Red Bluff Health Care Center

In the surveyor’s words

From the most serious findings on record at Red Bluff Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF835Apr 21, 2026

  Based on interview, and record review, the facility's Administrator (ADMIN) failed to ensure resident rights were honored during care when:1. Four out of seven residents reported that Certified Nursing Assistant (CNA A) did not treat them with respect, did not consider their self-determination, and individuality when she provided care. 2. Nursing administrative staff did not provide oversight and provide education/feedback to CNA A after multiple resident complaints. Refer to F550.This resulted in a violation of four residents' rights to receive individualized respectful care and put all residents at risk for not receiving dignified care. […]

• No harm, potential for more than minimal, patternF550Apr 21, 2026

  Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA A) provided residents with dignity and respect during direct resident care for four of seven sampled residents (Resident 1, 2, 3 and 4) when:1. CNA A was rough when providing care to Resident 1.2. CNA A ignored Resident 2's verbal request to be careful with her shoulder during care.3. CNA A did not listen to or provide individualized care to Resident 3.4. CNA A's behavior during care was not respectful toward Resident 4.This failure resulted in a violation of four residents' rights to receive individualized respectful and dignified care.Findings:During a review of the facility position description for Nursing Assistant State Certified/Licensed (CNA), dated October 2003, the Position Summary… […]

• No harm, potential for more than minimal, patternF584Jan 23, 2026

  Based on observation, interview, and policy review, the facility failed to maintain the facility in a clean, safe and comfortable home-like environment when:1. The sliding glass door in room [ROOM NUMBER] did not lock properly.2. room [ROOM NUMBER] had buckled, worn brown flooring that was on the right side of the sliding glass door, which made this door hard to slide.3. There was a hole in the bathroom door in room [ROOM NUMBER].4. The bathrooms on the south hall, rooms 14 through 25 needed repair and paint.5. The sliding glass doors were hard to open and slide and unclean in 10 resident rooms on the south hall.6. The nurses' station had chipped and worn areas around the sink and the molding and flooring.7. […]

• No harm, potential for more than minimal, patternF585Jan 23, 2026

  Based on interview, and record review, the facility failed to ensure that seven of eight sampled residents knew the correct procedure to file a grievance with the facility (Resident 1, Resident 19, Resident 22, Resident 23, Resident 25, Resident 39, Resident 45), three of the eight sampled residents were not informed of the findings of the investigations or any corrective actions that were taken for their grievances, (Resident 1, Resident 19, Resident 22), and three of the eight sampled residents stated that they were fearful of retaliation if they filed a grievance (Resident 22, Resident 39, and resident 45).This deficient practice had the potential for residents to be unaware or confused about the process for filing grievances, for grievances to be left uninvestigated or corrected, or… […]

• No harm, potential for more than minimal, patternF609Jan 23, 2026

  Based on interviews, and record reviews, the facility failed to report allegations of mistreatment, made by five of eight sampled residents (Resident 1, Resident 19, Resident 22, Resident 25, and Resident 39) to the appropriate local, state, and federal agencies nor were the residents informed of the progress of an investigation.This failure caused resident complaints/concerns of mistreatment by staff to go unreported with the potential of continued mistreatment, physical and/or psychosocial harm to residents. […]