Shasta View Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF801Aug 15, 2024

  Based on observation, interview, and record review the facility failed to ensure a full time Registered Dietician (RD) or a clinically qualified nutritional professional (CDM) to provide direct oversight of dietary staff to deliver safe and sanitary food service for 49 of 49 residents when: 1. Dietary staff did not follow safe and sanitary food service practices. Refer to F 802 and F 812. 2. RD, Unqualified Dietary Manager (UDM), and CDM did not ensure all dietary staff had required state and federal competencies to work in the kitchen upon hire. Refer to F 802 3. RD did not ensure all identified issues in the kitchen/sanitation audits were acted upon and resolved. Refer to F 812 4. […]

• Immediate jeopardy, widespreadF689Apr 24, 2024

  Based on observation, interview, and record review, the facility failed to ensure the safety and security for: 1. All residents that resided in the facility when five of eight facility entrance doors (Door 1 front door, Door 2 side door, Door 3 laundry hall door, Door 4 back door, Door 5 dining room door) were found to be unlocked during the night and staff were unaware how to lock them. 2. One of one sampled resident (Resident 1) when staff had disarmed, by unplugging, a wanderguard alarm system (a system that alarms and alerts staff when a resident, who was assessed to wander, (attempts to leave the building without staff knowledge or supervision), because the alarm was bothersome to the staff. […]

• Immediate jeopardy, patternF755Jan 18, 2024

  Based on observation, interview, and record review, the facility failed to ensure that medications were ordered, reordered, available, and administered in accordance with their physician ' s orders for 13 out of 31 sampled residents (Resident 2, 4, 10, 12, 13, 19, 22, 24, 25, 28, 31, 37 and Resident 38) when: 1. Resident 2 was not given two doses of Lovenox (a blood thinner) on 12/21/23 and 12/22/23. 2. Resident 4 was not given Lasix (a diuretic medication) and Coreg (a heart medication) on 12/21/23 at 8:00 pm. […]

• Actual harm, isolatedF686Jun 2, 2026

  Based on observations, interviews, and record reviews, the facility failed to provide one out of two sampled residents (Resident 1) with the necessary care and services to prevent the development of three facility acquired Pressure Injuries (PI-skin and tissue loss with exposed fat, muscle, or bone) a Stage 4 PI on the coccyx (tailbone), a Deep Tissue Pressure Injury (DTI, serious type of PI that caused damage to the tissue or muscle) to the posterior (back of) right heel, and a DTI to the tip of the right big toe when: 1. Licensed Nurses (LN) and Certified Nurse Assistants (CNA) did not identify the progression of skin changes, over a 24 day period, which led to the discovery of the PI's at advanced stages. 2. […]

• Actual harm, isolatedF692Aug 15, 2024

  Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status when staff did not identify insidious weight loss (gradual, unintended, progressive weight loss over time), implement, or modify a plan of care that was individualized and consistent with the resident's needs or preferences for one of two sampled residents (Resident 22). These failures resulted in severe weight loss and put Resident 22 at risk for further health decline. Refer to F 801. […]