Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vibra Hospital Of Northern California D/p Snf during CMS and state inspections, most recent first.
The facility did not maintain proper food safety and sanitation practices, including storing TCS foods at unsafe temperatures, failing to consistently reach required dishwashing temperatures, and inadequately cleaning food-contact surfaces such as the ice machine, butcher block, and food processor blades. Additionally, worn food preparation items were found in use, and staff were not fully aware of correct procedures or temperature standards.
The facility did not send required discharge notices to the Office of the State Long-Term Care Ombudsman for two residents—one transferred to the hospital with diabetes and kidney disease, and another who left AMA with COPD—despite facility policy requiring such notification. Staff confirmed this omission during interviews.
Surveyors observed that medications were not administered according to manufacturer instructions and facility policy. A resident was not prompted to finish a prepared dose of MiraLAX, which was left unattended at the bedside, and another resident received consecutive Lovenox injections at the same abdominal site without proper site rotation. These actions resulted in a medication error rate of 9.7%.
A resident performing self-catheterization was not provided with appropriate gender-specific supplies, as only male kits were available despite the resident's requests for female kits. Staff were unaware of the need for different kits, and the correct supplies were not stocked. Additionally, there was no physician order or documented nursing assessment to confirm the resident's competency and safety in performing self-catheterization, contrary to facility policy.
Surveyors found that metoprolol injectable vials were not protected from light as required by manufacturer guidelines, and expired MediSense glucose control solution vials were not discarded by nursing staff. The Director of Pharmacy and Assistant Director of Nursing confirmed these lapses, which were not in accordance with facility policy or manufacturer instructions.
Staff did not follow standardized recipes or use correct portioning tools when preparing and serving meals, including not weighing meat portions and using high-sodium broth instead of the specified ingredient. Incorrect scoop sizes were also used for various menu items, as confirmed by the RD, affecting all residents receiving meals from the kitchen.
Two residents on specialized diets received grilled cheese sandwiches as meal substitutes that were not equivalent in protein or calories to the planned entree, due to staff using less cheese than required by the recipe. Additionally, a resident with documented dislikes for certain vegetables was repeatedly served those items, despite her preferences being known. The Registered Dietitian confirmed that meal substitutes should match the nutritive value of the original entree and that food preferences should be honored.
A CNA did not perform hand hygiene between resident care tasks, including after handling dirty trays and touching various surfaces and objects, as required by facility policy. This lapse was confirmed by both the CNA and the Director of Staff Development, highlighting a failure to maintain proper infection control practices.
A facility failed to thoroughly investigate an alleged abuse incident where a resident reported being hit by a CNA with a call light, resulting in a bruise. The investigation lacked interviews with all involved parties and did not maintain required documentation, as confirmed by the DON and CNO. The resident, who was cognitively intact, was not shown a picture of the CNA to confirm the identity of the alleged perpetrator.
A resident with a DNR order was given CPR despite documented wishes for no resuscitation. The facility staff initiated CPR after a Code Blue was called, and confusion arose regarding the resident's DNR status. The Chief Nursing Officer confirmed the error, and a family member instructed the continuation of CPR after it had already started.
Multiple Food Safety and Sanitation Failures in Kitchen and Food Service
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines in several key areas, impacting all 30 residents who consumed food prepared in the kitchen. Time/Temperature Control for Safety (TCS) foods were not stored at appropriate temperatures in the nourishment refrigerator, with internal food temperatures recorded above the recommended 41 degrees Fahrenheit on multiple occasions. The Director of Plant Operations and the Dietary Manager were unaware of the correct temperature parameters, and the refrigerator was set to a maximum of 46 degrees Fahrenheit, which is above the safe limit for perishable foods. Temperature monitoring was conducted remotely, but there was no backup thermometer, and the Registered Dietician did not inspect the nourishment refrigerators. Temperature logs showed repeated temperature excursions above safe levels. The dishwashing process was also deficient, as the automatic dish machine did not consistently reach the manufacturer's required minimum temperature of 120 degrees Fahrenheit for both wash and rinse cycles. Observations showed that the machine often operated below this threshold, and staff had to run multiple cycles to attempt to reach the correct temperature. Additionally, the kitchen's ice machine was found to have black matter on the underside of the top surface of the storage bin, indicating inadequate cleaning. The Dietary Manager and Director of Plant Operations confirmed that cleaning responsibilities were split and that the area in question was not regularly cleaned according to manufacturer guidelines. Further sanitation issues were observed with food preparation equipment. A butcher block wooden cutting board was sanitized without first being cleaned with soap and water, contrary to facility policy. Two food processor blades were found with brown discoloration, and a plastic cutting board and three plastic bowls showed excessive wear, all of which were confirmed by the Dietary Manager. These lapses in cleaning and maintenance of food-contact surfaces and utensils were in direct violation of facility policies and federal food safety codes.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman for two out of three sampled residents. According to the facility's policy and procedure on transfer and discharge, a written notice of discharge must be provided to the resident and a copy sent to the Ombudsman. However, record review and staff interviews confirmed that this notification was not completed for residents who were transferred to the hospital or who left against medical advice (AMA). Specifically, one resident with type 2 diabetes mellitus and diabetic chronic kidney disease was transferred to the hospital and discharged, while another resident with chronic obstructive pulmonary disease left the facility AMA and was discharged. The case manager and the director of nursing both confirmed that the required notifications to the Ombudsman office were not sent for these discharges.
Medication Administration Errors and Failure to Follow Manufacturer Instructions
Penalty
Summary
The facility failed to ensure that medications were administered according to manufacturer instructions and accepted clinical standards during medication administration observations. In one instance, a licensed nurse prepared MiraLAX for a resident by mixing it in approximately 8 ounces of fluid, but the resident only consumed half of the solution and left the remainder on the bedside table. The nurse did not prompt the resident to finish the dose or remove the medication before leaving the room. Manufacturer directions for MiraLAX require the full contents to be ingested immediately after mixing, and facility policy prohibits leaving prepared medications unattended at the bedside without a licensed practitioner's order. In another instance, a licensed nurse administered Lovenox subcutaneously to a resident in the right lower abdomen, the same site used for the previous day's dose, without verifying prior injection sites. The nurse stated she relied on the resident's preference for injection location. The manufacturer's instructions for Lovenox specify that injection sites should be rotated among different areas of the abdomen to prevent local irritation or tissue damage. These observed failures resulted in a medication error rate of 9.7%, exceeding the acceptable threshold.
Failure to Provide Appropriate Self-Catheterization Supplies and Oversight
Penalty
Summary
The facility failed to follow its self-catheterization policy and procedure for a resident who performed self-catheterization. The facility did not maintain adequate supplies, as only male self-catheterization kits were available, despite the resident being female and requesting the appropriate female kits. Both the Infection Preventionist and Materials Manager confirmed a lack of awareness regarding the need for gender-specific catheterization kits, and the central supply room did not stock female kits. The resident expressed frustration at not having the correct supplies and was observed using a male kit, which was not appropriate for her. Additionally, there was no physician order in place for the resident to perform self-catheterization, as confirmed by a review of the resident's medical orders with the Charge Nurse and Director of Nursing. Furthermore, there was no documented nursing assessment to ensure the resident was competent and able to perform self-catheterization safely, despite the facility's policy requiring such an assessment. The resident's plan of care noted self-catheterization, but no supporting assessment was found in the medical record.
Improper Storage and Expired Medication Handling
Penalty
Summary
The facility failed to ensure proper storage and handling of medications and biologicals in accordance with manufacturer recommendations and facility policy. Specifically, three injectable vials of metoprolol were observed stored in a small container directly under an overhead light in the pharmacy, without being enclosed in an amber bag or otherwise shielded from light. The Director of Pharmacy confirmed that the vials were not protected from light, as required by the manufacturer's guidelines, which state that metoprolol must be protected from heat and light to maintain its stability and potency. Facility policy also requires medications to be stored under proper conditions as determined by the manufacturer's labeling. Additionally, two MediSense glucose control solution vials, labeled HI and LOW, were found in the medication room with expiration dates that had already passed. The Assistant Director of Nursing confirmed that the vials should have been checked and discarded by nursing staff according to the manufacturer's guidelines, which require control solutions to be discarded three months after opening or on the printed expiration date, whichever comes first. Facility policy also mandates that blood glucose meters be maintained and calibrated per the manufacturer's guidelines.
Failure to Follow Dietary Menus and Portion Control Procedures
Penalty
Summary
The facility failed to ensure that dietary menus and recipes were properly followed in the preparation and serving of meals to residents. Specifically, a staff member did not weigh pork portions as required by the pureed pork recipe, instead estimating the amount by sight. Additionally, regular chicken broth, which contained significantly more sodium than specified in the recipe, was used in the preparation of pureed pork. This resulted in a sodium content that exceeded the recipe's guidelines. The Registered Dietician confirmed that food portions should be weighed and that regular broth should not be used in the recipe. Further, the facility did not consistently use the correct scoop sizes for portioning food items during meal service. The staff member used different scoop sizes than those specified in the diet menu spreadsheet for various food items, citing a lack of available correct-sized scoops. The Registered Dietician confirmed that the scoop sizes used should match those outlined in the menu spreadsheet. These actions affected all residents receiving food from the facility kitchen.
Failure to Provide Equivalent Meal Substitutes and Honor Food Preferences
Penalty
Summary
The facility failed to provide meal substitutes that were equivalent in nutritive value and did not honor food preferences for certain residents. Specifically, two residents on specialized diets (carbohydrate controlled and low potassium) received grilled cheese sandwiches as meal substitutes for lunch. The facility's menu indicated that the standard entree, pork roast, provided 23 grams of protein and 173 kilocalories, while the grilled cheese sandwiches, as prepared, only provided 5 grams of protein and 90 kilocalories. The recipe called for three ounces of cheese per sandwich, but staff used only two slices (one ounce) of cheese, resulting in a significant shortfall in both protein and caloric content. The Registered Dietitian confirmed that the meal substitute should be equivalent in nutritive value and that the sandwiches were not prepared according to the recipe. Additionally, the facility did not honor the food preferences of another resident who had documented dislikes for certain vegetables, including squash, carrots, and green beans. Despite this, the resident was served a vegetable mixture containing these items and reported that this occurred frequently. The Menu Planner stated that the Registered Dietitian had instructed her to serve a hot vegetable to all residents, but the Dietitian later clarified that a salad could be substituted if a resident disliked the hot vegetables and that it was not necessary to serve both a salad and hot vegetables.
Failure to Perform Hand Hygiene Between Resident Care Tasks
Penalty
Summary
Certified Nursing Assistant (CNA) F failed to adhere to the facility's infection control policy, which requires staff to perform hand hygiene upon entering and exiting resident rooms, after touching residents, and after contact with inanimate objects in the resident's immediate vicinity. During a period of observation, CNA F was seen handling dirty lunch trays, writing with a pen and paper stored in her pocket, and touching various surfaces such as bed footboards, privacy curtains, bedside tables, and the nourishment refrigerator, all without performing hand hygiene between these activities or between resident care tasks. CNA F confirmed during an interview that she did not perform hand hygiene as required during the observed period, including after handling dirty trays and between entering different resident rooms. The Director of Staff Development also stated that the expectation was for staff to perform hand hygiene between resident care and after touching potentially contaminated items. The failure to follow these infection control practices had the potential to spread infection within the facility.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged staff-to-resident abuse incident in accordance with its Abuse Policy. The incident involved a resident who reported being hit on the hand with a call light by a CNA, resulting in a bruise. The resident, who was cognitively intact with a BIMS score of 13 out of 15, reported the incident to the Director of Staff Development (DSD) the following morning. However, the DSD could not recall who had been interviewed regarding the allegation and confirmed there was no supporting documentation. Additionally, the resident was unable to remember the CNA's name, and the DSD had never seen the CNA, further complicating the investigation. The facility's investigation was incomplete as it did not include interviews with all involved residents, employees, and witnesses, nor did it maintain a confidential file with necessary statements as required by the facility's Abuse Policy. The Director of Nursing (DON) and Chief Nursing Officer (CNO) confirmed these deficiencies during an interview and record review. Furthermore, the resident was not shown a picture of the CNA to positively confirm the identity of the alleged perpetrator, which was a critical step missing from the investigation process.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's end-of-life wishes by performing cardiopulmonary resuscitation (CPR) on a resident who had a documented Do Not Resuscitate (DNR) order. The resident, who was admitted with high blood pressure and congestive heart failure, had a Physician Orders for Life-Sustaining Treatment (POLST) form and physician's orders indicating a preference for no CPR. Despite these documented wishes, when the resident was found unresponsive without a pulse, a Code Blue was called, and CPR was initiated by the facility staff. The Chief Nursing Officer confirmed the resident's DNR status and acknowledged the error, attributing it to confusion over the POLST form's verbiage. A Licensed Vocational Nurse (LVN) and a Medical Doctor (MD) involved in the incident reported that there was confusion about the resident's DNR status during the emergency. The MD, after contacting a family member, was instructed to continue CPR, which was already in progress. This incident highlights a failure in communication and adherence to the resident's documented end-of-life care preferences.
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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.
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Nursing homes near Redding
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quartz Hill Post Acute | 0.9 mi | ★★★★★ | 1 | 0 |
| Redding Post Acute | 1.2 mi | ★★★★★ | 16 | 0 |
| River Valley Healthcare & Wellness Centre, Lp | 1.4 mi | ★★★★★ | 8 | 0 |
| Copper Ridge Care Center | 2.4 mi | ★★★★★ | 15 | 0 |
| Crestwood Wellness And Recovery Center | 3.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.