★★★★★ | 22 | 0 |
| Crestwood Wellness And Recovery Center | 28.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Red Bluff Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.