Health inspection·December 24, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect two of five sampled residents, (Resident 1 and Resident 2) from financial abuse, manipulation and exploitation when:1.The Activity Assistant (AA) J played on Resident 1's sympathy and manipulated Resident 1 out of $800, and promised services she never delivered. 2.AA J loaded Resident 2's bank card onto her personal well-known online shopping website to buy her coffee creamer, when the facility could have bought the coffee creamer for Resident 2, without using her bank card. These failures caused Residents 1 and 2 anxiety, embarrassment, and humiliation and the potential for negative emotional and psychosocial outcomes. Findings: The facility's policy revised 2025, titled, Transactions Involving Resident Funds, was reviewed and indicated it is the practice of this facility that anytime there is a transaction involving resident funds, the resident must be provided with a receipt of such transaction. Copies of each transaction are filed in the business office. Policy Explanation and Compliance Guidelines: The facility will establish and maintain a system that assures a complete and separate accounting of each resident's personal funds and is according to generally accepted accounting principles. The facility will ensure resident funds are not comingled with facility funds or funds of someone other than a resident, such as a staff member managing the resident's personal funds. The Business Office Manager, or his/her designee, is responsible for providing residents with receipts for withdrawals and for requested or needed personal items when such funds are withdrawn from the resident's personal funds account managed by the facility. A copy of such transactions and receipts are maintained by the Business Office Manager, or designee, in order to verify account transactions and to reconcile resident fund balances with withdrawals and expenditures. Personal items purchased by Social Services, or other authorized staff members on behalf of residents, provide the Business Office Manager, or designee, with a copy of receipts upon return to the facility. The facility's policy revised 2025, titled, Abuse, Neglect and Exploitation, was reviewed and indicated the definition of Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. The definition of Mistreatment means inappropriate treatment or exploitation of a resident. The facility's policy revised 2025 titled, Abuse, Neglect and Exploitation, was reviewed and indicated it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 1.A review of Resident 1's record indicated she had been admitted to the facility on [DATE] with diagnoses that included osteomyelitis of cervical vertebra (an infection of the neck bones causing severe pain, stiffness, and can lead to numbness or weakness), acute respiratory failure with hypoxia (sudden loss of oxygen needed in the blood making it hard to breathe), pressure ulcer of sacral region stage 4 (a severe, open sore on the tailbone area that involves full-thickness tissue loss, extending through skin Page 1 of 6 055489 055489 12/24/2025 Shasta View Care Center 1795 Walnut Street Red Bluff, CA 96080

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and fat to expose muscle, tendon, ligaments, or even bone), diabetes (too much sugar in the blood), chronic pain (long standing pain that persists), Bi-polar disorder (a mental health condition causing extreme mood swings), attention deficit hyperactivity disorder (condition that makes it hard to manage your attention, control impulses, leading to challenges with focus, organization, and self-control in daily life), history of deep vein thrombosis embolism (DVT, is a blood clot forming in a deep vein, usually the leg) and embolism (when the blood clot or part of it breaks off, travels, and blocks a blood vessel elsewhere, most dangerously in the lungs), major depressive disorder (persistent sadness, and loss of interest), and high blood pressure. The physician noted in his admission orders that Resident 1 was capable of making healthcare decisions and was listed as her own responsible party (RP). Resident 1 was discharged to home on [DATE]. During a review of Resident 1's most recent Minimum Data Set, (MDS, a resident assessment), dated 8/31/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, memory and decision making skills), score of 15 of 15 and was cognitively intact (able to think and reason). During an phone interview on 12/18/25 at 2:10 pm, Family Member (FM) stated, No one has called or contacted me from the facility about [Resident 1's] money being taken and services not being provided. [Resident 1] told me l about the plan with [AA J] before she was discharged home. [AA J] was supposed to buy groceries and make meals for [Resident 1] after being discharged . [Resident 1] is very detailed when it comes to money, she knows exactly what she has down to the penny. [Resident 1] was really upset over this incident. During a phone interview on 12/18/25 at 3:11 pm, Resident 1 indicated between August 2025 and October 2025, AA J played on her sympathy and borrowed money from Resident 1. Resident 1 stated, [AA J] was out at the smoking area and she kept complaining she didn't have any money, and she was broke and she couldn't afford cigarettes, and she didn't have gas money. I felt sorry for her and gave her my debit card and pin number. [AA J] took $500 from my bank account using the ATM and gave me $300 and kept $200 for herself. Then [AA J] asked me to borrow money and again took $500 from my account and kept $200, for herself. I was not paid back nor did I receive any receipts for these transactions. Just before I was going to be discharged home in October, [AA J] approached me and convinced me she was my friend and that I should have her come to my house and cook my meals once I was at home. I agreed, but then [AA J] said she would need gas money to get to my house and I gave [AA J] a $100.00 bill for gas and $200 for groceries. Once I was home, I tried calling [AA J] for three days about coming over and fixing my meals. [AA J] never did respond and never came to my house with groceries and this was very upsetting to me because I had called and called and left her many messages. I was so anxious. I eventually ended up calling the facility and told them that I had given [AA J] $100 for gas and $200 for groceries and she never showed up. In that same week before I discharged home, [AA J] approached me and asked if I wanted a going away party. Of course, I said yes. At the end of the going away party, [AA J] told me I had to pay her $100 because she had to pay for my going away party out of her own pocket, and she could not afford that and that the Administrator refused to reimburse her. I felt so guilty, I gave [AA J] a $100 right then an there. [AA J] had convinced me that was the rule. I did not say anything because she made me feel sorry for her that she was always broke and I did not want to make things worse for her, I thought we were friends. Now I feel so embarrassed and foolish for letting [AA J] manipulate me out of $800, I was taken advantage of by someone who pretended to be my friend. I thought [AA J] cared about me. I still have never heard from [AA J] or anyone else from the facility. An interview was conducted by phone on 12/23/25 at 10:17 am, with AA J. AA J stated, Yes, I did go to the bank for [Resident 1] one time. Yes, she gave me her pin number, and I took out $500.00 and gave all the money to [Resident 1]. I did make her cupcakes for her party, but I paid for all the 055489 Page 2 of 6 055489 12/24/2025 Shasta View Care Center 1795 Walnut Street Red Bluff, CA 96080

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some supplies.A review of the facility's 5 day abuse investigation follow up report submitted by the Administrator (Admin) B to the California Department of Public Health (CDPH), on 11/5/25 indicated, Some time in November a conversation was had between Resident 1 and Staff 1 [AA J] regarding Staff 1 providing cooking services for Resident 1 upon discharge from [the facility name] Resident 1 indicated that she gave $200-300 to [AA J] to buy groceries before she discharged and once she discharged they never spoke again and she indicated that Staff 1 kept the money. Staff 1 indicated that she never received any money and that the idea was for Resident 1 to buy the groceries and she would prepare the meals. Once Resident 1 discharged Staff 1 was hit with automobile problems and indicated this to Resident 1. Staff 1 indicated that for now she would not be able to drive to Resident 1's home and cook the food and that possibly at a later date once the auto issues were dealt with she could. The report indicated that the facility would, reimburse Resident 1 $300. The report additionally indicated that they had not substantiated Resident 1's allegation and allowed AA J to return working at the facility. 2. A review of Resident 2's record indicated she had been admitted to the facility on [DATE] with diagnoses that included lupus (a chronic disease where your immune system mistakenly attacks your own healthy tissues, causing inflammation, pain, fatigue, and potential damage to skin, joints, kidneys, heart, and lungs. A lifelong condition with unpredictable flare-ups), chronic kidney disease (when the kidneys cannot filter the blood properly), schizoaffective disorder (a mood disorder with delusions and hearing voices), bi-polar, depression, chronic obstructive pulmonary disease (COPD, a progressive lung disease), hyponatremia (low sodium levels in the blood) and high blood pressure. During a review of Resident 2's most recent MDS, dated [DATE], indicated Resident 2 had a BIMS score of 15 of 15 and was cognitively intact. During an interview on 12/11/25 at 5:10 pm, the Business Office Manager (BOM) stated, It's under the abuse policy that Activity staff are not allowed to take any cash from any resident whatsoever. I never received receipts from [AA J] for withdrawing money from [Resident 1's] bank account or for the online purchase she made for [Resident 2], and I should have. During an interview on 12/18/25 at 12:50 pm, Resident 2 stated, Yes, I remember [AA J], she quit. Yes, she did order me coffee creamer. She ordered two bottles of French vanilla. That's the creamer I like to use in my coffee. I gave her [AA J] my bank debit card. She uploaded my bank card number onto her personal [on line shopping website] to order it. I didn't know I wasn't supposed to do that. I just talked to [Admin B] about this. Resident 2 added that she was not sure if she had received a receipt for the coffee creamer, but then her debit card came up missing and she had called the bank and cancelled the card immediately.During a phone interview on 12/19/25 at 8:41 am, Admin A stated, Yes, I remember the investigation of [Resident 1]. I tried to finish it before I left the facility, and I was told that the next administrator would do it. I confirm the investigation had not been completed for Resident 1 and it was late. I immediately suspended [AA J] until I could gather more information. I was never asked to reimburse money for [Resident 1's] going home party by [AA J]. I would never expect any residents to pay for their own party. I remember she did have a party. We have funds for all activities. I was there the day of the party. We have a money policy. No staff member can take any money from any resident for any reason. A review of an undated witness statement written by AA O indicated, Witness Statement. I am providing this statement regarding incidents I personally observed involving [AA J] and [Resident 1]. On multiple occasions, I witnessed [Resident 1] give money directly to [AA J] and her daughter [who is a volunteer]. I also overheard [AA J] and her daughter discussing the money that had been given to them by [Resident 1]. These are my personal observations, and this statement reflects what I directly witnessed and heard. During an interview on 12/23/25 at 8:50 am, AA O confirmed she had written the above statement regarding witnessed 055489 Page 3 of 6 055489 12/24/2025 Shasta View Care Center 1795 Walnut Street Red Bluff, CA 96080

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interactions between AA J and Resident 1. During an interview on 12/23/25 at 12:20 pm, Certified Nursing Assistant (CNA) M stated, I did hear [AA J] complain about the Activity budget a lot. I did hear residents gave her money to fund the activity budget. I do know [Resident 1] used her own money for some of the supplies. Some of the residents that used their money are no longer here, they're discharged . [AAJ] used to complain to all the residents. It did upset the residents to hear her complaints. Some residents only wanted to do activities with [AA J], so she could get more hours. A review of an email sent to Activity Supervisor (AS), by AA P, dated 11/12/25, titled, To Whom It May Concern, indicated the following, [AA J] is telling residents that she is getting less hours for work and that she is being overworked when she does come into work are unnecessary conversations to have with the residents. These are not concerns for the residents to have for her. If she has concerns about scheduled hours or that she's given too much to handle at once, she should be talking to her manager and not the residents. The residents have nothing to do with that aspect of her work. [AA J] sharing has caused residents to be uncomfortable, stressed out and unwilling to participate in activities when it's not [AA J] who leads those activities for the day. [AA J] is informing residents that she spends money out of her own pocket to provide for materials because the facility is not providing or doesn't have funds to provide. She says the facility lacks funding for materials to run activities for the residents. Again, this is unnecessary information to disclose to the residents. The budget on materials for activities shouldn't be something to share with the residents. Residents should not have to worry about the facilities funds. When [AA J] is telling residents about these things, it makes it difficult for employees to work with them. There shouldn't be conflict between employees and residents, and this is what is being caused because of how [AA J] is involving residents and things they should not have to worry about. Can someone please follow up. It would be greatly appreciated. During an interview on 12/23/25 at 9:35 am, AS confirmed she received the above email from AA P. AS stated, I did send the email up the chain of command, but nothing was done. AS indicated that she had already ordered the coffee creamer for Resident 2, and had informed AA J of this, but AA J took Resident 2's bank card and uploaded it to her personal online shopping site anyway. AS indicated that the creamer for Resident 2 was delivered to AA J's home. AS stated that was a violation of the facility's money policy. During an interview on 12/23/25 at 12:45 pm, AA P confirmed he had sent an email to AS on 11/25/25. AA P indicated that AA J was always talking about her personal problems in front of the residents. She would say things like we don't have specific supplies we need, and I have to pay out of my own pocket. It's not fair. They need to give us a bigger budget. These comments would upset the residents and then the residents would mention it to us. The residents felt sorry for her. A facility disciplinary action document for AA J titled, Violation of Facility Resident Finance Policy, dated 11/28/25, was reviewed. The document indicated; Date of Violation 11/23/25. Nature of violation: Conduct, uncooperative, carelessness, and disobedience. Final written warning. 3-day suspension effective 11/28/25. Admin B documented on 11/28/25, Employee walked out of discussion meeting, said that she is done and not going to work. We will get a written statement of resignation/Admin to term. During an interview on 12/24/25 at 8:54 am, with Regional Registered Nurse Consultant, she confirmed the facility's Transactions Involving Resident Funds policy was violated by AA J for Residents 1 and 2. 055489 Page 4 of 6 055489 12/24/2025 Shasta View Care Center 1795 Walnut Street Red Bluff, CA 96080

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate a financial abuse allegation and report the results of their investigation within five (5) days to the California Department of Public Health (CDPH) for one of five sampled Residents. (Resident 1)Refer to F600 This failure had the potential to result in further financial abuse to other residents.Findings: The facility's policy revised 2025 titled, Abuse, Neglect and Exploitation, was reviewed and indicated, Investigation of Alleged Abuse, Neglect and Exploitation, will include the following: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations that are included: Identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); Investigation of different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and provide a completed and thorough documentation of the investigation.The facility's policy revised 2025 titled, Abuse, Neglect and Exploitation, was reviewed and indicated it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. A review of Resident 1's record indicated she had been admitted to the facility on [DATE] with diagnoses that included osteomyelitis of cervical vertebra (an infection of the neck bones causing severe pain, stiffness, and can lead to numbness or weakness), acute respiratory failure with hypoxia (sudden loss of oxygen needed in the blood making it hard to breathe), pressure ulcer of sacral region stage 4 (a severe, open sore on the tailbone area that involves full-thickness tissue loss, extending through skin and fat to expose muscle, tendon, ligaments, or even bone), diabetes (too much sugar in the blood), chronic pain (long standing pain that persists), Bi-polar disorder (a mental health condition causing extreme mood swings), attention deficit hyperactivity disorder (condition that makes it hard to manage your attention, control impulses, leading to challenges with focus, organization, and self-control in daily life), history of deep vein thrombosis embolism (DVT, is a blood clot forming in a deep vein, usually the leg) and embolism (when the blood clot or part of it breaks off, travels, and blocks a blood vessel elsewhere, most dangerously in the lungs), major depressive disorder (persistent sadness, and loss of interest), and high blood pressure. The physician noted in his admission orders that Resident 1 was capable of making healthcare decisions and was listed as her own responsible party (RP). During a review of Resident 1's most recent Minimum Data Set, (MDS, a resident assessment), dated 8/31/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a test of memory and decision making abilities) score of 15 of 15 and was cognitively intact (able to think and reason). During a review of a facility document titled, Facility, dated 10/29/25, indicated CDPH received a verbal report of an allegation of financial abuse on 10/30/25 at 8:37 am to Resident 1 by the facility's Activity Assistant (AA) J. A 5 day report of the results of the facility's abuse investigation should have been submitted to CDPH by 11/3/25. During a review of the facility's document titled, Update for Facility Reported Event dated 11/5/25, indicated CDPH received the facility's 5 day abuse investigation results report on 11/5/25 at 2:42 pm, two days late, from the facility. The report indicated, [AA J] will be in-serviced regarding receiving money from residents and that will go in her employee file. The facility will reimburse [Resident 1] $300.00. During an interview Residents Affected - Few 055489 Page 5 of 6 055489 12/24/2025 Shasta View Care Center 1795 Walnut Street Red Bluff, CA 96080

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 12/18/25 at 12:03 pm, Administrator (Admin) B confirmed the investigation of alleged abuse by AA J towards Resident 1 was submitted late to CDPH. Admin B stated, I entered the facility on 11/3/25, and the report was dated 11/5/25. It was only a few days late. During a follow up interview on 12/18/25 at 12:25 pm, Admin B confirmed the facility had not reimbursed Resident 1 the $300 as they indicated in their 5 day abuse allegation investigation results on 11/5/25. Admin B stated, I did not substantiate the abuse. I didn't have any proof that it happened. There was no written contract statement, it was a verbal agreement if she wanted [AA J] to cook meals. [Resident 1] confirmed there was a car problem or a delay, but I have no proof. [AA J] explained she needed to replace her tires and there was a conversation between them both, so I cannot substantiate it. During an interview on 12/18/25 at 1:55 pm, the Director of Nursing (DON) confirmed the abuse allegation for Resident 1 was not complete or thorough. DON stated, I confirm the investigation was no complete, we need more witnesses and more interviews. During a concurrent interview and record review of the facility's Abuse Policy part V: A and B, page 4 (Investigation of Alleged Abuse, Neglect and Exploitation), on 12/18/25 at 2:03 pm, Admin B confirmed the investigation of the abuse allegation of Resident 1 was not complete and did not follow their facility's abuse policy instructions to provide complete and thorough documentation of the investigation.During an phone interview on 12/18/23 at 2:10 pm, Family Member (FM) of Resident 1 stated, No one has called or contacted me from the facility to ask what I knew about [AA J] taking money from [Resident 1] and not providing promised services. During a phone interview on 12/18/25 at 3:11 pm, Resident 1 indicated that she was never reimbursed any money by the facility or contacted by the facility regarding the abuse allegation or the results of their investigation. During a phone interview on 12/19/25 at 8:41 am, Admin A stated, Yes, I remember the investigation of [Resident 1]. I tried to finish it before I left the facility, and I was told that the next administrator would do it. I confirm the investigation had not been completed for Resident 1 and it was late. I immediately suspended [AA J] until I could gather more information. I was never asked to reimburse money for [Resident 1's] going home party by [AA J]. I would never expect any residents to pay for their own party. I remember she did have a party. We have funds for all activities. I was there the day of the party. We have a money policy. No staff member can take any money from any resident for any reason. During an interview on 12/23/25 at 10:25 am, the Regional Registered Nurse Consultant stated, I confirm this was not a proper or complete investigation. [AA J] should have never been allowed to come back to the facility until this allegation was thoroughly investigated. I also confirm [AA J] never had the one on one abuse training as the report indicated that was sent to [CDPH]. The last abuse training for [AA J] was completed in August 2024. During an interview on 12/23/25 at 11:10 am, DON confirmed the abuse investigation was not thorough. DON stated, I have a list of all the names of the alert and oriented residents I interviewed on 12/20/25, which should have been part of the documentation for this investigation of alleged financial abuse. 055489 Page 6 of 6