Quartz Hill Post Acute

In the surveyor’s words

From the most serious findings on record at Quartz Hill Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF758Jun 29, 2022

  Based on interview and record review, the facility failed to safely monitor and evaluate a newly prescribed high-risk medication (drugs with potential to cause significant harm)called [MEDICATION(S)] (medicine used to treat mood swings) in one (Resident 1) out of three sampled residents when: The Medical Doctor (MD 1) did not order the necessary laboratory (or lab- blood test) tests to evaluate the drug level, did not address the warning signs of drug toxicity (severe medical condition as result of drug effect on the body) and/or did not seek specialized expert opinion in handling the case or consult the facility's Consultant Pharmacist (CP, a pharmacist that helped facility with drug review and monitoring). […]

• No harm, potential for more than minimal, widespreadF812Jan 23, 2025

  Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation requirements were met in accordance with professional standards for food service safety when: 1. Dietary Manager (DM) was not wearing a hair net in the kitchen. 2. Food was not properly covered, labeled and dated. These failures created a potential risk for exposure to foodborne illnesses in a medically vulnerable population of 110 residents who received food prepared in the kitchen. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF812Mar 10, 2023

  Based on observation, interview and record review, the facility failed to ensure professional food safety and sanitation practices were in place when: 1. Inappropriate use of hats and hairnets were observed for three dietary staff members. 2. Four out of four chicken breasts were not stored and handled according to professional standards of practice. 3. Chlorine test strips were not available to all staff, two out of two staff used the wrong test strip, and chlorine test strip results were incorrectly. 4a.The walk-in freezer floor, dry storage rice bin, prep area drawers, stationary and non-stationary fans, reach-in refrigerator, and the ice machine were not clean. b. […]

• No harm, potential for more than minimal, widespreadF908Mar 10, 2023

  Based on observation, interview and record review, the facility failed to maintain resident food in safe storage when the facility's walk-in freezer had severe ice buildup and was not maintained in a safe operating condition. This had the potential for equipment failure. Findings: During a concurrent observation and interview with Dietary Manager (DM) on 3/7/23 at 9:40 AM, the walk-in freezer was observed to have severe ice buildup on the floor, shelves, walls, ceiling, condenser fans, the piping that hooks up to the condenser fans, and black mat that covered the floor. DM confirmed the severe ice found in all locations of the walk-in freezer and stated the walk-in freezer floor is cleaned weekly or as needed, including the black mat that covered the floor. […]

• No harm, potential for more than minimal, patternF759Feb 13, 2025

  Based on observation, record review, interview, document review, and facility policy review, the facility failed to ensure a medication error rate of five percent or less. There were three errors out of 29 opportunities, which yielded a medication error rate of 10.34% for 2 (Resident #77 and Resident #75) of 4 residents observed for medication administration. Findings included: A facility policy titled, Administering Medications, revised 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame and 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. […]