Health inspection·July 25, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure direct care and administrative staff reported allegations of staff to resident abuse to the mandated agencies for one of two sampled residents (Resident 1). This had the potential to put all residents at risk for abuse from staff at the facility. Findings: A review of a facility policy titled Abuse Prevention Program revised December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of property, verbal, mental, sexual, and physical abuse. Identify and assess incidents of abuse. Investigate and report any allegations for abuse within the timeframes as required by federal requirements. Protect residents during the abuse investigations. A review of facility policy revised April 2012, titled, Recognizing Signs and Symptoms of Abuse/Neglect indicated abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with physical harm, pain, or mental anguish. Signs of actual physical abuse are welts and bruises, abrasions or lacerations, and black eyes. Resident 1 was admitted to the facility on [DATE] for diagnoses that included dementia, heart disease, pain, and a history of falling. A review of the Minimum Data Set (MDS, a resident assessment) dated 5/17/23, indicated for functional ability Resident 1 was totally dependent on staff for transfers and needed two assistants. Resident 1 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs, and unable to recall events due to severe memory loss. A review of Resident 1's medical record a document dated 6/3/23 titled Progress Note, indicated Certified Nursing assistant reported a bruise to coccyx for Resident 1, MD notified and monitor until resolved. A review of Resident 1's medical record a document dated 6/4/23 titled Change in Condition Progress Note, indicated Resident 1 up in wheelchair and noticed a dark bluish bruise around Resident 1's right eye, Also bluish bruise on Resident 1's left wrist, updated MD and Responsible party. A review of Resident 1's medical record, a document dated 6/8/23, titled Interdisciplinary Team Page 1 of 7 555356 555356 07/25/2023 Quartz Hill Post Acute 2120 Benton Drive Redding, CA 96003

F 0609 Level of Harm - Minimal harm or potential for actual harm (IDT) Review of Skin alteration, indicated Resident 1 was found on 6/4/23 by the am staff to have a purple discoloration to her medial eye socket of the right eye. There is also a purple discoloration on the left dorsal wrist. IDT met and determined that the cause for the bruise could be anti-coagulant therapy, (use of blood thinners for heart disease). Also, Resident 1 is noted to prefer to sleep on her right side, often holding onto the quarter rail and leaning her head on the rail. Residents Affected - Few A review of Resident 1's medical chart indicated no mandatory reporting or investigation documentation of new blue discolorations for Resident 1's right eye, left wrist and coccyx area through 6/13/23. During an interview on 6/13/23 at 11:50 am, the administrator (Admin) confirmed the allegation of abuse to Resident 1 from an employee was not reported to CDPH and stated, I was here on Monday 6/5/23 and saw the bruising to Resident 1's eye but thought since we removed the bedrail I did not have to report. Admin confirmed etiology, (cause) of bruises are still unknown and the facility staff was not sent home for an investigation to be completed for allegations of abuse to Resident 1. During an interview with the Director of Nursing (DON) on 6/13/23 at 12:10 pm. DON stated, We did not send a report to California Department of Public Health (CDPH) for Resident 1's bruising of Right eye and left wrist. The staff accused of alleged abuse to Resident 1 was not in the building on 6/4/23. I think the bruising was from the bed rail. No, I cannot say for certain. During an interview on 6/13/23 at 12:50 pm, the DON and Admin confirmed they were aware of the allegations of Employee to Resident abuse because the California Board of Registered Nursing (BRN) had emailed and called the DON to obtain information and update the facility an allegation had been filed against an employee. DON stated, BRN would inform me how to proceed with options to protect the staff and residents. We were emailing back and forth and talking on the phone. During an observation on 6/13/23 at 3:10 pm, Resident 1 was lying in bed, severe bruising noted to right periorbital (around the eye) area, three small bruises on the left wrist, no bruising area noted to the coccyx. Resident 1 also had two new bruises, dark purple areas, not documented to the right top of forehand, and upper right arm. During an interview on 6/13/23 at 3:20 pm, Registered Nurse (RN) B stated, I could not determine what could have happened to Resident 1, that is why I was calling the staff, no one reported the bruising to me. I did not report or fax CDPH, when I called the DON and she said they would follow up on it. During a follow up interview on 6/13/23 at 3:25 pm, RN B also confirmed two new dark purple bruises on Resident 1, one large purple area covering the top of right hand, the other dark purple bruise on the upper right arm. RN B stated, No I did not see those new bruises, I will go tell the Admin now. During an interview on 6/13/23 at 3:45 pm, RN A stated, I thought Resident 1's bruising was going to be reported or I would have. There are fax forms at all the nurses' stations. I do not think this bruising was handled right, they should have reported it, we are all mandatory reporters. During an interview on 6/13/23 at 4:02 pm, the ADON stated, I had no idea I was being accused of abuse, I just found out today. I did bring up the bruising of Resident 1 to her right eye, left wrist, and coccyx at Interdisciplinary Team (IDT) meeting, and there was no known cause at the time it was 555356 Page 2 of 7 555356 07/25/2023 Quartz Hill Post Acute 2120 Benton Drive Redding, CA 96003

F 0609 reported by RN B. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/13/23 at 4:32 pm, the Director of Staff Development stated, I heard about the bruising to Resident 1 from the Admin. Should I have reported it? I teach the staff to report, without the Admin if needed. Residents Affected - Few During a follow up interview on 7/12/23 at 3:40 pm, the Admin and DON confirmed the alleged abuse should have been reported to CDPH and all entities per abuse policy, and the resident should have been protected while this allegation was investigated. The DON stated, I will make sure moving forward all this is completed as well as the five day follow up report. I will work together with the Admin to meet the time frame per policy. 555356 Page 3 of 7 555356 07/25/2023 Quartz Hill Post Acute 2120 Benton Drive Redding, CA 96003

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure allegations of staff to resident abuse were investigated and residents were protected during this process for one of two residents (Resident 1). Residents Affected - Few This put all residents at risk for staff to resident abuse. Findings: A review of a facility policy titled Abuse Prevention Program revised December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of property, verbal, mental, sexual, and physical abuse. Protect residents during the allegation of abuse investigations. A review of facility policy revised April 2012, titled, Recognizing Signs and Symptoms of Abuse/Neglect indicated abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with physical harm, pain, or mental anguish. Signs of actual physical abuse are welts and bruises, abrasions or lacerations, and black eyes. Resident 1 was admitted to the facility on [DATE] for diagnoses that included dementia, heart disease, pain, and a history of falling. A review of the Minimum Data Set (MDS, a resident assessment) dated 5/17/23, indicated for functional ability Resident 1 was totally dependent on staff for transfers and needed two assistants. Resident 1 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs, and unable to recall events due to severe memory loss. A review of Resident 1's medical record a document dated 6/3/23 titled Progress Note, indicated Certified Nursing assistant reported a bruise to coccyx for Resident 1, MD notified and monitor until resolved. A review of Resident 1's medical record a document dated 6/4/23 titled Change in Condition Progress Note, indicated Resident 1 up in wheelchair and noticed a dark bluish bruise around Resident 1's right eye, Also bluish bruise on Resident 1's left wrist, updated MD and Responsible party. A review of Resident 1's medical record, a document dated 6/8/23, titled Interdisciplinary Team (IDT) Review of Skin alteration, indicated Resident 1 was found on 6/4/23 by the am staff to have a purple discoloration to her medial eye socket of the right eye. There is also a purple discoloration on the left dorsal wrist. IDT met and determined that the cause for the bruise could be anti-coagulant therapy, (use of blood thinners for heart disease). Also, Resident 1 is noted to prefer to sleep on her right side, often holding onto the quarter rail and leaning her head on the rail. A review of Resident 1's medical chart indicated no mandatory reporting or investigation documentation of new blue discolorations for Resident 1's right eye, left wrist and coccyx area through 6/13/23. During an interview on 6/13/23 at 11:50 am, the administrator (Admin) confirmed the allegation of abuse to Resident 1 from facility staff was not reported to CDPH and stated, I was here on Monday 6/5/23 and saw the bruising to Resident 1's eye but thought since we removed the bedrail I did not have 555356 Page 4 of 7 555356 07/25/2023 Quartz Hill Post Acute 2120 Benton Drive Redding, CA 96003

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to report. Admin confirmed etiology of bruises are still unknown and the alleged staff member was not sent home for an investigation to be completed for allegations of abuse to Resident 1. During an interview on 6/13/23 at 12:50 pm, the DON and Admin confirmed they were aware of the allegations of facility staff member to Resident abuse because the California Board of Registered Nursing (BRN) had emailed and called the DON to obtain information and update the facility an allegation had been filed against an employee. DON stated, BRN would inform me how to proceed with options to protect the staff and residents. We were emailing back and forth and talking on the phone. During an observation on 6/13/23 at 3:10 pm, Resident 1 was lying in bed, severe bruising noted to right periorbital (around the eye) area, three small bruises on the left wrist, no bruising area noted to the coccyx. Resident 1 also had two new bruises, dark purple areas, not documented to the right top of forehand, and upper right arm. During an interview on 6/13/23 at 4:02 pm, the ADON stated, I had no idea I was being accused of abuse, I just found out today. I did bring up the bruising of Resident 1 to her right eye, left wrist, and coccyx at Interdisciplinary Team (IDT) meeting, and there was no known cause at the time it was reported by Registered Nurse (RN) B. During a follow up interview on 7/12/23 at 3:40 pm, the Admin and DON confirmed any employee will be sent home to protect all residents until a thorough investigation has been completed to rule out any type of alleged abuse per facility abuse policy. 555356 Page 5 of 7 555356 07/25/2023 Quartz Hill Post Acute 2120 Benton Drive Redding, CA 96003

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transfer one of two sampled residents, (Resident 1) safely using a Hoyer lift (a mechanical lift used to transfer residents) when one Certified Nursing Assistant left Resident 1 without a mat in place beside the bed while leaving the room. This failure resulted in an avoidable accident when Resident 1 sustained a fall hitting her head, right shoulder, and right elbow. Findings: During a review of a policy revised March 2018, titled Falls, and Fall Risk, Managing, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. During a review of a policy revised July 2017, titled Safe Lifting and Movement of Residents, indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. This policy also indicated resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. During a review of a policy revised July 2017, titled Accidents and Incidents, indicated incident and accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility, and to analyze any individual resident vulnerabilities. Resident 1 was admitted to the facility on [DATE] for diagnoses that included dementia, heart disease, pain, and a history of falling. A review of the Minimum Data Set (MDS, a resident assessment) dated 5/17/23, indicated for functional ability Resident 1 was totally dependent on staff for transfers and needed two assistants. Resident 1 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs, and unable to recall events due to severe memory loss. During a record review of Resident 1's medical record, a review of a care plan revised on 5/23/23 indicated Resident 1 is at risk for falls related to dementia, non-ambulatory, chronic pain and history of falls. This care plan also indicated Resident 1 is at risk for injury from falls related to anti-coagulant therapy (blood thinners) required for heart disease. During a record review of Resident 1's medical record, a document dated 7/3/23 at 3:00 pm, titled Interdisciplinary Team Fall (IDT) Review, indicated Resident 1 had an unwitnessed fall out of bed in resident's room. Root cause indicated Certified Nursing Assistant (CNA) had removed mattress on floor beside bed and went to get the Hoyer lift for a transfer, when CNA returned with the Hoyer lift, the resident was found on the floor beside the bed. During a record review of Resident 1's medical record, a document dated 7/3/23 titled Progress Notes, indicated CNA found Resident 1 at bedside on her right side, as Resident 1 was calling out. 555356 Page 6 of 7 555356 07/25/2023 Quartz Hill Post Acute 2120 Benton Drive Redding, CA 96003

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a record review of Resident 1's medical record, a document dated 7/4/23 at 9:50 pm, titled Progress Notes, indicated Resident 1 is on alert monitoring for a recent fall. Resident had a bluish bruise to the right temple area, also bruising noted to right shoulder and right elbow areas. During a record review of Resident 1's medical record, a document dated 7/4/23 at 1:52 pm, titled Progress Notes, indicated Resident 1 had periorbital bruising and hematoma. Resident was found on night shift out of bed with bruising which later developed to hematoma above right eye. During a record review of Resident 1's medical record, a document dated 7/5/23 indicated resident has bruising to right forehead, right shoulder, and right elbow related to a recent fall. During an interview on 7/12/23 at 12:30 pm, the Director of Nursing confirmed Resident 1's fall was preventable and was due to the CNA not placing the mat beside the bed when he stepped out of Resident 1's room. 555356 Page 7 of 7