Marquis Care at Shasta

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not protect one of five sampled residents (Resident 2) from physical abuse when Certified Nursing Assistant (CNA) C was seen putting their hands on Resident 2's shoulders, firmly shaking Resident 2, and telling Resident 2 loudly to stop. This had the potential to result in physical harm, pain, and mental anguish.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to report two allegations of physical abuse to the California Department of Public Health (CDPH, protected the public's health), the local police department, or the Ombudsman's office (an agency that protected resident rights) for two out of five sampled residents (Residents 1 and 2) when: 1. Resident 1 told the Resident Care Manager (RCM) that they sustained a fracture (broken bone) in the left ulna (lower arm) that resulted from rough care that was provided by two Certified Nursing Assistants (CNA). 2. CNA B indicated they had witnessed CNA C physically abuse Resident 2. These failures had the potential for abuse allegations to go unrecognized and placed residents at risk for abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not thoroughly investigate an allegation of abuse for one of two sampled residents (Resident 1) when Resident 1 reported that facility staff provided rough care that caused an injury. This failure placed residents that lived in the facility at risk for further potential abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure federal regulations related to the education qualification requirements of the dietarymanager were followed as outlined in the California Code, Health and Safety Code (HSC1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines. Cross references to F812 examples #1, #2, #3 and #4 .

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure the menus were followed when:1. The regular zucchini recipe was not followed.2. The puree zucchini recipe was not followed.3. The BBQ chicken recipe for regular diets was not followed.4. The puree BBQ chicken recipe was not followed. These failures had the potential to not meet the residents' nutritional needs for the 8 (Residents 8, 9, 35, 128, 22, 72, 91, 119) of 124 residents who received a pureed diet and 82 of 124 who received a regular diet.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food safety and sanitation requirements were followed when:1. The kitchen environment was not cleaned adequately around stoves, ranges, and some refrigerators.2. Kitchen utensils and equipment were stored wet.3. Plastic cutting boards were found to be excessively scored & cut.4. Dry storage floors were found to be dirty. These failures posed the risk of foodborne illnesses in a highly susceptible resident population of 124 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate discharges for two of five sampled residents when the facility transferred (when a resident goes to the hospital for an evaluation and is expected to return to the facility), the residents the hospital then refused to allow them to return to the facility and discharged (formal and final release of the resident without intention of them returning) them. Resident 3 and 137's medical records contained no documented reasons by their physicians for not allowing them to return to the facility, the residents were not prepared or notified in advance that they were being discharged from the facility, and the residents and their family members (FM) were not provided with a notice that they had the right to appeal the facility's decision to discharge them. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served was palatable, appetizing, or at an appealing temperature for eleven of 124 Residents' (Resident 7, 13, 53, 68, 82, 131, as well as five confidentially interviewed residents) whose meals were cold and or unappetizing. These failures had the potential for decreased meal intake which could result in weight loss, decreased nutritive value and negatively impact the residents' quality of life. (Cross references to F803)Findings During an interview on 3/2/28 at 1:54 pm, Resident 53 stated, Food is horrible. Once in a while it is ok. Once in a while they have a good food. I do not like the watered-down milk. I didn't know I could ask for something else. During an interview on 3/2/26 2:00 pm, Resident 82 stated, Food not good. Does not taste good. Chicken is tough, not good. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure glucose testing (blood sugar level check for diabetics) was performed in accordance with the facility's infection control policies and procedures for three of three sampled residents when hand hygiene was not performed before and after wearing gloves and alcohol wipes used to sanitize residents fingers was not allowed to air dry. (Residents 14, 94, and130) This failure put the residents at risk for infections and negatively impact their physical well-being by exposing them to germs.

Inspectors wroteBased on interview and record review the facility did not ensure two out of two sampled residents (Residents 11 and 130) were free from chemical restraints (behavioral management medication that could cause excessive sleepiness) when:The facility failed to appropriately monitor the specific symptoms for which psychoactive medications (altered the brain) were prescribed to Resident 11; andThe facility failed to appropriately monitor the specific symptoms for which psychoactive medications were prescribed to Resident 130. This failure caused the inability to know if the medication was working for its intended use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise a comprehensive care plan for two of eight sampled residents (Resident 81 and Resident 131) when: 1. Resident 81 did not have activity interventions for specific needs and preferences. 2. Resident 131 did not have specific nursing interventions for shaving himself and getting out of bed. These failures had the potential to result in the residents' needs not being identified, feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a telephone order (when the doctor calls the nurse to give an order for a resident) for a medication was correctly transcribed for one of eleven sampled residents when an order to give a medication in the eye was mistakenly written to be given in the ear. (Resident 58)This error has the potential for residents to receive medication via the incorrect route. Not receiving the medication via the correct route, the medication would be ineffective to treat what it was prescribed for. Findings A record review of facility policy titled, Physicians Medication Orders revised 1/16 indicated on line 6, Orders for medication must include d. Route of administration if other than oral. Line 11 stated, Physicians orders are reviewed and sent to the primary care provider monthly for ongoing order reviewing. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to remove expired medications from one of four treatment carts and were available for resident use. This had the potential for residents to receive expired medications which would not be effective or safe for use.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure:1. One of three sampled resident's minced and moist (MM5) therapeutic diets (special needs diet plans), was prepared according to the recipe. (Resident 143)2. Nursing staff had a current and complete diet manual reference. These failures had the potential to result in residents receiving diets that do not match physicians' orders and incorrect preparation of special therapeutic diets and for nursing staff not to have reference material to recognize when a diet is served incorrectly.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents, (Resident 1) was treated with respect and dignity during direct personal care when Certified Nursing Assistant (CNA) I rushed Resident 1 and held his arms to prevent hitting staff when the bed linen was changed. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff responded in a timely manner to residents' requests for assistance for one of four sampled residents, (Resident 1), when call-lights were not answered for greater than 20 minutes multiple times. These failures had the potential to negatively impact residents' physical, emotional and psychosocial well-being and left Resident 4 feeling unfairly treated.

Inspectors wroteBased on interview, and record review, the facility failed to review and revise the care plan for one of four sampled residents (Resident 4), when Resident 4 had an unintentional significant weight loss of 5 percent (%) in one month. This failure had to potential for Resident 4 to have unwanted weight loss and negatively impact his physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff demonstrated appropriate competencies (knowledge, skills, and abilities that were required to provide safe and effective care to residents) when providing care for three out of three sampled residents (Residents 1, 2, and 3) when: 1. Licensed Nurses (LN) did not perform an assessment of Resident 1 ' s surgical site. 2. A Certified Nurse Assistant (CNA) documented Resident 2 received a shower when Resident 2 did not receive a shower. 3. Residents 1, 2, and 3 experienced long call light wait times. 4. The competency checklist for registry staff (third party staff, employed by a registry agency and travels to different facilities to work) consisted of a self-evaluation and did not include oversight for evaluation of competencies or skills. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the pureed food (food that is either ground, mashed or blended into a pudding like consistency), recipes were followed. This failure resulted in unappetizing food and had the potential for 11 residents who received pureed food, to receive diets that had not met their nutritional needs.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the facility food was appetizing and palatable when 14 of 115 residents (Residents 328, 329, 36, 576, 72, 26, 529, 86, 580, 119, 587 and three confidential residents), who received food prepared in the facility kitchen were not satisfied with the facility food. This failure had the potential for 14 residents to have decreased intake which could lead to unplanned weight loss and other medically related concerns.

Inspectors wroteBased on observation, interview, facility document, and policy and procedure review, the facility failed to ensure seven of 116 resident's (Resident 577, 61, 579, 580, 69, 587 and 114) food preferences were honored. This failure posed the potential for facility residents to not be satisfied with their meals which could contribute to decreased intake and further lead to unintentional weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The cool down process for time, temperature control, and safety of food (TSC, foods that need to be kept at specific temperatures to prevent bacteria growth and foodborne illness), was not monitored. 2. Dish machine wash and rinse temperatures did not meet manufacturer's guidelines. 3. Hair restraints were not worn. 4. Food preparation equipment was not in proper working order. 5. Kitchen equipment was not clean. 6. Food preparation equipment and silverware were not air dried. 7. Food was not stored properly in the kitchen. 8. Kitchen cleaning supplies were not stored properly. 9. Non-functioning kitchen equipment was not discarded. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four out of 25 sampled residents' (Resident 19, 36, 112, and Resident 121) care plans were develped, reviewed and revised when: 1. Significant unplanned weight loss for Resident 19 was not updated on the care plan. 2. Unplanned weight loss and a room change for Resident 36 was not updated on the care plan. 3. End of life care for Resident 112 was not updated on the care plan. 4. A Urinary Tract Infection (UTI, a bladder infection), for Resident 121 was not updated on the care plan. These failures had the potential to result in the residents' needs not being identified, and resident's feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADLs, basic needs as personal hygiene, dressing, toileting, transferring, walking, and eating), were provided for three of eight sampled dependent residents (residents who depend on staff to help them), (Resident's 2, 29 and 112), when: 1. Routine grooming activities were not completed for Resident 2 and Resident 29. 2. Routine and scheduled showers were not completed for Resident 112. These failures had the potential to result in the residents feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to meet the needs of each resident when expired medications and an expired Emergency Drug Kit (E-Kit, medications that are readily available for use when the Pharmacy is closed), were available for use in the [NAME] Unit medication room. This had the potential for the residents to receive expired medications that are no longer considered viable, safe or effective for treating their illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 10/08/24 and 10/09/24, four medication errors were observed out of twenty-seven opportunities for four of six residents (Residents 17, 328, 103), which resulted in an overall medication error rate of 14.81%, when: 1. Licensed Nurse (LN) 4 administered an iron supplement to Resident 17 with milk. This failure had the potential to reduce absorption of the iron supplement. 2. LN 6 did not follow the manufacturer's instruction for administration of the Breo Ellipta Inhaler (a medical device for administering a respiratory medication, which is to be inhaled). This failure had the potential for Resident 328 to not receive the full dose of the medication and could possibly cause contamination of the inhaler and its contents. 3. [...]

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure the facility was free from pests. This failure posed the risk of 116 residents who resided in the facility to be exposed to pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dignity of one of eight sampled residents (Resident 36) when she was left in a soiled brief, and not changed in a timely manner. This failure resulted in Resident 36 to feel increased anxiety, and depression and had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of eight sampled residents' bedroom (Resident 29) was maintained in a comfortable and homelike setting, when Resident 29 could not see his wife's pictures due to clutter on his dresser. This failure resulted in Resident 29 becoming frustrated and violated the right to have a home like environment.

Inspectors wroteBased on observation, interview, medical record review and Policy and Procedure (P&P) review, the facility failed to ensure one of 25 sampled residents (Resident 19), received acceptable nutritional services when: 1. Resident 19's nutritional status was not assessed by the Registered Dietitian (RD) upon admission. 2. Resident 19's significant unplanned weight loss was not assessed by the RD and the Interdisciplinary Team (IDT, facility managers who discuss resident concerns and develop plans to correct them). 3. Resident 19's admission weight was not obtained in a timely manner upon readmission, in accordance with the facility policy. As a result of these failures, Resident 19's compromised nutritional status was not addressed timely, which could lead to further medical complications.

Inspectors wroteBased on observation, and interview, the facility failed to ensure federal regulations related to the education qualification requirements of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines.

Inspectors wroteBased on observation, interview and facility record review, the facility failed to ensure one of 116 resident's (Resident 48) received the appropriate textured diet when chopped meats were not the appropriate size. This failure had the potential for residents who received chopped meats to not receive the appropriate texture which could lead to chewing and/or swallowing concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage properly. These failures had the potential to result in attracting insects and rodents affecting all 116 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they coordinated resident care needs with the Hospice Agency (an outside agency that specializes in end of life care), for one of four sampled residents (Resident 112). This failure caused a delay in personal care, comfort, and had the potential to result in emotional stress, feelings of neglect, and negative clinical outcomes for residents who received Hospice services.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of three residents sampled for abuse (Resident 1), from physical abuse received by staff, when a registry staff aggressively grabbed the resident ' s wrists while providing care. This failure had the potential to result in long term ill effects on the residents physical and mental health resulting in the resident ' s lack of trust towards staff for all care and negative emotional interactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from verbal abuse when Certified Nursing Assistant (CNA) 1 cursed at her while providing care. This had the potential to cause a decline in Resident 1's psychosocial well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional food safety standards when: 1. Kitchen staff did not follow professional standards of practice to minimize cross contamination. 2. Two out of three observed nursing unit pantries contained expired resident food. 3. Kitchen equipment was not maintained in a sanitary manner These practices had the potential to result in foodborne illness for residents consuming food in the facility, which could lead to negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident grievances and complaints were promptly reviewed, investigated, resolved, and documented for five confidential residents. This failure resulted in the loss of personal property, and the potential for psychosocial issues and concerns related to the resident's loss of personal property.

Inspectors wroteBased on interview, and record review, the facility failed to provide sufficient staff to meet the individual care needs for one out of sample resident (Resident 24), three of five confidentially interviewed residents, and eight of 25 sampled residents (Residents 32, 41, 53, 56, 68, 70, 93, and 409), when these residents complained of long wait times (up to 30 minutes) for their calls for staff assistance to be answered. The facility's failure to ensure sufficient staff to answer resident calls for assistance promptly contributed to residents' frustration and had the potential to cause emotional and physical harm to residents who did not receive the care when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label and store medications and biologicals when: 1. Glucometer (a small portable device used for blood sugar testing) calibration control solution had expired on the Transitional Care Unit (TCU)-B medication cart which affected two residents (Residents 97, and 410). 2. Blood specimen collection tubes had expired in the [NAME] Hall Medication Room. 3. Loose wasted pills and a used bupenorphine (narcotic medication) patch were in a large, unlocked bin in the TCU Medication Room. 4. Two signed prescriptions for a controlled substance written on a physician prescription pad for two residents (Residents 31, and 36) were loose in the [NAME] Hall Medication Room. This failure had the potential to cause Residents 97, and 410, to receive care and treatment based on inaccurate blood glucose level results; [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the qualifications, competencies, and skill sets of the Registered Dietitian (RD), and the Dietary Services Supervisor (DSS) were in place and supported to carry out the functions of the food and nutrition service when: 1. There was inadequate oversight and mentoring provided by the RD to the DSS to make sure an effective system was in place to ensure food was prepared in a safe and sanitary environment. 2. The RD and Certified Dietary Manager (CDM) had ineffective oversight, training, and competence of staff. 3. Nutrition assessment, monitoring, and response to resident weight loss were not performed timely. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were competent to carry out the responsibilities of the Food and Nutrition Services when: 1. Staff were unable to determine food use-by dates. 2. The Dish Room staff were unclear regarding dish machine water temperature requirements in a machine that used hot water to sanitize dishes. 3. Staff did not state or follow manufacturer's instructions when testing quaternary ammonia sanitizer concentration. 4. Staff did not label or store chemicals per policy, and two staff interviewed were unclear regarding the correct number of tablets to use for the disinfectant they mixed. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all resident meals were palatable when 5 of the 25 sampled residents (Resident 32, 41, 70, 81, and 93) complained that their meals were consistently served too cold. This failure had the potential to negatively affect the health and nutrition of all residents and may have contributed to ongoing and significant weight loss for the residents leading to negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the care plan for one of 25 sampled residents (Resident 41), when the resident experienced a series of falls. This lack of revision had the potential for interventions to be inconsistently utilized placing Resident 41 at risk of further falls that could result in injury, or further negative clinical outcomes.

Inspectors wroteBased on interview, and record review, medication administration did not meet professional standards of quality, when laxatives (treats constipation) were not given according to the physician orders, for one of 25 sampled residents (Resident 77). This had the potential to result in severe constipation or intestinal blockage, which could lead to negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming and hygiene when one of 25 sampled residents (Resident 18) had long, dirty fingernails. This failure had the potential to cause skin scratches that could have become infected which could lead to negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of 25 sampled residents (Resident 41) maintained acceptable parameters of nutritional status. This failure had the potential for the lack of nutritional goals to be maintained which could lead to negative clinical outcomes.

Inspectors wroteBased on interview, and record review, the facility's pharmacy consultant failed to identify drug irregularities which included Centers for Medicare and Medicaid Services' (CMS) requirement to limit as needed (PRN) psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications to 14 days, unless there was a documented rationale which included why the medication needed to be extended past 14 days, and the duration, for one of five sampled resident records reviewed for unnecessary medications (Resident 65). This resulted in, or had the potential to result in residents receiving unnecessary medication with adverse side effects, some of which could include permanent neurological side effects, and a deterioration in the clinical condition of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make sure that one resident (Resident 46) was free of significant medication errors when they received less than the prescribed dose of aspirin (an anti-platelet agent given to prevent blood clots). This failure had the potential to threaten Resident 46's health and well-being, which could lead to negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident preferences were honored for two of 25 sampled residents (Residents 9, and 70). This failure not to provide food in accordance with resident preferences could result in decreased meal satisfaction and overall caloric intake which could lead to undesired weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the physician ordered diet for one of six sampled residents, (Resident 56) when the Consistent-Carbohydrate Diet (CC), diet for diabetics to control blood sugar management) was not followed. This failure resulted in high blood sugars and did cause Resident 56 increased anxiety, which could lead to negative clinical outcomes.