Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shasta Healthcare during CMS and state inspections, most recent first.
Food storage and sanitation practices were not followed when a partially used gallon of milk, bread, and jelly packets were left undated, food and single-service items were stored on the floor, and baking pans had crusty debris. The red and green cutting boards had cuts in their surfaces, and the ice machine chute and storage bin were observed with residue; the CDM and Maint confirmed the findings.
A resident with mild cognitive impairment and poor decision-making ability was documented as lacking capacity, with the MD listed as surrogate decision-maker. Facility policy required an IDT for treatment decisions when a resident could not provide informed consent and had no health care decision-maker, but the MD stated she was not required to attend IDT meetings, and the DON and Admin said no IDT meetings were held for this resident while the MD made the decisions.
A resident's Albuterol inhaler was kept at the bedside with a physician order allowing bedside storage, but the IDT had not documented an assessment or approval of the resident's ability to safely self-administer it. An LN confirmed the inhaler was at the bedside, and the DON confirmed there was no IDT note in the EMR showing approval for self-administration.
Resident rights were not discussed during Resident Council meetings. A review of council minutes showed no rights discussions, and five residents interviewed said rights were not reviewed with them. The AD, who attended the meeting at residents' request, confirmed rights had not previously been discussed.
Survey Results Not Readily Accessible to Residents: The facility failed to make the most recent recertification survey available to residents. During a Resident Council interview, attendees said they did not know where to find survey results, and the DON confirmed the survey results binder was kept in the foyer in an unlabeled binder on a shelf, where residents who could not open the interior doors would be unable to access it without help.
Missed bathing and inadequate nail care: Two residents did not receive needed ADL support. One resident with muscle weakness and a BIMS of 15/15 missed scheduled showers and reported frustration and discomfort. Another resident with dementia and Parkinsonism was dependent on staff for personal care, yet had dirty, untrimmed fingernails with a dark crusted substance under them, and the LPN confirmed there was no documentation that nail care had been offered.
The facility failed to ensure that two CNAs providing resident care received annual performance evaluations. The DON and DSD confirmed that a process for annual CNA evaluations had not been implemented, and that evaluations had not been initiated for CNA B and CNA C. Record review showed CNA B’s most recent evaluation was dated years earlier, while CNA C’s most recent evaluation was also not current.
Medication administration errors exceeded the allowed rate when an observation found 3 errors in 25 opportunities. A resident with bipolar disorder did not receive ordered Depakote because the med was out, and another resident did not receive ordered Lidocaine patches because the facility was out of them. The same resident was also given Fluticasone without instructions and self-administered more sprays than ordered. The DON stated all nurses were responsible for preventing meds from running out, but ultimately the DON was responsible.
Medication Label Did Not Match Physician Order: A resident with mild cognitive impairment had Celebrex in the med cart labeled for PRN use, while the MAR/physician orders included both a scheduled daily order and a separate PRN order. An LPN confirmed there was no blister pack for the scheduled dose and said the PRN-labeled pack had always been used; the DON stated, “ideally we get a new label.”
A resident with mild cognitive impairment and poor decision-making ability was documented as lacking capacity, yet the MD was listed as the surrogate decision-maker. Facility policy required help obtaining an unaffiliated RP when a resident could not make decisions, but the resident’s sister was not used and no documentation showed that the Department of Aging obtained a patient representative. The MD stated she knew the resident for years, did not know the RP policy, and agreed to act as the resident’s decision maker.
The facility failed to maintain an in-service training program for two CNAs to address areas of weakness identified in annual evaluations and to provide the required 12 hours of continuing education, including dementia care and abuse training. The DON and DSD confirmed there was no documentation of the required training, and employee file review showed one CNA had an outdated annual evaluation with only hand hygiene and PPE training documented, while the other CNA also lacked documentation of the required annual training.
A resident who was admitted without a pressure injury developed a sacral PI that worsened from Stage 2 to Stage 4 with infection due to staff failing to notify the attending physician of changes, delaying treatment, and performing wound debridement without physician orders. The lack of timely communication and adherence to wound care protocols led to the resident's hospitalization for an infected PI, sepsis, and osteomyelitis, and the resident later died in the hospital.
A resident with a sacrum fracture and Stage 4 pressure injury left AMA to a location three hours away without a physician's order, proper documentation, or discussion of risks and alternatives. The facility did not offer an AMA form, failed to notify the physician or APS, and did not document or discuss safer discharge options. The resident was hospitalized with an infection shortly after leaving.
A resident developed a pressure injury that progressed from Stage 2 to Stage 4 with infection, but the care plan was not updated to reflect these changes or necessary interventions. Despite facility policy requiring care plan revisions after significant changes in condition, the care plan remained outdated, leading to inconsistent and delayed treatment.
Nursing staff did not notify the physician when a resident's sacral pressure injury worsened and performed conservative sharp wound debridement without a physician's order. The wound progressed from Stage 2 to unstageable and then to Stage 4 with infection, and the resident was later hospitalized for sepsis and osteomyelitis. These actions were not in accordance with facility policy or state regulations.
A resident with multiple medical conditions, who was cognitively intact, was subjected to verbal abuse when a CNA admitted to using inappropriate language out of frustration. The incident was reported to the DON, who confirmed the staff member's admission and the facility's policy requiring respectful treatment of residents.
The facility failed to implement its Legionella Water Management Program, with no recent water testing conducted. Additionally, an LVN did not follow hand hygiene and medication handling protocols, handling medications with bare hands and administering pills that fell on the cart to a resident with a history of hypertension and anxiety.
A facility failed to secure a computer screen on a medication cart, leaving residents' PHI visible. The nurse responsible was not present, and the cart was unattended. Staff interviews confirmed the policy to lock screens, but it was not followed, resulting in a breach of confidentiality.
The facility failed to prepare for a scheduled EMR outage, resulting in the inability to access MARs, TARs, and Physician's Orders for 41 residents. Nursing staff could not administer medications or treatments, leading to residents missing critical medications. The administration admitted to not having a backup system or policy for such outages, and outdated paper charts compounded the issue.
A resident with dementia and a history of wandering was not properly assessed or monitored for elopement risks in an LTC facility. Despite multiple elopements, including one where the resident was found injured near a highway, the facility lacked a formal system to monitor at-risk residents. The alarm system was inadequate, and staff failed to provide consistent supervision, contributing to the resident's repeated elopements.
Food Storage and Sanitation Deficiencies
Penalty
Summary
Food safety and sanitation guidelines were not followed in the kitchen and storage areas. During a kitchen tour, the Dietary Aid confirmed there was a gallon of milk in the refrigerator that had been partially used but was not dated upon opening. The Certified Dietary Manager also confirmed there was an undated bag of bread and an undated box of individual jelly packets in the dry goods storage area. In addition, a box of potatoes was stored on the floor of the dry goods storage area, and a box of paper dining napkins was stored on the floor of an outdoor storage area. The Certified Dietary Manager further confirmed there was brown crusty debris on baking pans and that the red and green cutting boards had cuts in their surfaces. During a concurrent observation, interview, and record review, the Maintenance Director confirmed there was a pale brown substance on a clean white paper towel used to wipe the inside of the ice machine's ice chute and that the inside of the ice storage bin was not clean. Facility records showed the ice machine had last been cleaned on 11/21/25, with prior cleanings documented on 8/23/25, 5/22/25, and 2/20/25.
Failure to Ensure IDT Participation for Resident Decision-Making
Penalty
Summary
The facility failed to ensure that one resident’s representative had the ability to exercise the resident’s rights by having an Interdisciplinary Team (IDT) meeting with all team members present when decisions were being made for Resident 8. The report states that Resident 8 was admitted with diagnoses including mild cognitive impairment, and the quarterly MDS BIMS completed by the Social Services Director showed a score of 6 out of 15, indicating poor decision-making ability. The resident’s health record also included Special Instructions stating that the resident did not have capacity to make decisions and that the surrogate decision-maker was the MD. The facility policy titled Consent: Residents Unable to Provide Informed Consent and Without a Health Care Decision-Maker states that an IDT can make treatment decisions when a physician determines the resident is unable to provide informed consent and has no health care decision-maker. During interview, the Medical Director stated she was not required to be at IDT meetings and that the DON gathered information at the meetings and reviewed it later. The DON and Administrator later stated that there had been no IDT meetings to make decisions for Resident 8 and that the MD had been making decisions for the resident.
Bedside inhaler kept without IDT approval for self-administration
Penalty
Summary
The facility did not ensure that one resident was able to safely self-administer medication when the resident's Albuterol inhaler was stored at the bedside and available for use. The facility policy titled, Medication, Storage at Bedside, dated 1/16/26, stated that medications could only be kept at a resident's bedside if there was a physician's order and the IDT had evaluated and approved the safety of self-administration. Resident 46 was admitted on 4/14/26 with diagnoses of atrial fibrillation and hypertension. During a concurrent observation, interview, and record review on 4/23/26 at 9:09 a.m., an Albuterol inhaler was observed on the bedside table in Resident 46's room, and the LN confirmed the observation and reviewed the physician's order dated 4/16/26 allowing the inhaler to be kept at the bedside. During an interview on 4/23/26 at 11:59 a.m., the DON confirmed there was no IDT note in the resident's electronic medical record showing that the IDT had assessed or approved the resident's ability to safely self-administer the Albuterol inhaler.
Resident Rights Not Discussed in Council Meetings
Penalty
Summary
The facility did not ensure ongoing communication about resident rights during Resident Council meetings. A review of the Resident of Rights, dated 8/1/25, stated that residents had the right to be fully informed of their rights at admission and during their stay in the facility. However, review of Resident Council Minutes from 10/23/25 through 4/16/26 did not show any discussion of resident rights. During an interview on 4/23/26 at 10:01 am, five out of five confidentially interviewed residents said the facility did not discuss or review resident rights during Resident Council meetings, which are monthly meetings used to discuss care concerns and rights. The Activities Director, who was present at the Resident Council at the residents' request, confirmed that resident rights had not previously been discussed and stated, 'I haven't ever done that.'
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that the most recent recertification survey was available to residents of the facility, resulting in a violation of resident rights. During a confidential interview with the Resident Council on 4/23/26 at 10:01 am, attendees stated that they did not know where in the facility to find the results of surveys conducted at the facility. During a concurrent observation and interview on 4/23/26 at 10:37 am, the DON confirmed that the survey results binder was located in the foyer, where any resident who could not open the interior doors to the foyer would be unable to access the survey results stored in an unlabeled binder on a shelf without asking for help.
Missed bathing and inadequate nail care
Penalty
Summary
The facility failed to ensure that Resident 6 received needed bathing assistance to maintain personal hygiene. Resident 6 was admitted with diagnoses including rhabdomyolysis and generalized muscle weakness, and the MDS indicated a BIMS score of 15 out of 15 and that the resident needed partial assistance with bathing. During interview, Resident 6 stated that she did not receive a shower from 4/3/26 until 4/15/26 and reported that she normally received showers on Tuesdays and Fridays. She stated that missing the regular shower schedule made her frustrated and uncomfortable. Review of the shower tracking calendar and interview with the DSD confirmed that Resident 6 was scheduled for showers on Tuesdays and Fridays and did not receive the showers due on 4/7/26 and 4/10/26. The facility also failed to ensure that Resident 25 received needed nail care and hand hygiene. Resident 25 had diagnoses including dementia, Parkinsonism, cognitive communication deficit, and need for assistance with personal care, and the quarterly MDS indicated the resident was dependent on staff for toileting hygiene, bathing, and personal hygiene. During observation, Resident 25’s fingernails on both hands had a dark dry substance caked under them and appeared dirty and untrimmed. During interview, LN D confirmed that the nails were dirty and needed to be trimmed, that Resident 25 was dependent on staff for nail care and hand hygiene, and that nail care for dependent residents was carried out as needed or twice weekly at the time of showering. LN D also confirmed that there was no documentation that nail care had been offered.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that two of two Certified Nurse Aide (CNA) staff currently providing resident care received annual performance evaluations. During a concurrent interview and record review with the DON and DSD, both confirmed that a process to ensure all CNAs received annual evaluations had not been implemented. The DSD stated she was aware that staff performance evaluations had not been carried out annually and was unclear how long this had been ongoing, and both the DON and DSD confirmed that annual evaluations had not yet been initiated for CNA B and CNA C. Review of CNA B’s employee file showed a hire date of 6/27/11, and the most recent annual evaluation was dated 7/2/14. Review of CNA C’s employee file showed a hire date of 11/28/22, and the most recent annual evaluation was dated 8/29/24.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent when a medication administration pass observation identified 3 medication errors out of 25 opportunities, resulting in a 12 percent error rate. The report states that Resident 8, who was admitted with bipolar disorder, had a physician order for Depakote 125 mg by mouth once daily, but during a concurrent observation and interview, the nurse did not administer the medication because the resident was out of Depakote and it was on order with the pharmacy. The report also states that Resident 46, admitted with atrial fibrillation and hypertension, had a physician order for two Lidocaine 4% patches once daily, but the nurse did not provide the patches during the observation because the facility was out of them. In the same observation, the nurse handed Resident 46 Fluticasone nasal spray without verbal instructions, and the resident administered two sprays to the left nostril and three sprays to the right nostril, although the order was for one spray in each nostril once daily. The DON stated that all nurses were responsible to ensure medications did not run out, but ultimately the DON was responsible.
Medication Label Did Not Match Physician Order
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles for Resident 8. The facility’s policy on labeling and storage of drugs, dated 1/16/26, stated that medication labels would include specific directions for use and that when a label was incorrect, the medication would be returned to the pharmacy or the LN would flag the label to show a change in directions. Resident 8 was admitted on 9/29/25 with mild cognitive impairment and breakdown of internal fixation device of the right humerus. During a concurrent observation, interview, and record review on 4/23/26 at 8:39 am, LN A was observed preparing Resident 8’s morning medication. The Celebrex blister pack in the medication cart was labeled 100 mg, take one capsule by mouth daily as needed. LN A reviewed the physician’s orders and confirmed there were two separate orders for Celebrex: one for 100 mg once every morning scheduled and another for every 24 hours as needed for pain. LN A confirmed there was no blister pack in the medication cart for the Celebrex ordered daily and stated that the blister pack labeled for PRN use had always been used. During an interview later that day, the DON stated, “ideally we get a new label.”
Medical Director Served as Resident’s Decision Maker Without Unaffiliated RP
Penalty
Summary
The facility did not ensure that the Medical Director effectively implemented resident care policies for one sampled resident when it failed to obtain a resident representative who was unaffiliated with the facility. Facility policy stated that the facility was responsible for assisting residents in obtaining a representative if they could no longer make their own decisions or had no family to fill that role, and the compliance manual stated employees should not place themselves in positions involving conflicts of interest. Resident 8 was admitted with mild cognitive impairment, and later assessment showed poor decision-making ability. The resident’s record also stated that he did not have capacity to make decisions and that the surrogate decision-maker was the MD. The MD documented that the social services director informed her that the resident refused to have his sister as decision maker, and the MD then asked the resident if she could be his decision maker if he was not able to decide for himself; he agreed. The DON stated the resident did not currently have an RP and that the MD was acting as an intermediary between the resident and his sister. The MD stated she knew the resident for 15 years, did not know the facility policy on responsible parties, and did not contact the Department of Aging for a patient representative because the resident would not be able to express what he wanted to someone he did not know. The SSD believed the DON had contacted the Department of Aging, but no documentation was produced showing that a patient representative had been obtained.
CNA Training and Annual Evaluation Deficiencies
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program for two of two CNAs to ensure that deficiencies identified during annual performance reviews were addressed and to provide the required 12 hours of continuing education. During an interview and record review with the DON and DSD, both stated that the facility did not have documentation of in-service trainings meeting the annual requirement for 12 hours of training, including dementia management, abuse training, and training to address areas of weakness identified during annual evaluations. They also confirmed that a process to ensure all CNAs received annual evaluations had not been implemented. Review of employee files with the DSD and LN Con. showed that CNA B, hired 6/27/11, had a most recent annual evaluation dated 7/2/14 and the most recent training documented was hand washing and PPE use dated 4/16/25. The DSD confirmed CNA B's file did not contain documentation of the required 12 hours of training. CNA C, hired 11/28/22, had a most recent annual evaluation dated 8/29/24, and the DSD confirmed CNA C's file also did not contain documentation of the required 12 hours of training.
Failure to Prevent and Manage Pressure Injury Progression
Penalty
Summary
A resident was admitted to the facility without a pressure injury (PI) and subsequently developed a PI on the sacrum during their stay. The PI was first identified as a Stage 2 injury, but over the course of 18 days, it progressively worsened to an unstageable PI and then to a Stage 4 PI with signs of infection. Throughout this period, nursing staff, including the wound care nurse (WCN/RN) and a registered nurse (RN A), failed to notify the resident's attending physician (AP) of the changes in the PI's condition, despite facility policy requiring physician notification for significant changes in a resident's condition. Documentation showed that the AP was not informed of the PI's worsening status until six days after it was first identified as a Stage 2 injury, by which time the injury had already deteriorated further. The WCN/RN performed a conservative sharp wound debridement (CSWD) on the resident's PI without obtaining a physician's order, and there was no documentation that the AP was notified about the procedure or the continued deterioration of the wound. Interviews with staff confirmed that the AP was not kept informed of the PI's progression or the lack of healing, and the AP stated that if they had been aware of the worsening condition, they would have referred the resident to a wound care physician. The AP also confirmed that no specific orders were given for the CSWD procedure. The facility's documentation and staff interviews revealed a breakdown in communication and failure to follow established policies regarding notification and wound care management. Two days after discharge from the facility, the resident was admitted to an acute care hospital with an infected PI, sepsis, and osteomyelitis of the sacrum. Hospital records indicated that the resident's family sought hospital care due to the non-healing and foul-smelling wound. The resident passed away at the hospital ten days later. The failure to provide timely and appropriate wound care, notify the physician of significant changes, and obtain necessary orders for wound procedures directly contributed to the resident's worsened condition and subsequent hospitalization.
Failure to Ensure Safe Discharge for Resident Leaving Against Medical Advice
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who left against medical advice (AMA). The resident, who had a sacrum fracture and a Stage 4 pressure injury, left the facility with family members to a location three hours away, rather than returning to her home in a nearby town as documented. There was no physician's order for the discharge, and the medical director was not notified of the resident's departure. The discharge summary inaccurately stated the resident's destination, and the facility did not complete or offer an AMA form to the resident or her family. There was no documentation of any discussion with the resident or her family regarding the risks and implications of leaving the facility AMA or the suitability of the discharge location. The facility also failed to document any discussion of alternative, more appropriate discharge options, nor did they record that such options were offered and refused. Interviews with family members confirmed that no alternatives or consequences were explained to them prior to the resident's departure. Additionally, the facility did not conduct an investigation or determine if a referral to Adult Protective Services (APS) was necessary, as required by their policy when a resident is discharged to a potentially unsafe setting. Staff interviews confirmed that these steps were not taken, and the director of nursing acknowledged that the required notifications and documentation were not completed. The resident was admitted to an acute care hospital within two days of leaving the facility with an infection.
Failure to Update Care Plan Following Worsening Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated in response to significant changes in the resident's condition, specifically the worsening of a pressure injury (PI) to the sacrum. The resident was admitted without any pressure injuries and was cognitively intact. Initial assessments and documentation showed no PIs, but subsequent records indicated the development of a Stage 2 PI, which progressed to an unstageable PI and then to a Stage 4 PI with signs of infection, including eschar and slough. Despite these changes, the care plan was not updated in a timely manner to reflect the resident's current status, treatments, or interventions. Interviews and record reviews confirmed that the care plan had not been revised after the initial update, even as the PI worsened. The Wound Care Nurse and the Director of Nursing both acknowledged that the care plan did not reflect the resident's deteriorating condition or the necessary interventions. Facility policy required care plans to be reviewed and revised when there was a significant change in a resident's condition, but this was not followed, resulting in inconsistencies and delays in treatment for the resident's pressure injury.
Failure to Notify Physician and Obtain Orders for Wound Care Procedures
Penalty
Summary
Nursing staff failed to demonstrate competency in wound care management and in responding to changes in a resident's condition, as required by facility policy and state regulations. Specifically, a registered nurse and the wound care nurse did not notify the attending physician when a resident's sacral pressure injury worsened from Stage 2 to an unstageable wound, and later showed signs of infection. Documentation and interviews confirmed that the physician was not informed of these significant changes in the resident's condition, despite facility policy requiring such notification for significant changes. Additionally, the wound care nurse performed conservative sharp wound debridement (CSWD), an invasive procedure, on the resident's unstageable pressure injury without obtaining a physician's order. Both the wound care nurse and the director of nursing stated that they believed a physician's order was not necessary for this procedure, contrary to state regulations and facility policy, which require treatments to be administered only on the order of an authorized person. There was also no evidence that the physician was notified of the worsening wound or the procedure performed. The resident, who had been admitted with a sacrum fracture and was cognitively intact, developed a pressure injury during her stay that progressed in severity without appropriate physician notification or intervention. Within two days of leaving the facility, the resident was hospitalized for sepsis and osteomyelitis of the sacrum, conditions secondary to the infected pressure injury. These failures resulted in a delay in treatment and contributed to the worsening of the resident's wound.
Verbal Abuse of Resident by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) verbally abused a resident by using inappropriate language. The resident, who was cognitively intact and had diagnoses including diverticulitis, type 2 diabetes, depression, and complications of a colostomy, reported to the Director of Nursing (DON) that the CNA had cursed at her. The incident was documented in the resident's progress notes, and the resident expressed reluctance to discuss the matter further. An internal investigation was conducted, during which the CNA admitted to being frustrated with the resident and confirmed that she used the term 'bulls**t' when speaking to her. The facility's abuse prevention policy explicitly states that residents have the right to be free from abuse and that staff are expected to treat residents with respect. The DON confirmed the CNA's admission and acknowledged the expectation for respectful treatment of residents.
Deficiencies in Water Management and Medication Handling
Penalty
Summary
The facility failed to implement its Legionella Water Management Program as outlined in its policy. The Maintenance Director, who had been employed for a year, confirmed that he had not tested the water for Legionella, and the Director of Nursing was unable to find records of the last water testing. The Administrator admitted that the facility had changed maintenance staff and that Legionella testing was not included in their orientation, leading to uncertainty about when the last test was conducted. This oversight in water management had the potential to affect all residents in the facility. Additionally, the facility did not adhere to its hand hygiene and medication handling policies during medication administration. An LVN failed to wash or sanitize her hands before preparing medications for a resident with a medical history of hypertension, atrial fibrillation, angina, and anxiety disorder. The LVN handled medications with bare hands and administered pills that had fallen on the medication cart. Interviews with staff, including another LVN, the Infection Preventionist, and the DON, confirmed that the facility's protocols required hand hygiene and proper handling of medications, which were not followed in this instance.
Failure to Secure Medication Cart Computer Screen
Penalty
Summary
The facility failed to maintain the confidentiality of residents' protected health information (PHI) by not securing a computer screen on a medication cart. During an observation, the surveyor noted that the computer on the medication cart was left unlocked, displaying Resident #28's list of medications and other residents' PHI. The nurse responsible for the medication cart was not present, and the cart was left unattended and out of the nurse's visual field. The nurse was later found in the dining room and acknowledged that she could not see the medication cart from her location and would have another staff member lock the screen. Interviews with staff, including a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), the Director of Nursing (DON), and the Administrator, confirmed that the facility's policy required computer screens on medication carts to be locked when not in use or out of the nurse's view. The staff had been educated on this policy to protect residents' PHI. However, the failure to lock the computer screen on the medication cart resulted in a breach of confidentiality, as sensitive information was left visible and accessible to unauthorized individuals.
Failure to Prepare for EMR Outage Leads to Medication and Treatment Lapses
Penalty
Summary
The facility failed to ensure an alternative system was in place for accessing resident Medication Administration Records (MARs), Treatment Administration Records (TARs), and Physician's Orders during a scheduled Electronic Medical Record (EMR) system outage. The EMR system administrator had notified the facility of a planned outage, but the facility did not take any preparatory actions. As a result, the nursing staff was unable to administer medications or perform treatments for all 41 residents, as they had no access to the current physician's orders. Interviews with residents revealed that they did not receive their medications during the outage. One resident expressed anxiety over not receiving heart medications, while another was concerned about constipation due to missed stool softeners. A third resident experienced pain from untreated gout. Nursing staff confirmed the inability to access current MARs, TARs, and Physician's Orders, and the facility's paper charts contained outdated information from April 2024. The facility's administration acknowledged the lack of a backup system and the absence of a policy for EMR outages. The Director of Nursing Services admitted to not reading EMR outage warnings and failing to print current Physician's Orders for several months. The Business Office Manager noted that EMR outage alerts were ignored, as previous outages were brief. The Medical Director and Pharmacist were informed of the outage but indicated that medication card labels were not reliable for administering medications.
Inadequate Monitoring and Assessment of Resident at Risk for Elopement
Penalty
Summary
The facility failed to ensure adequate assessment and monitoring of a resident at risk for unsafe wandering and elopement. Resident 1, who had a history of dementia, anxiety disorder, and other medical conditions, was not assessed for wandering or elopement risks upon admission. Despite exhibiting wandering behavior, no care plan was developed to address these risks. The facility's policy required such assessments and care plans, but these were not implemented for Resident 1. Resident 1 eloped from the facility on multiple occasions. On one occasion, she was found by police in a ditch near a highway with injuries, including a scratched face and bruised chin. The facility's alarm system was inadequate, as it did not differentiate between residents, staff, or visitors, and the alarm sound was low due to needing new batteries. Staff interviews revealed that there was no formal system to monitor residents at risk of elopement, and the existing alarm system was insufficient to alert staff effectively. The facility's staff, including the DON and CNAs, acknowledged the lack of proper monitoring and supervision for Resident 1. Despite being aware of the resident's elopement risk, the facility did not implement consistent one-to-one supervision or use tracking devices as indicated in the care plan. The facility's failure to develop and implement appropriate interventions and monitoring systems contributed to Resident 1's repeated elopements and subsequent injuries.
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