Health inspection·July 30, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the most recent care plan for one of two residents (Resident 1) to provide one on one checks per physician orders for safety after a recent suicide attempt. This failure had the potential to cause Resident 1 physical and psychosocial harm. Findings: A review of the facility's policy titled Depression-Clinical Protocol revised 11/2018, indicated number 2, The nurse shall assess and document/report the following: Vital signs, description of affect, level of activity and responsiveness, whether mood decline is associated with anorexia, (not eating), crying and sleeplessness; pain assessment, suicidal ideation, (If present, follow facility policy/protocol for suicide threats). A review of the facility's policy titled Suicide Threats dated 12/2007, indicated resident suicide threats shall be taken seriously and addressed appropriately. Number seven stated, If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised 3/2022, indicated Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation including the right to receive the services and/or items included in the care plan. During a record review of a document titled, Care Plan revised [DATE], indicated new interventions for new problem, Resident 1 had mood problem and verbalized want to self-harm, as well as engaged in actual self-harm, cutting behavior. One on one supervision to be provided for increased visual accountability of safety and wellness of patient. Every fifteen-minute checks for safety, daily visits daily with DSS for 72 hours, and longer if indicated. A review of a document titled Individual Progress Note dated [DATE] from a local hospital for Crisis evaluation indicated Resident 1 was being evaluated for danger to self, following [Resident 1] engaging in cutting behavior, he has a superficial cut to the left wrist. Resident 1 was admitted to the facility on [DATE] for diagnoses that included repeated falls, injury of the head, and major depressive disorder (a persistently low or depressed mood that causes a (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555356 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quartz Hill Post Acute 2120 Benton Drive Redding, CA 96003 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)