Shasta Healthcare

In the surveyor’s words

From the most serious findings on record at Shasta Healthcare, in the surveyor’s own words.

• Immediate jeopardy, widespreadF684Jul 24, 2024

  Based 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. […]

• Immediate jeopardy, patternF689Jul 12, 2024

  Based 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. […]

• Actual harm, isolatedF686Sep 12, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Apr 24, 2026

  Based 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… […]

• No harm, potential for more than minimal, widespreadF880Jan 15, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to implement a water management program as directed by their policy. This deficient practice had the potential to affect all residents who currently resided in the facility. The facility further failed to ensure a nurse washed her hands prior to medication administration, did not handle medication with her bare hands, and did not administer medications to a resident that had fallen on top of the medication cart for 1 (Resident #15) of 3 residents observed for medication administration. Findings included: 1. […]