Health inspection·September 12, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure safe discharge for one of two residents sampled (Resident 1), when Resident 1 chose to leave the facility Against Medical Advice, (AMA, when the physician does not agree with the resident leaving the facility because of their medical condition) and the facility failed to ensure;1. There was a physician's order to discharge Resident 1 AMA.2. Discussion and documentation was done with Resident 1 of alternatives to discharging AMA to the location to which Resident 1 discharged .3. An Against Medical Advice form (A form that a resident signs acknowledging understanding of the consequences for leaving the facility AMA), was not offered to Resident 1.4. A facility investigation was done and an Adult Protective Services (A government service to protect vulnerable individuals in the community from abuse, neglect and exploitation) report filed.These combined failures resulted in Resident 1 not being informed by the facility of the consequences of leaving the facility AMA and Resident 1 was admitted to the acute care hospital within two days after leaving the facility, with an infection. Findings:1.Review of a facility policy titled, Discharging a Resident without a Physician's Approval, revised October 2022 indicated, A physician's order is obtained for discharges, unless a resident or representative is discharging himself or herself against medical advice, 3. If the resident or representative (sponsor) requests discharge without the approval of the attending physician, the resident and/or representative (sponsor) will be asked to sign a release of responsibility form. 4. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and will: a. discuss with the resident, (and/or his or her representative, if applicable) and document the implication and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; b. document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; c. document that despite being offered other options that could meet the resident's needs, the resident refused those more appropriate settings; d. determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge. Review of the admission record for Resident 1, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included a sacrum fracture (a break in the large triangular 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 Brief Interview for Mental Status (BIMS), score of 12 out of 15 which indicated that Resident 1 had good memory and decision making skills. Review of Resident 1's record titled, Physician Order Report: 7/2/25 to 8/20/25 indicated that there was no physician's order Page 1 of 10 055807 055807 09/12/2025 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 055807 Page 2 of 10 055807 09/12/2025 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure the care plan (a document that outlines a patient's health care needs and the actions and interventions required to address them), was revised and updated when one of two sampled residents (Resident 1), had a pressure injury (PI, a bedsore) that worsened and the care plan had not reflected this.This failure resulted in no identified problem, goals or interventions to promote the healing of Resident 1's PI to her sacrum (the large triangular bone at the base of the spine), and inconsistencies and delayed treatments of Resident 1's PI, which had a negative impact on her clinical status.Findings:Review of a facility policy titled, Goals and Objectives, Care Plans revised April 2009, indicated, 5. Goals and objectives are reviewed and/or revised: a. when there has been a significant change in the resident's condition.Review of the National Pressure Injury Advisory Panel's (a nationally recognized professional resource for the staging and treatment of pressure injuries a global driver of quality improvement and patient safety in healthcare) website document titled, NPIAP Pressure Injury and Stages, at https://npiap.com, dated September 2016 indicated;-Stage 1 pressure injury: non-blanchable (skin redness or discoloration that does not fade or turn white when pressure is applied) erythema (reddening of the skin), which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes.-Stage 2 pressure injury: partial-thickness skin loss with exposed dermis (the middle, living layer of the skin, located between the outermost epidermis and the innermost hypodermis).Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (thick stringy yellow infected tissue or eschar (black dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. -Stage 3 pressure injury: full-thickness loss of skin, in which adipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough (dead tissue, usually moist and stringy) and/or eschar (dead tissue that is hard or soft) may be visible. If slough or eschar obscures the extent of tissue loss this is and Unstageable Pressure Injury.-Stage 4 pressure injury: full-thickness loss of skin and tissue with exposed Fascia (a thin fibrous connective tissue that surrounds and supports all muscles, organs, and other structures in the body), muscle, tendon (a tough, fibrous cord-like tissue that connects muscles to bone) ligament (a tough, fibrous band of connective tissue that connects two bones together, providing stability and support to joints), cartilage (a smooth, elastic connective tissue that provides support and protection to joints, bones, and other tissues in the body) in the injury. Slough or eschar may be visible. Epibole, undermining (the destruction of tissue or injury extending under the skin edges so that the pressure injury is larger at its base than at the skin surface) and/or tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) often occur.Review of the admission record for Resident 1 indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including sacrum fracture (a break in the large triangular bone at the base of the spine), and was not admitted with any PIs.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. 055807 Page 3 of 10 055807 09/12/2025 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 055807 Page 4 of 10 055807 09/12/2025 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. Within two days of Resident 1 discharging from the facility, she was admitted to the acute care hospital for an infected PI and sepsis (an infection in the bloodstream) and osteomyelitis of the sacrum (an infection in the bone). This failure had the potential to delay wound healing for any resident who had wounds and/or PI's and subject them to substandard quality of care.Refer to F726 Findings:Review of the National Pressure Injury Advisory Panel's (a nationally recognized resource for professionals), website document titled, NPIAP Pressure Injury and Stages, at https://npiap.com, dated September 2016 indicated;Stage 1 pressure injury: non-blanchable (skin redness or discoloration that does not fade or turn white when pressure is applied) erythema (reddening of the skin), which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes.Stage 2 pressure injury: partial-thickness skin loss with exposed dermis (the middle layer of the skin). The wound bed is visible, pink, or red, moist and may also present as an intact or ruptured serum-filled blister (a raised pocket of skin filled with fluid, caused by skin injury from friction (rubbing), heat, or certain diseases). Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue may be visible (a type of new, temporary tissue that forms during the wound healing process). These injuries commonly result from adverse microclimate (temperature and moisture on the skin), and shear in the skin (injury that occurs when skin layers are pulled in opposite directions, damaging tissues, and blood vessels beneath the skin).Unstageable Pressure Injury: Obscured (hidden or difficult to see) full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (thick stringy yellow or gray dead tissue or eschar (black, brown or tan scab-like dead tissue attached firmly to the wound). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stage 3 pressure injury: full-thickness loss of skin, in which adipose is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Undermining (the destruction of tissue or injury extending under the skin edges so that the pressure injury is larger at its base than at the skin surface), and tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) may occur. Fascia (a thin fibrous connective tissue that surrounds and supports all muscles, organs, and other structures in the body), muscle, tendon (a tough, fibrous cord-like tissue that connects muscles to bone), ligament (a tough, fibrous band of connective tissue that connects two bones together, providing stability and support to joints), cartilage (a smooth, elastic connective tissue that provides support and protection to joints, bones, and other tissues in the body), are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.Stage 4 pressure injury: full-thickness loss of skin and tissue with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the injury. Slough or eschar may be visible. Epibole, undermining (tissue separation that creates a pocket of dead space), and/or tunneling often occur.According to the NIH National Library of Medicine (a nationally recognized professional Residents Affected - Few 055807 Page 5 of 10 055807 09/12/2025 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0686 Level of Harm - Actual harm Residents Affected - Few resource for healthcare providers), website at www.ncbi.nlm.nih.gov, dated 1/3/2024, the most common problem with Stage 3 and Stage 4 pressure injuries is infection. Bacteria in the pressure ulcer wound spreads to deeper tissues and bone causing sepsis (infection in the bloodstream) and osteomyelitis (infection in the bone). Older patients with pressure injuries have a 3.6-fold increased mortality (death) rate. Managing pressure injuries should always be done with an interprofessional approach such as consulting with a general surgeon, a wound care physician (a physician who specializes in wound care), or a dermatologist (a physician who is an expert on skin care).Review of a facility policy titled, Change in a Resident's Condition or Status revised February 2021, indicated, 1. The nurse will notify the resident's attending physician or physician on call when there has been a: d. significant change in the resident's physical/emotional/mental condition.Review of the admission record for Resident 1, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included a fractured (broken) sacrum bone (the large triangular bone at the base of the spine). Resident 1 discharged from the facility, on 8/11/25. Review of Resident 1's admission Minimum Data Set (MDS, a federally mandated assessment that measures the health status in nursing home residents), dated 7/11/25, and completed by MDS/Registered Nurse (MDS/RN), indicated under Section C Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment of a resident's memory and decision-making skills and uses a scoring system of 0-very impaired to 15-no impairment). Resident 1 scored 12 of 15, which indicated Resident 1 had no memory or decision-making problems. Section M indicated Resident 1 was admitted without a PI.Review of Resident 1's progress note, dated 7/24/25, written by Wound Care Nurse/Registered Nurse (WCN/RN) indicated, Wound Rounds for week of 7/20/25 - 7/24/25: Late last week noted skin discoloration over sacrum that resembled wounding under wrinkled skin. This week, however, noted discolored areas beginning to break down. Upon closer inspection, characteristics of breakdown resembles stage 1 pressure injury. Exposed tissue coated with yellow fibrotic residue. There was no documentation that the WCN/RN notified Resident 1's Attending Physician (AP) of this change in the condition of Resident 1's PI.A 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. There was no documentation that RN A had notified Resident 1's AP, that Resident 1's PI had worsened.A review of Resident 1's progress note, dated 7/28/25, written by RN A indicated, Wound is getting worse. There was no documentation that RN A had notified Resident 1's AP that the PI had worsened.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 when there was a change of condition and Resident 1's PI began to worsen. RN A stated that she notified the WCN/RN, instead of Resident 1's AP, because the WCN/RN would decide what changes needed to be reported to the AP. A review of Resident 1's record titled, Wound Management Detail Report dated 7/24/25 to 8/11/25, documented by the WCN/RN indicated the following; On 7/24/25, Resident 1 had a PI on her sacrum that measured (length by width), 6.5 centimeters (cm, 2.5 cm equal approximately 1 inch) by 4 cm and was a Stage 2 with no tract/tunneling present, and a light amount of seropurulent exudate (watery pus that is cloudy, yellow or tan and is a sign of infection), that was yellow, or tan, cloudy and thick. The report had not indicated that Resident 1's AP was notified.On 7/30/25, Resident 1's sacrum PI worsened to 7 cm by 3.5 cm, and was Unstageable with slough and eschar, no tract/tunneling present and a light amount of seropurulent exudate that was yellow, or tan, cloudy and thick. The report had not indicated that Resident 1's AP was notified of this change from a Stage 2 PI to an Unstageable PI.On 8/3/25, Resident 1's sacrum PI continued to worsen and measured of 7.3 cm by 3.5 cm, and was Unstageable with slough and eschar, no tract/tunneling or undermining present, and a moderate amount of seropurulent exudate (increased seropurulent drainage-a sign that the wound was 055807 Page 6 of 10 055807 09/12/2025 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0686 Level of Harm - Actual harm Residents Affected - Few becoming infected), that was yellow, or tan, cloudy and thick. The report had not indicated that Resident 1's AP was notified.On 8/11/25, the WCN/RN documented that she performed Conservative Sharp Wound Debridement (CSWD, a procedure where dead tissue is removed from a PI by using sharp instruments such as a scalpel, scissors and forceps), on Resident 1's sacrum PI. WCN/RN documented, CSWD completed.with scissors/forceps, then using forceps with #15 [number 15, the size of a scalpel blade], scalpel blade, sm-mod [small to moderate], amount slough removed. Documentation reflected that Resident 1's PI then measured, 6 cm by 2.5 cm, and was a Stage 4 with undermining that measured 2.6 cm and a heavy amount of seropurulent exudate (increased sign of infection), that was yellow, or tan, cloudy and thick. There was no documented evidence that Resident 1's AP was notified of the change in the condition of Resident 1's PI, or that CSWD procedure had been done.During a review of Resident 1's record titled, Physician Order Report: 7/2/25 - 8/20/25, the record indicated that there were no orders for the WCN/RN to perform a CSWD on Resident 1's PI.A review of a facility document titled, Physician Notification & Orders dated 7/30/25, indicated that six days after Resident 1's PI was determined to be a Stage 2 (identified on 7/24/25), AP was notified but at that point, on 7/30/25, Resident 1's PI had already worsened to an Unstageable PI. There were no other Physician Notification & Orders notification documents for Resident 1.During a concurrent interview and record review of Resident 1's record titled, Physician Order Report: 7/2/25 -8/20/25 on 8/20/25 at 2:38 p.m., with the Director of Nursing (DON), the DON confirmed that there was a six-day delay, from 7/24 to 7/30/25, in notifying Resident 1's AP and getting orders for treatment and during that time, Resident 1's PI had worsened from a Stage 2 to an Unstageable PI. DON confirmed that RN A should have notified Resident 1's AP on 7/24/25, when she identified that Resident 1's PI was worsening. DON confirmed the WCN/RN had not notified Resident 1's AP when she identified that Resident 1's PI had progressed from a Stage 2 to an Unstageable PI and finally to a Stage 4. DON confirmed that WCN/RN had not obtained a physician's order prior to performing the CSWD on Resident 1's PI.During an interview on 8/22/25 at 10:33 a.m., with WCN/RN, the WCN/RN confirmed that Resident 1 was admitted without a PI. WCN/RN confirmed that Resident 1 acquired a Stage 2 PI while in the facility on 7/24/25, and the PI was not healing and worsened to a Stage 4 within 18 days. WCN/RN confirmed that she had not reached out to Resident 1's AP at any time during the deterioration of Resident 1's PI, to consider referring Resident 1 to their wound care physician for an evaluation and stated she did not think it was necessary. WCN/RN confirmed that RN A should have notified Resident 1's AP when she determined that Resident 1's PI was worsening on 7/24/25, instead of waiting for WCN/RN to make her weekly visit, because this delayed treatment. WCN/RN confirmed Resident 1's PI had already deteriorated from a Stage 2 to an Unstageable PI by the time her AP was notified and orders were obtained for treatment. During a second interview on 9/9/25 at 9:42 a.m., with WCN/RN, the WCN/RN confirmed that she had not obtained a physician's order to perform the CWSD on Resident 1's PI on 8/11/25. WCN/RN stated she did not need a physician's order to perform CSWD. The WCN/RN stated she could not recall whether or not she had notified Resident 1's AP each time Resident 1's PI worsened and was not showing signs of healing or that the PI was possibly infected. WCN/RN stated that she did not have direct communication with Resident 1's AP. During a phone interview on 8/22/25 at 10:47 a.m., with Resident 1's AP, AP confirmed the facility had a wound care physician available that they could consult with. AP stated, I believed that [Resident 1's] wound care was very routine and she did not need the to see wound care physician. The AP indicated she thought Resident 1 still had only a Stage 2 PI.During a second phone interview on 9/9/25 at 1:01 p.m., with AP, she indicated that she did not know about the progressive worsening and lack of healing to Resident 1's PI. AP stated that the WCN/RN and DON do not usually notify her 055807 Page 7 of 10 055807 09/12/2025 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0686 Level of Harm - Actual harm Residents Affected - Few 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. 055807 Page 8 of 10 055807 09/12/2025 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure nursing staff demonstrated competency in following the facility's policies in regard to wound care management and changes in resident conditions for one of two sampled residents (Resident 1) when;1.Registered Nurse (RN) A and Wound Care Nurse/ RN (WCN/RN), had not notified Resident 1's physician that Resident 1's sacrum (base of the spine) pressure injury (PI-a bedsore), had worsened. 2.WCN/RN performed conservative sharp wound debridement (CSWD, an invasive procedure to remove dead tissue from a PI using sharp instruments such as a scalpel (knife), scissors, and forceps (tweezers)), to Resident 1's PI, without a physician's order. These cumulative failures caused in a delay in the treatment and healing of Resident 1's PI and caused the PI to worsen. Subsequently, Resident 1 was hospitalized within two days after she left the facility, for sepsis (an infection in the blood stream) and osteomyelitis of the sacrum (an infection in the sacrum bone). This had the potential to negatively affect all residents who required care to heal wounds.Refer to F686 Findings:Review of a facility policy titled, Change in a Resident's Condition or Status revised February 2021 indicated, 1. The nurse will notify the resident's attending physician or physician on call when there has been a d. significant change in the resident's physical/emotional/mental condition. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted.Review of the National Pressure Injury Advisory Panel's (a nationally recognized professional resource for the staging and treatment of pressure injuries a global driver of quality improvement and patient safety in healthcare) website document titled, NPIAP Pressure Injury and Stages, at https://npiap.com, dated September 2016 indicated;-Stage 1 pressure injury: non-blanchable (skin redness or discoloration that does not fade or turn white when pressure is applied) erythema (reddening of the skin), which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes.-Stage 2 pressure injury: partial-thickness skin loss with exposed dermis (the middle, living layer of the skin, located between the outermost epidermis and the innermost hypodermis).Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (thick stringy yellow infected tissue or eschar (black dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. -Stage 3 pressure injury: full-thickness loss of skin, in which adipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough (dead tissue, usually moist and stringy) and/or eschar (dead tissue that is hard or soft) may be visible. If slough or eschar obscures the extent of tissue loss this is and Unstageable Pressure Injury.-Stage 4 pressure injury: full-thickness loss of skin and tissue with exposed Fascia (a thin fibrous connective tissue that surrounds and supports all muscles, organs, and other structures in the body), muscle, tendon (a tough, fibrous cord-like tissue that connects muscles to bone) ligament (a tough, fibrous band of connective tissue that connects two bones together, providing stability and support to joints), cartilage (a smooth, elastic connective tissue that provides support and protection to joints, bones, and other tissues in the body) in the injury. Slough or eschar may be visible. Epibole, undermining (the destruction of tissue or injury extending under the skin edges so that the pressure injury is larger at its base than at the skin surface) and/or tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) often occur.According to California State regulations 055807 Page 9 of 10 055807 09/12/2025 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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] 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], 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. 055807 Page 10 of 10