Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marquis Care At Shasta during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was not treated with respect and dignity during personal care when a CNA held the resident's hands down to prevent hitting during a linen change. The incident was witnessed and reported by another CNA, and facility leadership confirmed that the resident's rights were violated by this action.
A resident experienced significant delays in call light responses, with 54 instances exceeding 20 minutes and the longest wait being one hour. Despite the facility's policy to treat residents with dignity, the resident felt unfairly treated due to these delays. The resident, with multiple health conditions, was capable of making her own decisions, highlighting the importance of timely assistance.
A resident experienced a significant weight loss of 5% in one month, but the facility failed to update the care plan accordingly. Despite the resident's desire to regain weight and the facility's policy requiring re-weighing and dietitian consultation, the care plan was not revised. The resident consumed less than 25% of meals most of the time, and the Registered Dietitian had not addressed the issue with the resident. The facility's protocol did not account for the resident's refusal to be re-weighed.
The facility failed to ensure staff competency in assessing and documenting a surgical site, leading to a delayed infection diagnosis. A CNA incorrectly documented a resident's shower, and multiple residents experienced long call light wait times. Competency checklists relied on self-assessment without validation.
The facility did not adhere to pureed food recipes, affecting 11 residents on pureed diets. Staff used incorrect ingredient amounts and did not measure liquids accurately, leading to unappetizing food that potentially did not meet nutritional needs. The RD confirmed that recipes must be followed exactly.
The facility failed to provide appetizing and palatable meals to residents, with 14 residents expressing dissatisfaction with the food quality. Complaints included cold meals, hard meat, spoiled fruit, and incorrect meal orders. The Registered Dietician confirmed weight loss in a resident without a Nutritional at Risk Assessment, highlighting issues in the facility's food service.
The facility failed to honor the food preferences of several residents, leading to dissatisfaction and potential nutritional issues. A resident with foot wounds did not receive the ordered meals, affecting protein intake. Another resident with fractures received a different meal than ordered, which was too spicy. A cognitively impaired resident reported not receiving ordered meals, while another faced unavailable items and cold food. A resident with moderate cognitive impairment and her daughter noted frequent meal substitutions, particularly on Sundays.
The facility failed to follow food safety and sanitation guidelines, risking foodborne illness for 115 residents. Issues included unmonitored cool down processes, improper dish machine temperatures, lack of hair restraints, and unclean kitchen equipment. Observations showed worn can openers, chipped spatulas, and improper storage of food and cleaning supplies. Non-functioning equipment was not discarded, highlighting significant lapses in maintaining a safe food preparation environment.
A LTC facility failed to update care plans for four residents, leading to deficiencies in addressing their medical and personal needs. One resident's significant weight loss was not reflected in their care plan, while another's care plan lacked updates for a room change and weight loss. Additionally, a resident's end-of-life care was not updated after choosing Hospice services, and another's care plan did not include a new UTI diagnosis.
The facility failed to provide adequate ADL care for three dependent residents, leading to deficiencies in personal hygiene and grooming. A resident with contractures and diabetes had long, jagged fingernails, while another resident with multiple health issues also had untrimmed nails. Additionally, a resident with severe cognitive deficits did not receive scheduled showers, with no refusals documented. The DON confirmed the facility's failure to follow its policies.
Expired medications and an expired E-Kit were found in a unit's medication room, indicating a failure in the facility's pharmaceutical services. The DON admitted that while reviews for expired medications should occur monthly, there was no strict schedule, leading to the oversight.
A LTC facility reported a medication error rate of 14.81%, exceeding the acceptable threshold. Errors included a nurse administering an iron supplement with milk, improper use of a Breo Ellipta Inhaler by two residents, and a nurse crushing enteric-coated and delayed-release medications. These actions could potentially affect medication efficacy and safety.
The facility failed to maintain a pest-free environment, with multiple observations of flies in the kitchen and dining areas. The air curtain, meant to prevent flying insects, was found inoperative, and staff were unclear about its operation. The CDM did not report the fly issue to the POM or pest control company, contributing to the deficiency.
A resident with anxiety and depression was left in a soiled brief due to delayed toileting assistance, despite being able to verbalize her needs. The facility's staff failed to promptly respond, leading to increased anxiety and a violation of her dignity and rights, as confirmed by interviews with the resident and staff.
A resident in an LTC facility was unable to see his wife's pictures due to clutter on his dresser, leading to frustration and a violation of his right to a homelike environment. The facility's policy emphasizes a clean and personalized setting, but staff confirmed the clutter, including hygiene products, obstructed the resident's view. The resident, with a history of anxiety and other medical conditions, expressed a preference for orderliness, which was not maintained.
A resident experienced significant unplanned weight loss due to the facility's failure to conduct a timely nutritional assessment and address the issue in NAR meetings. The RD was not notified of the resident's weight loss, and there was no documentation of IDT meetings or a care plan to manage the resident's nutritional needs. Additionally, the resident's admission weight was not obtained in a timely manner, delaying necessary interventions.
The facility did not ensure that the dietary manager met the educational qualifications as per California regulations. The Certified Dietary Manager (CDM) confirmed he had not received specific California dietary service training before assuming his role, potentially impacting meal distribution accuracy and food safety.
A resident was served pork pieces larger than the specified size for a chopped meat diet, contrary to the facility's diet manual. The resident, who was on an Easy to Chew diet, expressed dislike for the meat after chewing and spitting it out. The CDM was unaware of the specific size requirements for chopped meats, leading to this dietary oversight.
The facility failed to properly dispose of garbage, with broken down cardboard boxes left in the kitchen and various items cluttering the area outside the kitchen door. The CDM confirmed the boxes were only removed at the end of shifts, and the ADM acknowledged no specific person was assigned to manage the area, leading to potential pest issues affecting all 116 residents.
A facility failed to coordinate care with a Hospice agency for a resident with severe cognitive deficits and multiple diagnoses, resulting in unmet personal care needs. Despite being under Hospice care, the facility did not update the care plan or communicate effectively with the Hospice agency, leading to potential negative outcomes.
A resident with hemiplegia, vascular dementia, and kidney cancer was physically abused by a registry staff member who aggressively grabbed the resident's wrists during care. The incident was witnessed by a CNA and confirmed by the facility's administration.
A resident with dementia was verbally abused by a CNA during care. The resident became combative, and the CNA responded with inappropriate language. The incident was reported, and the CNA was suspended and later terminated. The resident did not recall the incident.
Resident Dignity Violated During Personal Care by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to treat a resident with respect and dignity during direct personal care. The resident, who had severe cognitive impairment and multiple complex diagnoses including Alzheimer's disease, vascular dementia with agitation, delusional disorder, and other significant medical conditions, became agitated and combative during a linen change. During this episode, the CNA held the resident's hands down on his chest to prevent him from hitting staff, despite being told multiple times by another staff member to stop. The facility's policy requires that all residents, including those with cognitive impairments, be treated with dignity and sensitivity, and that staff address the root causes of behaviors rather than physically restraining or contradicting residents. The incident was witnessed by another CNA, who intervened and reported the misconduct immediately. Interviews with facility leadership and staff confirmed that the resident's rights and dignity were violated during the incident, and that holding a resident's hands or restraining them in this manner is unacceptable. The resident's medical record indicated a need for maximum assistance with personal care and a history of combative behaviors, but staff are expected to respond appropriately without compromising the resident's dignity.
Delayed Call Light Responses Impact Resident Dignity
Penalty
Summary
The facility failed to ensure timely responses to residents' requests for assistance, specifically for one resident who experienced significant delays in call light responses. The facility's policy on resident rights emphasizes the importance of treating residents with respect, kindness, and dignity, yet this was not upheld as evidenced by the delayed response times. During an interview, the resident expressed feelings of unfair treatment due to the frequent long waits for assistance, which were documented in the call light logs. The resident, who was admitted with multiple diagnoses including depression, diabetes, and chronic obstructive pulmonary disease, was capable of making her own decisions as indicated by her BIMS score. Despite this, the call light logs revealed 54 instances where the response time exceeded 20 minutes, with the longest wait time being one hour on several occasions. The Director of Staff Development acknowledged that staff are expected to answer call lights promptly, yet the logs indicated a pattern of delayed responses, contributing to the resident's feelings of neglect.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 call lights will be responded to timely. How the facility will identify other residents having the same potential to be affected by the same deficient practice and what corrective action will be taken? All residents could be affected by this practice. Facility QA committee to meet to review call light logs for any patterns/units/shifts where longer call light times may be occurring and conduct a Root Cause Analysis for overall improvement in meeting timely call light times. What measures will be put into place or what systematic changes will you make to ensure that the deficient practice does not recur? DSD inserviced all staff on answering call lights in a timely manner. Including turning off call light when responding to needs, reactivating call light if more assistance is required by resident. Often call lights are forgotten to be deactivated until after all cares are delivered. How the facility plans to monitor its performance to make sure that the solutions are sustained. DSD will run call light report to ensure lights are being answered in a timely manner weekly x4 weeks, then monthly x90 days.
Failure to Revise Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to review and revise the care plan for a resident who experienced a significant unintentional weight loss of 5% in one month. The resident, who was admitted with multiple diagnoses including depression, adult failure to thrive, diabetes, and COPD, expressed a desire to regain weight. Despite the facility's policy requiring re-weighing and dietitian consultation for significant weight changes, the resident's care plan was not updated to address the weight loss. Interviews and record reviews revealed that the resident consumed 25% or less of meals 63 times out of 86 meals monitored over a month. The Registered Dietitian acknowledged the significant weight loss but had not discussed it with the resident or revised the care plan. The Resident Care Manager noted that the resident refused to be re-weighed, and the facility's protocol did not account for such refusals. The facility Administrator confirmed that the care plan should have been updated to reflect the resident's weight loss.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident 4's care plan was corrected to reflect the significant weight loss of 5% in one month. How the facility will identify other residents having the same potential to be affected by the same deficient practice and what corrective action will be taken? All other residents with significant weight loss have the potential to be affected. RD will conduct 100% audit of all residents with significant weight loss to ensure interventions and/or revisions are reflected in the care plan. What measures will be put into place or what systematic changes will you make to ensure that the deficient practice does not recur? Resident Care Managers, RD, and LN were inserviced by DNS to ensure care plan is to be updated with significant weight loss. How the facility plans to monitor its performance to make sure that the solutions are sustained. RCMs will check each care plan to ensure significant weight loss is present if indicated weekly x4 weeks, then monthly x90 days. Results will be reviewed by QA Committee. Date corrective action will be completed: 4/3/2025
Deficiencies in Staff Competency and Resident Care
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated appropriate competencies in assessing and documenting the condition of a surgical site for a resident. Despite the facility's policy requiring documentation of wound assessments, two licensed nurses did not document the presence of a surgical incision in the resident's progress notes. This oversight led to a delay in identifying an infection at the surgical site, which was later found to be inflamed and draining purulent material, necessitating antibiotic treatment. Additionally, a certified nurse assistant incorrectly documented that a resident received a shower, although the resident reported not having received one since admission. This discrepancy was confirmed by the CNA, who admitted to mistakenly documenting the shower. The resident expressed frustration over not receiving proper hygiene care, which was corroborated by the facility's documentation schedule. The facility also failed to address long call light wait times experienced by multiple residents, with documented instances of wait times exceeding 30 minutes. Residents reported waiting for assistance with basic needs, such as using the bathroom, which led to discomfort and distress. The facility's policy required prompt response to call lights, but the electronic time logs confirmed prolonged wait times. Furthermore, the competency checklists for registry staff relied on self-assessment without external validation, raising concerns about the adequacy of staff competencies.
Failure to Follow Pureed Food Recipes
Penalty
Summary
The facility failed to ensure that pureed food recipes were followed, resulting in unappetizing food that potentially did not meet the nutritional needs of 11 residents on pureed diets. Observations revealed that the staff did not adhere to the specified quantities and procedures outlined in the recipes for various pureed foods, including spinach, cornbread, sweet potatoes, and roast turkey. For instance, the staff used incorrect amounts of ingredients and did not measure liquids accurately, which deviated from the recipes' instructions. During interviews, the Registered Dietitian confirmed that recipes should be followed exactly and cannot be altered without approval. The facility's policy also indicated that recipes must be adhered to for menu items. The failure to follow these recipes as prescribed could lead to the residents receiving diets that do not meet their nutritional needs, as the food prepared was not in accordance with the dietary guidelines set by the facility.
Facility Fails to Provide Appetizing and Palatable Meals
Penalty
Summary
The facility failed to ensure that the food provided to residents was appetizing, palatable, and served at a safe and appetizing temperature. Observations and interviews revealed that 14 out of 115 residents expressed dissatisfaction with the quality of the food. Specific complaints included food not being to the residents' taste, meals not being warm, and the quality of the food being poor. Residents reported issues such as hard meat, spoiled fruit, overcooked vegetables, and incorrect meal orders. Several residents, including those with intact cognition and those with cognitive impairments, voiced their dissatisfaction during interviews. For instance, one resident mentioned that the food was not to their taste, while another stated that the food was not always warm and not very good. Another resident reported that the meat was very hard, and the vegetables were overcooked. Additionally, some residents noted that they did not receive the meals they ordered, and items were often missing from their trays. The Registered Dietician confirmed that one resident had experienced weight loss, and a Nutritional at Risk Assessment had not been completed. The Certified Dietary Manager stated that they had a good relationship with the residents and conducted monthly food satisfaction surveys. However, the dissatisfaction expressed by the residents indicates a failure in the facility's food service, potentially impacting the residents' nutritional intake and overall satisfaction with their meals.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of seven residents, leading to dissatisfaction with meals and potential nutritional issues. Resident 577, who was cognitively intact, reported not receiving the meals ordered and receiving food items like ham, which they disliked. This resident also expressed difficulty eating hard meat, which was necessary for protein intake to aid in healing foot wounds. Resident 61, who had multiple fractures, selected a pork chop but received a different meal, which she did not eat due to its spiciness. The Certified Dietary Manager could not explain the discrepancy in meal orders. Resident 579, who was severely cognitively impaired, also reported not receiving the meals ordered. Resident 580, who was cognitively intact, experienced issues with unavailable food items and cold meals. Resident 69, with moderate cognitive impairment, and her daughter noted frequent meal substitutions, particularly on Sundays. The daughter expressed discomfort in complaining to staff, understanding that the kitchen had run out of requested items. These incidents highlight a pattern of unmet food preferences and meal discrepancies for several residents.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, which posed a risk of foodborne illness to 115 of 116 residents who consumed food prepared in the facility's kitchen. The cool down process for time and temperature control of safety foods was not monitored, as confirmed by the Certified Dietary Manager (CDM), who admitted to not using a cool down log for ambient food items like tuna or chicken salad. Additionally, the dish machine's wash and rinse temperatures did not meet the manufacturer's guidelines, and the facility lacked chlorine test strips to ensure proper sanitization. Observations revealed that staff did not wear appropriate hair restraints, and food preparation equipment was not in proper working order. The can opener blade was worn, and rubber spatulas were chipped and discolored, yet they were still used in food preparation. The facility's kitchen was also found to be unclean, with dirty knife holders, floors, walls, and various kitchen equipment. The CDM confirmed these observations, acknowledging that the equipment and surfaces were not maintained according to the facility's policies. Furthermore, food and kitchen cleaning supplies were not stored properly, with items like cooking oil and brooms being placed on the floor. Non-functioning kitchen equipment, such as broken Robot Coupes, were not discarded and remained in the kitchen. These deficiencies highlight a significant lapse in maintaining a safe and sanitary environment for food preparation, which could potentially lead to foodborne illnesses among the residents.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to update and revise care plans for four residents, leading to deficiencies in addressing their medical and personal needs. Resident 19 experienced a significant unplanned weight loss of 23 pounds, which was not reflected in their care plan. The Registered Dietitian confirmed that the care plan should have been updated to address this weight change, but it was not. Resident 36 also experienced unplanned weight loss and a room change, neither of which were updated in their care plan. The Resident Care Manager acknowledged that the care plan should have included the resident's preference for bathroom assistance and addressed the weight loss with a Nutritional at Risk Assessment, which was not completed. Resident 112's care plan lacked updates for end-of-life care after choosing Hospice services, and there was a lack of communication between the facility and the Hospice agency. Similarly, Resident 121's care plan was not revised to include a new UTI diagnosis, despite an active order for antibiotics. The Director of Nursing confirmed that the care plans for these residents were not developed, reviewed, or revised as required.
Deficiencies in ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADLs) care for three dependent residents, leading to deficiencies in personal hygiene and grooming. Resident 2, who has contractures, diabetes, quadriplegia, and a cognitive deficit, was observed with long, jagged fingernails that were pressing into his hand due to contractures. This was confirmed by both a Certified Nurse Assistant (CNA) and a Licensed Nurse (LN), who acknowledged the need for nail trimming, especially given the resident's diabetes and risk of skin problems. Resident 29, with diagnoses including anxiety, hyperkalemia, sepsis, urinary tract infection, depression, and heart disease, was also found with long, jagged fingernails. The resident expressed a desire for nail trimming, which was confirmed by multiple CNAs and the Director of Nursing (DON), who admitted that the facility's nail care policy was not followed. Resident 29 was totally dependent on staff for all ADLs and unable to participate in interviews due to a moderate cognitive deficit. Resident 112, with severe cognitive deficits and multiple health issues such as adult failure to thrive, heart disease, and diabetes, did not receive scheduled showers as per the facility's policy. Records showed that out of eight scheduled showers in August and September, only a few were completed, with no refusals documented. The DON confirmed that the facility failed to ensure Resident 112 received the required showers, and any refusals should have been documented and followed up by the LNs.
Expired Medications Found in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, as evidenced by the presence of expired medications and an expired Emergency Drug Kit (E-Kit) in the [NAME] Unit medication room. During an observation, it was found that two bottles of unopened Acetaminophen, a nasal decongestant spray, and an E-Kit containing various antibiotics and intravenous solutions had expired. These expired medications were still available for resident use, which could potentially compromise the safety and effectiveness of treatments provided to residents. The Director of Nursing (DON) acknowledged that a medication review for expired medications should be conducted monthly. However, despite this schedule, expired medications were still present. The DON admitted uncertainty about why these medications were not removed and stated that nurses should ideally check for expired medications every 2 to 4 weeks, with the consultant pharmacist expected to perform a similar review every 3 months. It was noted that there was no strictly established schedule for these reviews, contributing to the oversight.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 14.81% during a medication pass. This was observed over two days, involving four medication errors out of twenty-seven opportunities for four residents. The errors included improper administration of medications and failure to follow manufacturer instructions, which could potentially affect the efficacy and safety of the medications administered. One of the errors involved a licensed nurse administering an iron supplement to a resident with milk, which is known to reduce the absorption of iron. The nurse was unaware of this interaction, which is contrary to medical guidelines that advise against consuming iron supplements with calcium-rich foods. Another error involved the improper use of a Breo Ellipta Inhaler for a resident, where the resident covered the vent and did not hold their breath as required, potentially leading to inadequate dosing. Additionally, a registered nurse crushed medications with special coatings for another resident, which is against the facility's policy. The medications included enteric-coated aspirin and delayed-release metoprolol, both of which should not be crushed as it compromises their intended release and absorption. The nurse acknowledged the error and the need to consult with the attending physician for alternative medications that can be safely crushed.
Pest Control Deficiency Due to Inoperative Air Curtain and Staff Oversight
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by multiple observations of flies in various areas, including the kitchen, dining room, and conference room. The facility's policy on vermin control, dated April 2018, mandates that the Food and Nutrition Services Department must be free from pests at all times, with arrangements made by the Administrator for an effective pest control program. Despite this, flies were observed in the kitchen near the food preparation sink, in the dish room, and on meal trays, indicating a lapse in pest control measures. Interviews with facility staff revealed a lack of clarity and responsibility regarding the operation of the air curtain, a device intended to prevent flying insects from entering the kitchen. The air curtain was found to be non-operational during the initial observation, and staff members, including the Certified Dietary Manager (CDM) and various dietary aides, were either unaware of their responsibility to operate it or had never done so. The Plant Operations Manager (POM) confirmed that the air curtain should be turned on at all times, but it was not functioning until manually activated during the survey. The CDM also failed to report the fly issue to the POM or the pest control company, further contributing to the deficiency.
Resident Dignity Compromised Due to Delayed Toileting Assistance
Penalty
Summary
The facility failed to ensure the dignity of a resident, identified as Resident 36, by not providing timely assistance with toileting needs. Resident 36, who was admitted with multiple diagnoses including anxiety and depression, was found to be totally dependent on staff for toileting and transfers. Despite having no cognitive deficits and being able to verbalize her needs, Resident 36 reported that staff often delayed responding to her requests for toileting assistance, sometimes making her wait up to an hour. This delay resulted in her being left in a soiled brief, which increased her anxiety and made her feel neglected. Interviews with Resident 36 and facility staff, including the Director of Social Services and the Resident Care Manager, confirmed the resident's feelings of anxiety and the violation of her rights. The Director of Nursing acknowledged that the staff's actions were a violation of the resident's rights and dignity. The facility's policies on dignity and resident rights emphasize the importance of treating residents with respect and promptly responding to their needs, which was not adhered to in this case.
Cluttered Dresser Obstructs Resident's View of Personal Pictures
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for one of its residents, identified as Resident 29, who was unable to see his wife's pictures due to clutter on his dresser. This deficiency was observed during a survey, where Resident 29 expressed frustration about the clutter, stating that he was accustomed to having things in order. The facility's policy, dated May 2011, emphasizes providing a safe, clean, and homelike environment, encouraging the use of personal belongings. However, the clutter on Resident 29's dresser, which included hygiene products left out in the open, violated this policy and the resident's right to a homelike setting. Interviews with facility staff, including two Certified Nursing Assistants (CNAs) and the Director of Social Services (DSS), confirmed the presence of clutter and acknowledged that Resident 29 was unable to view his personal pictures. The DSS noted that Resident 29, due to his background, preferred orderliness and should be able to see his personal pictures. The Director of Nursing also confirmed that the resident should have a homelike environment, and the clutter should be removed to allow the resident to view his family pictures. Resident 29's medical history includes anxiety, hyperkalemia, sepsis, urinary tract infection, depression, and heart disease, which may contribute to his need for a personalized and orderly environment.
Failure to Provide Adequate Nutritional Services
Penalty
Summary
The facility failed to provide adequate nutritional services to Resident 19, as evidenced by the lack of a timely nutritional assessment by the Registered Dietitian (RD) upon the resident's readmission. Despite the facility's policy requiring a nutritional assessment within seven to 21 days of admission, Resident 19's nutritional status was not assessed after readmission. The RD confirmed that there was no system in place to prevent missed nutritional assessments, and the RD was not notified of new admissions in a timely manner. Resident 19 experienced significant unplanned weight loss, which was not addressed by the RD or the Interdisciplinary Team (IDT). The resident's weight decreased from 215.4 lbs. to 192.4 lbs., a 10.6% loss over six months, which was not documented or addressed in the Nutrition at Risk (NAR) meetings. The RD and Licensed Nurse (LN) 8 confirmed that the weight loss was not communicated or documented properly, and there was no evidence of IDT meetings to address the issue. Additionally, the facility did not obtain Resident 19's admission weight in a timely manner, as required by their policy. The resident was not weighed until four days after readmission, which delayed the identification and intervention for the resident's weight loss. The RD and LN 8 confirmed that there was no documentation of a care plan to address the severe unplanned weight loss, and the resident's nutritional needs were not adequately monitored or managed.
Non-compliance with Dietary Manager Qualifications
Penalty
Summary
The facility failed to comply with federal regulations regarding the educational qualifications of the dietary manager, as specified in the California Code, Health and Safety Code (HSC 1265.4). This deficiency was identified during an interview with the Certified Dietary Manager (CDM), who stated that he received his CDM certificate from the University of Florida. However, he confirmed that he had not received the specific California dietary service requirements contained in Title 22 of the California Code of Regulations before assuming full-time duties as a dietetic services supervisor at the health facility. This oversight had the potential to result in inadequate oversight of the food and nutrition services department, which could affect meal distribution accuracy, safe food handling, and adherence to sanitation guidelines.
Inappropriate Diet Texture Provided to Resident
Penalty
Summary
The facility failed to provide the appropriate textured diet for one resident, identified as Resident 48, who was supposed to receive chopped meat as part of an Easy to Chew diet. During a lunch meal observation, Resident 48 was served pork pieces that were approximately one to one and a half inches in size, which did not meet the facility's diet manual specifications for chopped meat, defined as 1/4 inch to 1/2 inch pieces. This discrepancy was noted when Resident 48 was observed to have chewed and spit out a piece of pork, expressing dislike for the meat. The Certified Dietary Manager (CDM) was interviewed and confirmed that a Regular chopped meat diet was not listed on the therapeutic spreadsheet, which outlines the specifics of each diet type. Furthermore, the CDM admitted to not knowing the specific size requirements for chopped meats and indicated a need to refer to the diet manual for this information. This lack of knowledge and adherence to the diet manual's guidelines contributed to the failure in providing the appropriate diet texture for Resident 48.
Improper Garbage Disposal in Facility
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, which had the potential to attract insects and rodents, affecting all 116 residents. During an initial tour of the kitchen, more than ten broken down cardboard boxes were observed on a kitchen cart and two additional boxes were found next to a food preparation table. The Certified Dietary Manager (CDM) confirmed that these boxes were collected in the kitchen and only taken outside at the end of the shift. Additionally, outside the kitchen door, various items such as dietary carts, linen carts, mattresses, and wheelchair parts were found near a portable storage container next to the kitchen loading dock. The Plant Operations Manager (POM) stated that no one was assigned to pick up trash in this area. The Administrator (ADM) confirmed that there was no specific person in charge of the area outside the kitchen door, and acknowledged that trash should not be present there. The ADM mentioned that the POM was responsible for taking items that needed to be discarded to the dump.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to coordinate care needs with a Hospice agency for a resident receiving end-of-life care. The resident, who had severe cognitive deficits and was dependent on staff for all activities of daily living, was admitted to the facility with multiple diagnoses, including adult failure to thrive, heart disease, and diabetes. Despite being under Hospice care, there was a lack of communication between the facility and the Hospice agency, resulting in the resident not receiving necessary personal care, such as showers or baths, as required by the facility's policy. Interviews with facility staff and the Hospice agency revealed that the facility did not update the resident's care plan to reflect current needs, nor did they coordinate with the Hospice agency to ensure the resident's comfort and symptom management. The Director of Patient Care from the Hospice agency confirmed that the plan for end-of-life care had been sent to the facility, but the facility failed to communicate any changes or coordinate care effectively. This lack of coordination and communication led to a delay in personal care and had the potential to cause emotional stress and negative clinical outcomes for the resident.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse by a registry staff member. The incident involved a resident with a medical history that includes hemiplegia and hemiparesis following a cerebral infarct, vascular dementia, and kidney cancer. During care, a registry staff member aggressively grabbed the resident's wrists, which was confirmed by both the resident and a Certified Nursing Assistant (CNA) who witnessed the event. The facility's policy on abuse prevention, dated December 2020, explicitly states that residents have the right to be free from abuse and that the facility is committed to protecting residents from abuse by anyone, including staff from other agencies. Interviews conducted with the resident, CNA B, and CNA C revealed that the registry staff member grabbed the resident's wrists and pushed them down to the resident's chest while speaking in an aggressive tone. The registry staff member admitted to grabbing the resident's wrists to avoid the resident's attacks. The facility's administration confirmed that the incident occurred and was substantiated through their investigation.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse when a Certified Nursing Assistant (CNA) cursed at her while providing care. The incident involved a resident with diagnoses including intracranial hemorrhage, anxiety, and dementia. The California Department of Public Health received a report of possible verbal abuse by CNA 1 towards the resident. Another staff member witnessed CNA 1 calling the resident a derogatory term. CNA 1 was immediately suspended and later terminated. The resident had no recollection of the incident due to her dementia. During the investigation, it was revealed that the resident became combative during care, leading CNA 2 to request assistance from CNA 1. The resident's aggression escalated, and CNA 1 responded by making an inappropriate comment. CNA 1 admitted to the verbal abuse, citing personal stress as a contributing factor. The Director of Staff Development confirmed that CNA 1 was remorseful and acknowledged her wrongdoing.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 40 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Redding
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestwood Wellness And Recovery Center | 0.5 mi | — | 2 | 0 |
| Copper Ridge Care Center | 1.3 mi | — | 15 | 0 |
| River Valley Healthcare & Wellness Centre, Lp | 2.4 mi | — | 1 | 0 |
| Redding Post Acute | 2.6 mi | — | 16 | 0 |
| Veterans Home Of California - Redding | 3.5 mi | — | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Marquis Care At Shasta.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.