Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Quartz Hill Post Acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment experienced a fall, but the responsible party was not informed as required by facility policy. Despite the fall being documented and the physician being updated, the family was not notified, which was confirmed by the DON and nursing staff.
The facility exceeded the acceptable medication error rate, with errors observed in the administration to two residents. An LVN failed to prime an insulin pen and administered the wrong multivitamin to a resident, while another LVN gave plain senna instead of the prescribed senna-docusate sodium. Both instances involved a failure to adhere to the facility's medication administration policy.
The facility failed to report an abuse allegation within the required timeframe. A resident reported being attacked by their roommate, resulting in a scratch and bruising. Despite being notified, the Administrator did not report the incident to the state survey agency within two hours, as required by policy, due to a belief that there was no injury.
A resident with hypertension did not receive prescribed as-needed blood pressure medication on several occasions when their systolic blood pressure exceeded the threshold. Despite the facility's policy and care plan directives, nursing staff failed to administer clonidine hydrochloride as ordered, and interviews revealed a lack of adherence to physician orders.
A resident with obstructive sleep apnea used a non-invasive mechanical ventilator without a physician's order, as required by facility policy. Despite the resident's care plan indicating the need for respiratory therapy, the Order Summary Report lacked an active order for the ventilator. Staff interviews confirmed the necessity of such orders, highlighting a deficiency in ensuring proper documentation and adherence to policy.
A resident with severe cognitive impairment and hemiplegia received incontinence care from an LVN and a CNA who failed to perform proper hand hygiene and glove changes. The CNA did not wash hands or change gloves after cleaning bowel from the resident before applying a clean brief and touched the bed control with soiled gloves. Interviews confirmed the need for hand hygiene and glove changes between dirty and clean tasks.
The facility failed to meet food safety and sanitation standards when the Dietary Manager was observed not wearing a hair net in the kitchen, contrary to the facility's policy. Additionally, food items in the walk-in refrigerator were not properly covered, labeled, or dated, as required by the facility's procedures. These deficiencies posed a potential risk for foodborne illnesses among the 110 residents.
A resident's privacy was compromised when a nurse checked blood sugar and administered insulin at the dining table in front of others, contrary to the facility's privacy standards. The resident had dementia, cognitive communication deficit, and diabetes. The Infection Control Nurse confirmed the breach of privacy standards.
A Licensed Nurse failed to follow infection control procedures by checking a resident's blood sugar and administering insulin in the dining room, contrary to the facility's policy. The resident had conditions including dementia and diabetes, necessitating careful management. The Infection Control Nurse confirmed these actions did not meet infection control standards.
The facility did not clean five out of six mechanical lifts, which were found soiled with dust, sticky substances, and grime. This failure to adhere to the facility's policy on cleaning lifts posed a risk of infection spread. An LN confirmed the unclean state of the lifts during observations and interviews.
A resident with multiple health conditions and severe cognitive impairment received only one shower over two months, despite needing maximal assistance with ADLs. The facility's policy required routine bathing to promote cleanliness and skin condition observation, but records showed no documented refusals, indicating a lapse in care. The DON confirmed the oversight, noting the importance of showers for skin assessments and accommodating the resident's dialysis schedule.
A facility failed to provide appropriate dialysis care for a resident with ESRD, as their care plan lacked necessary post-dialysis assessments and had incorrect active orders for dressing removal. The care plan did not include assessments for the resident's left arm fistula or instructions to avoid taking blood pressure from the left arm. The DON confirmed the facility's non-compliance with its dialysis care policy.
A facility employed an RN without a valid nursing license, as required by California state laws. The RN worked from November 2023 to January 2024, using a license number that belonged to someone with a similar name. The DON confirmed the oversight in verifying the license, leading to the RN's termination.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to update the responsible party (RP) for a resident, identified as Resident 2, following a fall. This oversight violated the rights of the resident and the RP to be informed of changes in the resident's condition. Resident 2, who was admitted with multiple diagnoses including neoplasm of the colon, pneumonia, and congestive heart failure, had a severe cognitive impairment as indicated by a BIMS score of 8 out of 15. The resident required maximum assistance with daily activities. Despite the fall occurring on 2/21/25 and being documented in the medical record, the RP was not informed, as confirmed by interviews with the resident, nursing staff, and the Director of Nursing (DON). The facility's policy, as outlined in their Acute Condition Changes-Clinical Protocol, mandates that the RP be updated with any fall or change in condition, regardless of the resident's alertness, unless the resident specifically requests otherwise. Interviews revealed that the responsible nurse updated the physician but failed to inform the family member. The DON acknowledged that the update to the RP was missed, and the administrator confirmed the lapse in communication. This deficiency highlights a failure in adhering to the facility's communication protocols regarding resident condition changes.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, resulting in a rate of 10.34% during the survey. This deficiency was observed in the administration of medications to two residents. For Resident #77, a Licensed Vocational Nurse (LVN) administered a multivitamin with mineral tablet instead of the prescribed medication and failed to prime the insulin pen needle before administering insulin lispro, as per the prescriber's orders. The LVN admitted to not knowing the requirement to prime the insulin pen and incorrectly assumed the multivitamin order was interchangeable. For Resident #75, another LVN administered plain senna tablets instead of the prescribed senna-docusate sodium combination for bowel care. The LVN acknowledged the error, stating she should have checked the medication label against the order. Interviews with the Director of Staff Development and the Director of Nursing confirmed that the facility's policy required nurses to verify the five rights of medication administration and check the physician's orders three times, which was not adhered to in these instances.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents within the required timeframe, as outlined in their policy. The policy mandates that any suspicion of abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the administrator and other officials according to state law. Specifically, allegations involving abuse or resulting in serious bodily injury must be reported within two hours. In this case, the facility did not adhere to this policy when an incident occurred between two residents, where one resident reportedly attacked the other, resulting in a scratch and bruising. Resident #12, who was admitted to the facility with a history of muscle weakness, cognitive communication deficit, and arthritis, reported that their roommate, Resident #58, attempted to take their call light and scratched their hand. Resident #58 had a medical history that included cognitive communication deficit, psychotic disorder, major depressive disorder, anxiety disorder, and cerebrovascular disease. Despite the incident being reported to the Administrator and DON via text message, the allegation was not reported to the state survey agency within the required two-hour window. The Administrator delayed reporting because he believed there was no injury to the resident, which was contrary to the facility's policy and state regulations.
Failure to Administer As-Needed Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of an as-needed blood pressure medication for a resident with a history of essential primary hypertension. The resident, who was readmitted to the facility with moderate cognitive impairment, had a care plan that required staff to administer medication for hypertension and monitor blood pressure. Despite having an order for clonidine hydrochloride to be given when the resident's systolic blood pressure exceeded 150 mmHg, the medication was not administered on multiple occasions when the resident's blood pressure readings were above this threshold. Interviews with nursing staff revealed a lack of adherence to the physician's orders, as several Licensed Vocational Nurses (LVNs) acknowledged the oversight but could not recall administering the medication. The Director of Staff Development and the Director of Nursing both emphasized the importance of following physician orders and documenting medication administration. The facility's policy on administering medications also specified that medications should be given in accordance with prescriber orders, highlighting a clear deviation from established protocols.
Lack of Physician's Order for Non-Invasive Mechanical Ventilator
Penalty
Summary
The facility failed to ensure there was a physician's order for the use of a non-invasive mechanical ventilator for a resident diagnosed with obstructive sleep apnea. The resident was admitted to the facility with a medical history that included obstructive sleep apnea and required respiratory therapy. The care plan for the resident included interventions such as providing treatments per physician orders and monitoring oxygen saturation levels. However, a review of the resident's Order Summary Report revealed no active order for the use of the non-invasive mechanical ventilator, despite the resident using it successfully as noted in the Respiratory Therapy Daily and Weekly Progress Notes. Interviews with various staff members, including a Registered Nurse Respiratory Therapist, Licensed Vocational Nurses, the Director of Staff Development, and the Director of Nursing, confirmed that residents using non-invasive mechanical ventilators should have specific orders detailing the settings, application, maintenance, and cleaning of the equipment. The staff acknowledged that the resident used a non-invasive mechanical ventilator but did not have the necessary physician's order, which was a requirement according to the facility's policy and standard practice.
Failure in Hand Hygiene and Glove Use During Incontinence Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during incontinence care for a resident with severe cognitive impairment and a history of hemiplegia and hemiparesis following a cerebral infarction. The resident, who was dependent on staff for toileting hygiene and always incontinent of bowel, was observed receiving care from an LVN and a CNA. During the care, the CNA did not wash her hands or change her gloves after cleaning bowel from the resident's buttocks before applying a clean incontinence brief. Additionally, the CNA touched the bed control with the same gloves used for cleaning. Interviews with the CNA, LVN, Infection Preventionist, Director of Staff Development, and DON confirmed that hand hygiene and glove changes should occur between dirty and clean tasks during incontinence care. The CNA acknowledged her failure to perform hand hygiene or change gloves, and the LVN admitted that both she and the CNA should have changed gloves before placing a clean brief on the resident. The Administrator deferred concerns related to incontinence care to the DON.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation standards, as observed during a survey. The Dietary Manager (DM) was found not wearing a hair net while in the kitchen, which is a requirement according to the facility's Kitchen Cleaning Policy and Procedures. This was confirmed during an interview with the DM, who acknowledged the necessity of wearing a hair net in the kitchen. Additionally, the facility did not comply with its Procedure for Refrigerated Storage, as food items in the walk-in refrigerator were not properly covered, labeled, and dated. Specifically, two pans containing cranberry bars were observed to be uncovered, unlabeled, and undated. These lapses in food safety protocols posed a potential risk for exposure to foodborne illnesses among the 110 residents who rely on the kitchen for their meals.
Privacy Breach During Medical Care
Penalty
Summary
The facility failed to ensure the right to personal privacy for a resident when patient care was provided without privacy. The deficiency was observed when a licensed nurse checked the resident's blood sugar and administered an insulin shot at the dining table in the presence of other residents. This action did not align with the facility's standard practices for ensuring patient privacy and dignity. The resident involved had been admitted with diagnoses including dementia, cognitive communication deficit, and diabetes. The Infection Control Nurse confirmed that the actions observed did not meet the facility's standards for maintaining patient privacy.
Infection Control Breach in Dining Room
Penalty
Summary
The facility failed to adhere to infection control measures when a Licensed Nurse (LN A) provided patient care in the dining room, contrary to the facility's infection control policy. Specifically, LN A checked a resident's blood sugar and administered insulin at the dining table, actions that were confirmed by the Infection Control Nurse (IP) as not meeting the facility's infection control standards. The resident involved had been admitted with diagnoses including dementia, cognitive communication deficit, and diabetes, which required regular monitoring and management of blood sugar levels. The facility's infection prevention and control program, dated August 2016, emphasized the importance of instituting measures to avoid the spread of infection and adhering to proper techniques and procedures. However, during observations, LN A was seen performing blood sugar checks and insulin administration in the dining room, which posed a risk of spreading infection to other residents present. This was confirmed through an interview with the IP, who acknowledged that these actions did not align with the facility's infection control policy.
Failure to Clean Mechanical Lifts
Penalty
Summary
The facility failed to maintain cleanliness of assistive devices used for transferring residents, specifically five out of six mechanical lifts. During observations and interviews, it was noted that these lifts were soiled with cumulative dust, sticky yellow and brown substances, dried food particles, and grime. A Licensed Nurse confirmed the unclean state of the lifts, acknowledging the potential for infection spread to residents, staff, and visitors. The facility's policy, revised in July 2017, requires washing and sanitizing lifts according to the manufacturer's instructions, which was not adhered to in this instance.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for one resident, specifically in ensuring routine and scheduled showers and bathing were completed. The facility's policy on bathing, revised in February 2018, emphasized the importance of promoting cleanliness, comfort, and skin condition observation, with a directive to notify a supervisor if a resident refused a shower or bath. However, a review of the resident's medical records revealed that the resident only received one shower over a two-month period, with no documented refusals, indicating a lapse in adherence to the facility's policy. The resident in question was admitted with multiple health conditions, including a fracture, diabetes, high blood pressure, heart disease, and dependence on renal dialysis. The resident's care plan highlighted a potential impairment to skin integrity and required staff to keep the skin clean and dry. The resident was assessed as needing maximal assistance with ADLs, including bathing, and had a severe cognitive impairment, making them unable to make their own decisions. Despite these needs, the Director of Nursing confirmed the resident only received one shower in two months, acknowledging the importance of showers for skin assessments and the need to accommodate the resident's dialysis schedule.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident requiring renal dialysis, as evidenced by the lack of comprehensive assessments and pertinent interventions in the resident's care plan. The facility's policy on end-stage renal disease care, revised in September 2010, mandates that residents with ESRD be cared for according to recognized standards, and that staff be trained in the care and special needs of these residents. However, the care plan for the resident in question did not include necessary post-dialysis assessments, such as checking the left arm fistula for bleeding and ensuring that blood pressure was not taken from the left arm. Additionally, there was a discrepancy in the active orders for the resident, which indicated incorrect days for the removal of pressure dressings from the dialysis fistula site. The orders specified removal on Monday, Wednesday, and Friday, while the resident actually attended dialysis sessions on Tuesday, Thursday, and Saturday. This inconsistency in the care plan and active orders was confirmed by the Director of Nursing during an interview, acknowledging that the facility did not adhere to its policy and procedure for dialysis care for the resident.
Unlicensed RN Employed in Facility
Penalty
Summary
The facility failed to ensure that professional staff were licensed in accordance with California state laws, as evidenced by the employment of a registered nurse (RN) without a valid nursing license. The RN was employed from November 2, 2023, through January 4, 2024, without a valid license issued by the California Board of Registered Nursing. The facility's job description for the RN-Charge Nurse position required a current, unencumbered, active license to practice as an RN in the state. However, the RN presented a license number that, upon verification, was found to belong to an individual with a similar but differently spelled name and a different middle name. The Director of Nursing (DON) confirmed during an interview that the RN was not licensed and acknowledged missing the verification upon hire. The DON admitted to not checking the middle name for validity and confirmed the error in the spelling of the RN's first name. The RN's employment was subsequently terminated on January 5, 2024, after the discrepancy was discovered. This oversight had the potential to result in substandard quality of care for all residents in the facility.
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What surveyors actually found near you
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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.
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Nursing homes near Redding
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vibra Hospital Of Northern California D/p Snf | 0.9 mi | ★★★★★ | 0 | 0 |
| Redding Post Acute | 1.4 mi | ★★★★★ | 16 | 0 |
| River Valley Healthcare & Wellness Centre, Lp | 1.7 mi | ★★★★★ | 1 | 0 |
| Copper Ridge Care Center | 2.5 mi | ★★★★★ | 15 | 0 |
| Crestwood Wellness And Recovery Center | 3.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.