Shasta Healthcare

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure food safety and sanitation guidelines were followed when:There was an undated gallon of milk in the refrigerator that was partially used, undated bags of bread in the dry goods storage area, an undated box of individual jelly packets in the dry goods storage area. There was a box of potatoes stored on the floor of the dry goods storage area, and a box of paper dining napkins stored on the floor of an outdoor storage area. There was brown crusty debris on baking pans, and the red and green cutting boards had cuts in the surfaces. The ice machine had a pale brown substance in the internal ice chute (where the ice comes down from the storage bin). These failures had the potential to cause foodborne illnesses for all residents of the facility who ate food prepared by the kitchen and used ice.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure that one of twelve residents sampled (Resident 8) right to have an Interdisciplinary Team Meeting (IDT meeting, a meeting where the Interdisciplinary Team, a group of facility managers, discuss the care and services that the facility provides to their residents) with all the team members present to ensure decisions made regarding Resident 8 was in their best interest. This failure had the potential to result in decisions being made about Resident 8's health care that were not in their best interest. Refer to F841Findings:Review of a facility policy titled Consent: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure one out of 12 sampled residents (Resident 46) was able to safely self-administer medication when Resident 46's Albuterol inhaler (a fast-acting medication that opened the airways in the lungs and made breathing easier) was stored at the bedside and available for use. This had the potential for overdosing or incorrect usage which could lead to a decline in health status.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure there was ongoing communication regarding resident rights during group activities. This had the potential for residents not to know how to effectively exercise their rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the most recent recertification survey (an evaluation of the facility to ensure they are compliant with federal regulations, and clinical quality) was available to the residents of the facility. This failure resulted in a violation of resident rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of twelve sampled residents (Resident 6 and Resident 25) received the necessary services to maintain good personal grooming and hygiene when:1. Resident 6 did not receive a shower for twelve days.2. Resident 25 had a dark unknown substance crusted under their fingernails. These failures resulted in frustration and discomfort for Resident 6 and placed Resident 25 at risk for negative health outcomes related to poor hand hygiene.

Inspectors wroteBased on interview and record review, the facility failed to ensure that two of two Certified Nurse Aid (CNA) staff currently providing resident care received a performance evaluation annually. This resulted in the facility failing to asses staff's knowledge and skills to ensure staff had adequate skills and knowledge to provide quality care to all residents. During a concurrent interview and record review, on 4/24/26 at 9:00 am, with the Director of Nursing (DON) and the Director of Staff Development (DSD), both confirmed that a process to ensure all CNAs received annual evaluations had not been implemented by the facility. DSD indicated she was aware that staff performance evaluations had not been carried out annually, but was unclear how long this had been an ongoing problem. DSD confirmed that the annual evaluations were necessary to identify areas where training was needed. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure their medication error rate was less than 5 percent (5%), when the Medication Administration Pass Observation reflected three medication errors out of 25 opportunities resulting in a medication error rate of 12 percent (12%) as evidenced by: Resident 8 was not provided with a Physician ordered medication,2a. Resident 46 was not provided with a Physician ordered medication; and2b. Resident 46 was administered a higher dose of a medication than what the Physician ordered. This had the potential for residents to not attain or maintain their highest practicable level of physical, mental, functional and psycho-social well-being and have adverse medication outcomes.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure that medications stored in one of two medication carts contained labels for use that matched the Physician's orders for Resident 8. This failure had the potential to cause a medication error or for medication to run out early.

Inspectors wroteBased on interview, record review, and policy review, the facility did not ensure that the Medical Director (MD) effectively implemented resident care policies for one of two sampled residents (Resident 8) when:1. The facility failed to obtain a resident representative (RP, medical decision maker) who was unaffiliated with the facility (a person who is not connected to the business) for Resident 8.2. The MD acted as Resident 8's RP.This had the potential to result in decisions that were in the interest of the facility rather than the interest of Resident 8.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an in-service training program for two of two Certified Nursing Assistants (CNAs) to ensure areas of deficiencies in job performance that were identified during annual performance reviews were addressed and ensure that the facility provided 12 hours of continuing education for CNAs. This had the potential to negatively impact the quality of care to residents, particularly those with specialized care needs such as those with dementia or other cognitive impairments.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure that a resident who entered the facility without a pressure injury (PI, a bedsore) did not develop a PI, for one of two residents sampled for PI (Resident 1). Resident 1 developed a PI to her sacrum (bottom of the spine), which progressively worsened and the facility failed to follow their policies regarding wound care and changes of condition and inform Resident 1's physician when her PI changed and worsened. This delayed treatment for Resident 1's PI by six days, and resulted in a worsened and infected PI. Within two days of Resident 1 discharging from the facility, she was admitted to the acute care hospital for an infected PI and sepsis (an infection in the bloodstream) and osteomyelitis of the sacrum (an infection in the bone). [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure safe discharge for one of two residents sampled (Resident 1), when Resident 1 chose to leave the facility Against Medical Advice, (AMA, when the physician does not agree with the resident leaving the facility because of their medical condition) and the facility failed to ensure;1. There was a physician's order to discharge Resident 1 AMA.2. Discussion and documentation was done with Resident 1 of alternatives to discharging AMA to the location to which Resident 1 discharged .3. An Against Medical Advice form (A form that a resident signs acknowledging understanding of the consequences for leaving the facility AMA), was not offered to Resident 1.4. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the care plan (a document that outlines a patient's health care needs and the actions and interventions required to address them), was revised and updated when one of two sampled residents (Resident 1), had a pressure injury (PI, a bedsore) that worsened and the care plan had not reflected this. This failure resulted in no identified problem, goals or interventions to promote the healing of Resident 1's PI to her sacrum (the large triangular bone at the base of the spine), and inconsistencies and delayed treatments of Resident 1's PI, which had a negative impact on her clinical status.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure nursing staff demonstrated competency in following the facility's policies in regard to wound care management and changes in resident conditions for one of two sampled residents (Resident 1) when;1. Registered Nurse (RN) A and Wound Care Nurse/ RN (WCN/RN), had not notified Resident 1's physician that Resident 1's sacrum (base of the spine) pressure injury (PI-a bedsore), had worsened. 2. WCN/RN performed conservative sharp wound debridement (CSWD, an invasive procedure to remove dead tissue from a PI using sharp instruments such as a scalpel (knife), scissors, and forceps (tweezers)), to Resident 1's PI, without a physician's order. These cumulative failures caused in a delay in the treatment and healing of Resident 1's PI and caused the PI to worsen. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent verbal abuse for one of three sampled residents, (Resident 2) when Certified Nursing Assistant (CNA) A cursed at Resident 2. This failure violated Resident 2's right to be free from abuse and had the potential to negatively impact Resident 2's emotional and psychosocial well-being.

Inspectors wrote2. A facility policy titled, Handwashing/Hand hygiene, revised 10/2023, indicated, 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to the other personnel, residents, and visitors. A facility policy titled, Med [Medication] Pass Infection Control Review, dated 06/01/2023, indicated, Do not touch meds [medications] with ungloved hands. The policy specified, Use hand hygiene prior to handling medication and after administering to resident. Place a barrier between the cart and the medication while preparing the medication. A Resident Face Sheet, indicated the facility admitted Resident #15 on 09/10/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of hypertension, paroxysmal atrial fibrillation, angina pectoris, and anxiety disorder. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to lock the computer screen on 1 of 2 medication carts to ensure residents' protected health information (PHI) was not visible for all to see.

Inspectors wroteBased on interview and record review, the facility failed to ensure that there was an alternative system in place by which resident Medication Administration Records (MARs), Treatment Administration Records (TARs), and Physician's Orders, could be accessed by staff in the event that the facility's Electronic Medical Record system (EMR, a computerized system that contained resident MARs, TARs, and Physician's Orders), was not available for 41 of 41 residents. On 7/17/24, the facility's EMR system administrator notified the facility that there was going to be a scheduled outage for EMR maintenance and that the EMRs would not be available on 7/18/24. The facility took no action to prepare for this planned outage and subsequently had no way for the nurses to administer medications, treatments (wound and skin care), or see what the physician currently had ordered for each resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 1), sampled for unsafe wandering (a random, aimless or repetitive search for an exit that is non-goal-directed), and elopement (a resident leaves the premises or a safe area without the facility's knowledge and supervision) was assessed and monitored for unsafe wandering and elopement. Resident 1 eloped twice from the facility and had no wander/elopement risk assessments or care planning done, and the facility had no dedicated alarm system in place for residents who wandered or were at risk to elope. This resulted in Resident 1 eloping from the facility and was found by the police in a ditch near a highway with a scratched face, bruised chin and pain in her right leg. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents, (Residents 1 and 3) who were roommates, were free from verbal abuse when Certified Nursing Assistant (CNA) B yelled profanities at Resident 1 and 3 while in their room and continued yelling profanities in the hallway within hearing range after CNA B left the resident's room. This failure resulted in anger, frustration, and humiliation for Residents 1 and 3, and had the potential to negatively impact the emotional and psychosocial well-being of all the residents that CNA B cared for.

Inspectors wroteBased on observation, interview, record and Abuse Policy review, the facility failed to report an abuse allegation within the mandated timeframe for two of five sampled residents (Resident 1 and 3), when Certified Nursing Assistant (CNA) C witnessed CNA B cursing and yelling at Residents 1 and 3 around 10 pm on 9/20/23, and had not reported this until around 6:30 am on 9/21/23, about 8 hours later. This had the potential for abuse to continue to all residents and negatively impact their safety and emotional well-being, by not initiating investigations and protecting the residents immediately.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when: 1. The Registered Dietitian did not conduct regular audits of the Food and Nutrition Services to ensure food safety and sanitation practices and meal service requirements were in place and followed. 2. The facility's therapeutic menus and diet manual were not reviewed and signed off by the facility's Registered Dietitian and did not include all diets routinely ordered by providers at the facility. 3. The Dietary Services Manager did not complete the required six hours of State regulatory training prior to assuming the leadership role. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure their menus met resident needs when: 1. Therapeutic fortified diets served in the facility were not included in the facility-specific diet manual or cooks spreadsheets and had not undergone nutrient analysis to ensure resident nutrition needs were being met. 2. Staff did not use standardized recipes to ensure nutrient content for foods served to residents on fortified diets. 3. The current menus had not been updated in more than three years, were not seasonal, and were not signed off by the facility's Registered Dietitian. These failures had the potential to result in staff providing or not providing food to ensure compliance with the physician's written diet order, and to result in resident's nutritional needs not being met. This could negatively impact residents' health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sanitation of the Food and Nutrition Services Department when: 1. The ice machine was not sanitary. 2. Staff did not follow manufacturer's instructions when using their Sink and Surface Cleaner Sanitizer to clean food production equipment and surfaces. 3. Food preparation equipment and storage areas were not clean. 4. Staff did not exhibit professional standards of practice to decrease the likelihood of cross contamination during food production activities. 5. The storeroom floor had a buildup of black grime, and the floor drain was not sanitary. 6. An air gap device was not present in the food preparation/ manual warewashing sink. These failures had the potential to increase the risk of foodborne illness for residents living in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control system when insects resembling flies were present in multiple locations in the facility during the survey. This failure has the potential to result in transmission of disease to residents living at the facility.

Inspectors wroteBased on observation, interview and clinical record review, the facility failed to ensure that 3 of 12 sampled residents' (Residents 12, 20, and 2) nutritional care plans were person-centered, comprehensive and reviewed or revised by the interdisciplinary team (IDT- professional disciplines that work together in the best interest of the resident) when: 1. Resident 12's Nutritional Status care plan was created on 6/1/22, and was not revised to show that he had significant weight loss. 2. Resident 20's Nutritional Status care plan was created on 4/8/22, and not revised to show that she had significant weight loss. 3. Resident 2's Nutritional Status care plan was created on 2/23/22, and not revised to show he had significant weight loss and weight gain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility administration failed to ensure adequate oversight and provision of Food and Nutrition Services by qualified personnel when: 1. There was no full-time Dietary Services Manager (DSM), the position responsible for daily operations of the department and supervision of foodservice staff, from November 2021 through April 2022 when the dietary manager was out on leave of absence. 2. There was not a system in place to ensure the Registered Dietitian's training and competence in use of the facility's electronic medical record. These failures had the potential to result in inadequate supervisory coverage of Food and Nutrition Services responsibilities, and inadequate nutrition care documentation that could negatively impact food services and nutrition care for residents.

Inspectors wroteBased on observation, interview and record review the facility failed to adequately maintain equipment in the Food and Nutrition Services equipment when: 1. Two out of two freezers had ice buildup, potentially impacting the function and life of the freezers and the quality of food inside. 2. One freezer and one refrigerator had rusty shelves. 3. The cold food preparation area counter and cabinet had uncleanable surfaces. These failures had the potential to result in cross-contamination of food, loss of food, loss of food storage ability if freezers failed, and loss of food quality for residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately reflect the cognitive status for one of twelve sampled residents (Resident 20) when they failed to complete the Minimum Data Set (MDS), a required assessment tool. This failure had the potential for staff to be unaware of the level of memory and cognitive deficit experienced by Resident 20, which in turn could have placed her at risk for harm.