The resident ended up hospitalized with sepsis and a bone infection.
Federal inspectors found that staff at Shasta Healthcare repeatedly failed to notify the attending physician as a cognitively intact woman's sacrum wound progressed from a Stage 2 pressure injury to a Stage 4 over the course of three weeks in July and August.
The 12-day cascade of missed notifications began July 24, when the resident developed a Stage 2 pressure sore she had acquired at the facility. The attending physician was not told.
On July 25, Registered Nurse A documented during wound rounds that the "wound looks worse than 3 days ago." She did not notify the doctor.
Three days later, RN A wrote that the "wound is getting worse." Again, no physician notification.
Instead, RN A told inspectors during a September phone interview, she reported the worsening condition to the facility's wound care nurse a week later. That nurse, she said, was the one who decided what changes should be reported to doctors.
The wound care nurse worked only one day per week.
By July 30 — six days after the initial Stage 2 pressure sore appeared — the resident's sacrum wound had deteriorated to an "unstageable" pressure injury. Only then did staff notify the attending physician, and only through a memo.
The notifications didn't improve. On August 3, the resident's unstageable pressure sore showed signs of infection, with black dead tissue and thick yellow dead tissue that prevents wounds from healing. The attending physician was not notified.
Eight days later, the wound care nurse performed a procedure called conservative sharp wound debridement on the resident's pressure sore without obtaining a physician's order. The wound had progressed to Stage 4 by then.
The attending physician was not notified of the procedure.
During a September phone interview, the wound care nurse confirmed she had not obtained a physician's order before performing the debridement. She told inspectors she doesn't need physician orders for such procedures and said she could not recall informing the doctor about the changes and worsening stages of the resident's pressure injury.
"I do not have direct communication with the physician," she told investigators.
The attending physician confirmed during her own September interview that neither the registered nurse nor the wound care nurse had notified her of "the comprehensive changes of condition and worsening of the stages" of the resident's sacrum pressure injury.
Two days after leaving the skilled nursing facility, the resident was admitted to an acute care hospital on August 13 with sepsis secondary to osteomyelitis — a bone infection caused by the infected pressure sore.
The resident had been admitted to Shasta Healthcare with a sacrum fracture but no pressure injuries, according to her federally mandated assessment completed in July. She scored 12 out of 15 on a cognitive assessment, indicating she was mentally intact.
The Director of Nursing told inspectors during a September phone interview that the wound care nurse could perform conservative sharp wound debridement "using her own discretion and the protocol" without needing a physician's order.
State regulations require that no medication or treatment be administered except on the order of a person lawfully authorized to give such orders.
The inspection found that few residents were affected by the medication and treatment violations, with minimal harm or potential for actual harm documented.
The facility's failure to maintain proper physician communication left a cognitively intact woman's deteriorating wound untreated for weeks as it progressed through increasingly severe stages, ultimately requiring emergency hospitalization for a life-threatening blood infection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shasta Healthcare from 2025-09-12 including all violations, facility responses, and corrective action plans.