Shasta Healthcare
SHASTA HEALTHCARE in WEED, CA — inspection on September 12, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Summary dated 8/11/25 indicated, Discharge Destination: Resident to return to independent living with spouse support after acute stay.
This statement was incorrect, however, because Resident 1's home was in a nearby town, but she left the facility with her family to a city that was three hours away.
During an interview on 8/22/25 at 11:52 a.m., with Family Member (FM) 2, FM 2 indicated that she was angry about how Resident 1 was taken care of by the facility, and there were nurses in the family who could do better.During an interview on 8/22/25 at 12:14 p.m., with FM 3, FM 3 indicated that her family did not think that the facility was making sure Resident 1 was being turned often enough, and they had concerns because the WCN/RN was only available once a week which delayed treatments and interventions for healing Resident 1's pressure injury. 3.
During an interview on 9/9/25 at 10:24 a.m., with FM 2, FM 2 confirmed that the facility had not explained or offered to Resident 1 or FM 2, alternatives to taking Resident 1 to a town three hours away or the consequences of leaving the facility AMA.
During a phone interview on 8/20/25 at 1:54 p.m., with the Medical Director (MD), the MD indicated that it is not her decision when a resident discharges, rather it is a determination that is made by the Social Services Director (SSD) and DON) The MD indicated that the SSD monitors how the residents are doing and if they are meeting criteria to be discharged .
The MD indicated that she was not notified by the SSD or DON when Resident 1 left AMA and stated, It was very sudden.4.
During an interview on 8/21/25 at 10:42 a.m., with the SSD in her office.
The SSD indicated that FM 2 stated, I'm taking her [Resident 1] home right now.
The SSD indicated that she did not know that Resident 1 was not going to her home in a nearby town, but rather to FM 2's home in a town three hours away until after Resident 1 left the facility.
The SSD indicated that she did not think it was an appropriate discharge.
The SSD confirmed the facility did not complete an AMA document or investigate if there should have been a referral to APS.
During an interview on 9/9/25 at 9:42 a.m., with WCN/RN regarding Resident 1's leaving AMA, the WCN/RN confirmed, We should have done an AMA, I was really worried about the three-hour drive for her.
During an interview on 8/20/25 at 2:38 p.m., with the DON the DON confirmed that Resident 1 left the facility AMA and that Resident 1's physician had not given orders for Resident 1 to discharge AMA and that the facility had not notified APS to check on Resident 1 once she returned to the community, and all of those things should have been done.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Shasta View Estates
445 Park Street Weed, CA 96094
SUMMARY STATEMENT OF DEFICIENCIES
During an interview by email with the Director of Nursing (DON) on 8/29/25 11:12 a.m., the DON confirmed there was no evidence that Resident 1's care plan for her PI to the sacrum, had been update or revised since 7/30/25. DON confirmed Resident 1 left the faciity on 8/11/25.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Shasta View Estates
445 Park Street Weed, CA 96094
SUMMARY STATEMENT OF DEFICIENCIES
unless they need her to do something. AP confirmed she had not given specific orders to WCN/RN to perform a CSWD procedure. AP stated she, had no clue that nursing staff had identified Resident 1's PI was worsening and not healing. AP stated if she had known there were problems with worsening or lack of healing to Resident 1's sacrum PI, she would have referred her to their wound care physician for an evaluation.A review of Resident 1's acute care hospital records, dated 8/13/25, indicated that Resident 1's family had taken her to a local hospital on 8/13/25, two days after Resident 1 had left the facility, because Resident 1's PI was not healing and had a bad smell.
The hospital's admission Note, dated 8/13/25, reflected that Resident 1 had sepsis and osteomyelitis of the sacrum, from her PI being infected. Resident 1 passed away at that hospital 10 days later.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Shasta View Estates
445 Park Street Weed, CA 96094
SUMMARY STATEMENT OF DEFICIENCIES
During a phone interview on 9/9/25 at 9:42 a.m., with WCN/RN, the WCN/RN confirmed she had not obtained a physician's order for CSWD prior to performing the procedure on Resident 1. WCN/RN stated that she does not need a physician's order to perform CSWD.
The WCN/RN indicated that she could not recall informing Resident 1's AP of the changes and worsening of each stage of Resident 1's PI and stated, I do not have direct communication with the physician.
During a phone interview on 9/9/25 at 1:01 p.m., with AP, the AP confirmed she was not notified by either RN A or WCN/RN of the comprehensive changes of condition and worsening of the stages of Resident 1's PI to her sacrum.
During a phone interview on 9/9/25 at 10:47 p.m., with the Director of Nursing (DON) indicated that WCN/RN could perform CSWD using her own discretion and the protocol and does not need a physician's order.
Facility ID: