Health inspection·March 3, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that staff responded in a timely manner to residents' requests for assistance for one of four sampled residents, (Resident 1), when call-lights were not answered for greater than 20 minutes multiple times. These failures had the potential to negatively impact residents' physical, emotional and psychosocial well-being and left Resident 4 feeling unfairly treated. Findings: During a review of the facility policy titled, Resident Rights dated 5/2010, the policy indicated that 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity . Review of admission records for Resident 4 indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including depression, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), diabetes, insomnia, high blood pressure, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue), muscle weakness. A review of Resident 4's Minimum Data Set (MDS, an assessment tool), Resident 4 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) of 13 out of 15, which indicated she was able to make her own decisions. During an interview on 2/27/25 at 11:38 AM, with Resident 4, Resident 4 stated that she frequently had to wait for the call light to be answered for a long time. Resident 4 stated that this made her feel that facility staff were being unfair to her. During a concurrent interview and record review on 2/28/25 at 11:56 AM, with the Director of Staff Development (DSD) of call light logs for Resident 4 for 2/14/25 to 2/28/25 indicated 54 instances of call light responses being 20 minutes or longer. The longest wait time being 1 hour occurring on 2/16/24, 2/17/25, 2/18/25, and 2/20/25. The DSD stated that staff are expected to answer call lights as soon as possible. Page 1 of 3 056222 056222 03/03/2025 Marquis Care at Shasta 3550 Churn Creek Rd. Redding, CA 96002

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, and record review, the facility failed to review and revise the care plan for one of four sampled residents (Resident 4), when Resident 4 had an unintentional significant weight loss of 5 percent (%) in one month. This failure had to potential for Resident 4 to have unwanted weight loss and negatively impact his physical well-being. Findings: Review of admission records for Resident 4 indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including depression, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), diabetes, insomnia, high blood pressure, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue), muscle weakness. Review of the facility's policy titled, Weight Assessment and Intervention dated 5/2018, indicated, 3. Any weight change of 5 pounds or more since the last weight assessment .will be retaken the next day for confirmation , 4. The Dietitian will respond either in person, phone consult or through electronic consult , 1 month – 5% wt loss is significant . , 2. Individualized care plans shall address .a. The identified causes of weight loss, b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . During an interview on 2/27/25 at 11:38 AM, with Resident 4, Resident 4 indicated that she had lost weight and wanted to gain some weight back. During a review of Resident 4's meal monitoring documentation for 1/29/25 to 2/27/25 indicated that out of 86 meals, Resident 4 consumed 25% or less of the meals 63 times. During a review of Resident 4's Weights and Vitals Summary, the document indicated Resident 4 weighed in on the following dates: 1/14/25 175.8 lbs 1/21/25 173.3 lbs 2/4/25 171 lbs 2/11/25 167.3 Additionally, the document noted, MDS: -5.0% change over 30 day(s) [Comparison Weight 01/14/2025, 176.0 lbs, -5.1%, -9.0 lbs] During a review of Resident 4's Dietary admission dated 9/24/24, the document indicated that Resident 4 had lost weight and, Resident stated she has lost a significant amount of weight and would like 056222 Page 2 of 3 056222 03/03/2025 Marquis Care at Shasta 3550 Churn Creek Rd. Redding, CA 96002

F 0657 to gain some back and that her nutritional goal was To gain some weight back . Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 2/27/25 at 2:14 PM, with the Registered Dietitian (RD), the RD stated that Resident 4's weight loss was considered a significant weight loss. The RD stated that she had not spoken to Resident 4 about the weight loss. The RD confirmed that Resident 4's care plan had not been revised to reflect Resident 4's significant weight loss. Residents Affected - Few During a concurrent interview and record review on 2/28/25 at 8:51 AM, with the Resident Care Manager (RCM), the RCM stated that the facility usually re-weighs residents after a weight change to confirm that the resident's weight actually changed. The RCM stated that Resident 4 had not allowed them to re-weigh her, so they didn't know for sure if there was a weight loss. Review of the facility's document titled, NAR (Nutrition At Risk) no date, the document indicated that, Every morning review weights and vitals portal. Weekly run a weights and vitals summary report and review , If a weight change of 5# [pounds] or more has occurred- need reweigh-within 24 hours . The document was in flow chart form and gives two options, either the reweigh confirms the weight loss or the reweigh does not confirmed the weight loss. There is no option for how to proceed in the flow chart if the resident refuses to be weighed. During an interview on 2/28/25 at 9:49 AM, with the facility Administrator (ADM), the ADM confirmed that there should have been a care plan item that reflected Resident 4's significant weight loss. 056222 Page 3 of 3