Health inspection·February 28, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update the responsible party (RP) for one of two sample residents, (Resident 2) when Resident 2 had a fall. This failure violated the rights of Resident 2 and the RP to for all changes to be reported immediately. Findings: A review of the facility ' s policy undated, titled, Acute Condition Changes-Clinical Protocol, indicated the nurse and physician will discuss and evaluate the situation. The physician should request information to clarify the situation, for an example vital signs, physical findings, a detailed sequence of events, and descriptions of symptoms. Many acute changes of condition can be managed effectively in nursing facilities with outcomes that are comparable to those of hospitalization. This discussion should consider the patient ' s overall condition, prognosis, and wishes (either direct or as conveyed by a substitute decision-maker/ RP). Resident 2 was admitted to the facility on [DATE], for diagnoses that included neoplasm of the colon (a growth or tumor in the colon), pneumonia (lung infection causing inflammation and fluid), urinary tract infection (UTI, a bacterial infection of the urinary tract), Chronic Pulmonary Obstructive Disease (COPD, a progressive lung disease), dysphagia (difficulty swallowing), anxiety (an uncomfortable feeling of uneasiness, dread, or fear), atrial fibrillation (irregular and fast heart rate), congestive heart failure (serious disease when the heart cannot keep up with the body ' s need), Peripheral Vascular Disease (PVD, a slow and progressive blockage of the blood circulation) and presence of a heart pace maker (battery-powered, surgically placed device that helps the heart speed up and beat regularly). A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 1/9/25, indicated that Resident 2 had a Brief Interview for Mental Status, (BIMS) score of 8 out of 15 which indicated a severe cognitive (ability to think and reason) impairment. This MDS also indicated Resident 2 required maximum assistance with toileting, lower body dressing, all transfers, and bathing. During an interview on 2/28/25 at 1:30 pm, Resident 2 stated, I remember the fall, it was last Friday evening. They did not update my family member when I fell, I did when she came in to visit. She is very involved and worries about me. During a concurrent interview and record review on 2/28/25 at 12:45 pm. Registered Nurse (RN) A Page 1 of 2 555356 555356 02/28/2025 Quartz Hill Post Acute 2120 Benton Drive Redding, CA 96003

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confirmed Resident 2 fell in her room on 2/21/25 and a change in condition and a physician update was documented in the medical record on 2/21/25. RN A confirmed the RP was not updated on 2/21/25 when a change in condition was identified and documented. During a phone interview with the Director of Nursing (DON) on 2/28/25 at 12:50 pm, the DON confirmed the RP should be updated with any fall or change in condition. The DON confirmed it is the facility ' s policy to update the RP even if the resident is alert and oriented unless the resident specifically requests no updates. DON added, This update to the RP was missed for Resident 2 if it is not documented in the medical record, but I would ask the nurse who was present to be sure. During an interview on 2/28/25 at 2:10 pm, RN B confirmed he did not update the RP or family member on 2/21/25 when Resident 2 had a fall. RN B stated, I updated the doctor but did not update the family, I will know moving forward, even if there is no apparent injury. During an interview on 2/28/25 at 2:30 pm, the Administrator confirmed the RP was not updated for Resident 2 after a change in condition. 555356 Page 2 of 2