Shasta Healthcare

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

discharging (the official directive from a doctor to a healthcare facility that a patient no longer requires inpatient care and can safely transition to another level of care, such as home) Resident 1.2.Review of Resident 1's progress note dated 8/11/25 at 7:29 p.m., written by the Wound Care Nurse/Registered Nurse (WCN/RN, a registered nurse with specialized training and certification in wound care), the WCN/RN indicated that upon preparing for Resident 1's unplanned AMA she educated the family about Resident 1's extensive treatment for a Stage 4 (Bedsore, a severe form of skin damage, that involves full-thickness tissue loss that exposes muscle and bone), care needs that Resident 1 had developed while in the facility.

There was no documentation of discussion of the implications and/or risks of being discharged to a location that was not equipped to meet her needs or an attempt to ascertain why the resident chose that location.

There was no documentation of discussion on more suitable options of locations that were equipped to meet the needs of Resident 1. There was no documentation completed that despite being offered other options that could meet the resident's needs, the resident refused those more appropriate settings. Review of Resident 1's progress note dated 8/11/25 at 4:25 p.m. written by Registered Nurse (RN) B indicated that Resident 1's family arrived at the facility at 11:00 a.m., and requested to take Resident 1 home and that Resident 1 left the facility at 2:15 p.m. with her family.Review of Resident 1's, Transition of Care/Discharge 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Shasta View Estates

445 Park Street Weed, CA 96094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Section M indicated no pressure injuries.A comparison review of Resident 1's records titled, Wound Management Detail Report dated 7/24/25 to 8/11/25, and Care Plan History dated 7/30/25 reflected that:

On 7/24/25 Resident 1 had a Stage 2 PI on her sacrum and the care plan was not updated until 7/30/25, a week later and the PI had already worsened to an Unstageable PI.On 8/3/25 Resident 1's Unstageable PI worsened to a Stage 4 and showed signs of infection with eschar (dead black tissue) and slough (stringy thick yellow dead tissue, which is a breeding ground for bacteria and prevents wounds from healing), and there were no revisions or updates to her care plan.On 8/11/25 Resident 1's PI worsened to a Stage 4, and and no revisions or updates were made to her care plan.During a concurrent interview and record review

on 8/22/25 at 10:33 a.m., with Wound Care Nurse/Registered Nurse (WCN/RN), the WCN/RN confirmed Resident 1's skin integrity care plans had not been updated since 7/30/25, and had not reflected her current status, treatments, and interventions. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Shasta View Estates

445 Park Street Weed, CA 96094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Shasta View Estates

445 Park Street Weed, CA 96094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Title 22, S72317. Nursing Service-Administration of Medications and Treatments; (a) Medications and treatments shall be administered as follows: (l) No medication or treatment shall be administered except on

the order of a person lawfully authorized to give such orderReview of the admission record for Resident 1 indicated that Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including sacrum fracture (broken bone at the base of the spine).Review of Resident 1's admission MDS (Minimum Data Set- a federally mandated assessment tool that measures the health status in nursing home residents), dated 7/11/25, completed by Minimum Data Set/Registered Nurse (MDS/RN), section C, indicated Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 out of 15 indicating she was cognitively intact. Section M indicated that Resident 1 had no PI's upon admission to the facility.Review of Resident 1's acute care hospital record dated 8/13/25, indicated that Resident 1 was admitted to the hospital on [DATE REDACTED], two days after leaving the skilled nursing facility, with sepsis (an infection in the blood stream) secondary to osteomyelitis (a bone infection) from the infected PI to the sacrum. Review of Resident 1's progress note dated 7/25/25, written by Registered Nurse (RN) A indicated, Wound rounds:.Wound looks worse than 3 days ago. The progress note reflected no evidence that RN A notified Resident 1's AP of this change in condition of her PI.Review of Resident 1's progress note dated 7/28/25 written by RN A indicated, .Wound is getting worse. There was no evidence that RN A notified Resident 1's AP.During a phone interview on 9/9/25 at 2:07 p.m., RN A confirmed that she had not notified Resident 1's AP of the worsening of her PI on 7/25 and 7/28/25. RN A stated that when she identified the worsening to Resident 1's PI, she notified WCN/RN a week later instead of the AP. RN A stated the WCN/RN was the one who decided what changes should be reported to the AP. RN A added that the WCN/RN only worked one day a week.A comparison review of a facility documents titled, Physician Notification & Orders dated 7/30/25, and concurrent review of Resident 1's record titled, Wound Management Detail Report dated 7/24/25 to 8/11/25 reflected: On 7/24/25, Resident 1 had a Stage 2 PI that she acquired while in the facility, and the AP was not notified.On 7/30/25, one week later, Resident 1's sacrum PI had worsened from Stage 2 to an Unstageable PI, and the AP was notified by a memo.On 8/3/25, Resident 1's Unstageable PI showed presence of infection with eschar (dead black tissue) and slough (stringy thick yellow dead tissue that is a breeding ground for bacteria and prevents wounds from healing), and the AP was not notified.On 8/11/25, WCN/RN performed CSWD procedure on Resident 1's Unstageable PI, without a physician's order, and the AP was not notified. Resident 1's PI was then a Stage 4. 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.

Event ID:

Facility ID:

If continuation sheet