Sierra Valley Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed for one of three sampled residents (Resident 1). This failure resulted in a delay of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the binding Arbitration Agreement (a contract that requires parties to resolve disputes outside of court) was written in a form and manner resident could understand for three of three sampled residents (Resident 44, Resident 70, and Resident 329). This failure had the potential for Resident 44, Resident 70, and Resident 329 to sign the Arbitration Agreement without understanding the implications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice for infection control when: 1. One of one sampled resident (Resident 42) presented with signs and symptoms of a cough and treated with Influenza (flu-a contagious respiratory virus) medication was not put in Droplet Isolation Precautions (Isolation for residents with contagious respiratory symptoms requiring resident to be isolated and staff/visitors to wear a gown, gloves, and a mask. 2. Two of two sample residents (Resident 4 and Resident 42) requiring oxygen, did not have the tubing on their oxygen and nebulizer machine dated and timed and oxygen tubing found on the floor uncovered. 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the dining room was accessible and had space to accommodate the 132 Residents who reside at the facility. This failure had the potential to negatively affect the resident's social interaction, physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete MDS (Minimum Data Set- A tool used to collect data to establish person-centered care needs) for one of 55 sampled residents (Resident 47). This failure had the potential for Resident 47 to not receive care based on his specific needs.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, for one of 55 sampled residents (Resident 329) when communication interventions were not developed and implemented. This failure had the potential for Resident 329's communication and care needs to not be met.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow medication orders for one of 13 residents (Resident 76). These failures had the potential for Resident 76 to not receive the full effect of the medication.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Physician Orders, Accepting, Transcribing, Carrying Out and Implementing (Noting), for one of two sampled residents (Resident 126) when Resident 126's wound treatment orders were not implemented. This failure resulted wound care not being provided for Resident 126's right heel blister which had the potential for development of infection and delayed wound healing.

Inspectors wroteBased on interview and record review, the facility failed to provide hearing aids for one of one sampled resident (Resident 22). This failure had the potential to affect Resident 22's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Administration Set/Tubing Changes for one of one sampled resident (Resident 329). This failure had the potential to place Resident 329 at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual competencies were completed for one of five sampled Certified Nursing Assistants (CNA) 1. This failure had the potential for CNA 1 to not be competent when providing care to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Food Preparation, for one of one cooks (Cook 1) when [NAME] 1 did not measure recipe ingredients. This failure had the potential for residents' nutritional needs to not be met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistive feeding devices were available for one of one sampled resident (Resident 72). This failure had the potential to prevent Resident 72 from maintaining or improving his independence in self-feeding skills when consuming meals and snacks.

Inspectors wroteBased on observation, interview, and record review, the facility failed implement its Policy and Procedure (P&P) titled, Smoking, for one of 21 Residents (Resident 4) when tobacco was at the bedside, a smoking care plan and smoking assessment were not completed. These failures had the potential to place residents, visitors, and staff at risk for injury/harm due to potential unsafe smoking practices and access to tobacco.

Inspectors wroteBased on observation and interview, the facility failed to provide the minimum square footage as required by regulation in 20 of 48 facility bedrooms. This failure had the potential to affect the care and safety of residents.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse inflicted by his roommate (Resident 2). This failure resulted in Resident 1 being agitated, noisy, restless and the inability to sleep with the potential for psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1) when verbal abuse was not reported to the Administrator. This failure resulted in Resident 1 experiencing persistent verbal abuse from his roommate (Resident 2).

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure when a resident-to-resident allegation of abuse was not reported to California Department of Public Health (CDPH-state agency) per facility policy and procedure for two of two sampled residents (Resident 4 and Resident 5). This failure resulted in the allegation of abuse not being reported to CDPH timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan was followed for one of three sampled residents (Resident 3) when the mesh stop sign on Resident 3's door was not in use. This failure had the potential for residents to wander into Resident 3's room.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician orders were implemented for one of three sampled residents (Resident 3). This failure resulted in Resident 3 not receiving the medication as ordered by the physician and had the potential for adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled staff Licensed Vocational Nurses (LVN 1) competencies were completed. This failure had the potential for LVN 1 to be incompetent when providing care for the residents'.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication was documented when administered for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's medical record to be inaccurate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement comprehensive person-centered care plan for activities of a daily living (ADL) when Hoyer (mechanical, device used to safely lift and transfer patients who have limited mobility) lift was not used to transfer one of three sampled residents (Resident 1) from wheelchair to bed. This failure resulted in Resident 1 falling multiple times and sustaining two broken bones in each lower leg, requiring an open reduction and internal fixation (ORIF, surgical procedure to repair broken bones that may include use of screws, rods, or plates) of the left upper tibia and lateral tibial plateau plate (shin bone).

Inspectors wroteBased on interview and record review, the facility failed to ensure nutritional interventions were implemented for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have unmet nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan was implemented for one of six sampled residents (Resident 1) when Resident 1 was not provided a bed alarm (device that alerts staff when a resident gets out of bed). This failure had the potential to place Resident 1 at risk for falls resulting in injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of six sampled residents (Resident 5). This failure had the potential for Resident 5 to be unable to call for help and his needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 103, Resident 281, and Resident 49) dialysis (procedure to mechanically remove waste products and excess fluid from the blood when the kidneys stop working properly) assessments were completed. This failure had the potential for dialysis related complications to occur/worsening of residents health condition.

Inspectors wroteBased on interview and record review the facility failed to develop a system to demonstrate nursing competencies for licensed nursing staff. This failure had the potential to result in nursing staff not being competently skilled to meet the care needs of the facility's residents.

Inspectors wroteBased on interview and record review, the facility failed to discontinue Seroquel (a psychotropic medication used to treat mental disorders that affect a person's ability to think, feel, and behave clearly) for one of four sampled residents (Resident 95) when the physician agreed with the pharmacist's recommendation to discontinue the medication. This failure resulted in Resident 95 receiving a mind-altering medication unnecessarily for 89 days.

Inspectors wroteBased on interview, and record review, the facility failed to utilize the Registered Dietitian(s) (RD) expertise and skills sets to carry out the functions of the food and nutrition services when: 1. The RD documented imposed limitations of allowed hours the RD had at the facility impeded the following: timely weight reviews for residents, timely admission nutrition assessments for residents (Resident 18 and Resident 23), and inconsistent ability to conduct a monthly kitchen inspection to provide oversight over food safety, sanitation, evaluation of menus and therapeutic diets and lack of nutritional products/resources to offer choices to residents, when needed. 2. The RD was not incorporated into the IDT (interdisciplinary) weight review (care planning for weight change), in a timely manner, to address Resident's 10 significant weight loss. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the contract for Registered Dietitian (RD) services included clear guidelines for the development of action plans, prompt implementation and monitoring of the Registered Dietitian's recommendations to address the nutritional needs of the residents. This failure resulted in an untimely RD assessment for Resident 10, and had the potential for delay in identifying and addressing other residents' nutritional needs in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 53) was assessed by the Interdisciplinary Team (IDT) for his ability to safely self-administer medication Cough Drops Mouth/Throat Lozenge 5.8 MG [milligrams-metric unit of weight]. This failure had the potential to adversely affect Resident 53's health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 50 sampled residents (Resident 119) and her Responsible Party (RP) were provided a copy of the baseline care plan (BCP). This failure had the potential for Resident 119 and her RP to be unaware of her plan of care.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a person-centered care plan for 1 of 50 sampled residents (Resident 18) when the facility continued to offer an oral nutrition supplement (ONS) after Resident 18 expressed dislike of the ONS. This failure had the potential to result in further significant weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 50 sampled residents (Resident 10) care plan was updated and revised after Resident 10's order for tube feeding (TF-a way to provide nutrition when you cannot eat or drink safely by mouth) was changed. This failure had the potential to result in further significant weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nail care was provided for two of 50 sampled residents (Resident 42 and Resident 10). This failure had the potential to result in skin injuries, infections, and pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 50 sampled residents (Resident 18) bowel (the tubes in your body through which digested food passes from your stomach to your anus) management protocol was followed. This failure resulted in Resident 18 not having bowel movement for four days and had the potential to result in worsening of his health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 10) was accurately assess for risk of elopement (leaving an area without supervision or permission). This failure had the potential for Resident 10 to get out of the facility without supervision and compromise his safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled resident's (Resident 54) Foley Catheter (FC - flexible tube inserted into the bladder to drain urine) was monitored. This failure had the potential to result in FC dislodgement.

Inspectors wroteBased on interview, and record review the facility failed to ensure timeliness of Registered Dietitian (RD) nutrition assessment after a significant weight loss for one of four sampled residents (Resident 10) who received nutrition via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach). This failure resulted in delayed nutrition interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Medication Administration for one of six sampled residents (Resident 93) when nursing staff did not administer the correct medication and dose ordered by the physician. This failure had the potential to adversely affect Resident 93's health condition.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Obtain a physician's order for one of four sampled residents (Resident 95) to discontinue Seroquel (medication used to treat mental disorders that affect a person's ability to think, feel, and behave clearly) after the physician had agreed to the recommendation of the pharmacy consultant. 2. Follow-up/obtain physician's order for one of four sampled residents (Resident 42) to include parameter/recommendation by pharmacy consultant in administering Percocet (Oxycodone-Acetaminophen - pain medication used to treat moderate to severe pain, known to cause drowsiness and respiratory distress or even death when taken in high doses or combined with other substances). These failures had the potential for Resident 95 and Resident 42 to received unnecessary medications for prolonged period of time.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 15) pain level was properly assess prior to administering narcotic (highly addictive controlled medication used to relieve pain) pain medication. This failure had the potential for Resident 15's pain to not appropriately treated and worsening of her health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled Dietary Aide (DA)1 demonstrated the correct technique for testing the sanitation of dishes after running dishes through the low temperature dish machine. This failure had the potential to cause foodborne illness (illness caused by contaminated food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and/or facility's diet manual as planned for two of eight sampled residents (Resident 23 and Resident 85) when: 1. Lettuce in the tossed green salad and whole, sliced tomatoes were served that were larger than 1/2 (inch) pieces for Resident 23's mechanical soft (diet designed for people that have trouble chewing and swallowing) diet order. 2. Entree alternates were not nutritionally evaluated by a registered dietitian (RD) for Resident 85's CCHO (controlled carbohydrate diet for diabetes) diet. This failure had the potential for Resident 23 to choke and Resident 85 to have elevated blood sugars.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling and sanitation when: 1. A Time Temperature Control for Safety (TCS- food that requires time-temperature control to prevent the growth of bacteria) food was not cooled down according to facility's policy. 2. One of one sampled dietary aide (DA 2) washed her hands after handling dirty dishes and prior to handling clean dishes. These failures had the potential to result in the development of foodborne (caused by contaminated food) illness.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Ensure an accurate and complete clinical record (CR) for one of one sampled resident (Resident 10). This failure resulted in weight loss interventions not carried out in a timely manner. 2. Follow its policy and procedure (P&P) titled, Resident Participation - Assessment/Care Plans for one of six sampled residents (Resident 52). This failure had the potential for Resident 52 to not have the opportunity to participate in, be aware of and develop care goals and outcomes, and incorporate his personal and cultural preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Handwashing/Hand Hygiene when a Licensed Vocational Nurse (LVN) 1 did not change gloves or perform hand hygiene after checking the blood sugar for one of two sampled residents (Resident 126). This failure had the potential to result in the spread of bloodborne pathogens (germs that are carried in the blood and can cause disease in people).

Inspectors wroteBased on interview and record review the facility failed to follow its policy and procedure titled Consent to Treat for three of 50 sampled residents (Resident 10, Resident 280, and Resident 282 when: 1. Resident 10 was given Flu (contagious respiratory illness) vaccine without obtaining a consent. 2. Resident 280 and Resident 282 were not assessed and offered Flu vaccines on admission. These failures had the potential to spread miss information and infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the minimum square footage as required by regulation in 20 of the facility's bedrooms. This had the potential to affect the care and safety of residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was transferred using a Hoyer (assistive device that allows patients to be transferred between a bed and a chair) lift according to the comprehensive care plan. This failure resulted in Resident 1 falling and sustaining an acute intertrochanteric (fracture [broken bone] of the proximal [near the center of the body] femur [thigh bone] that occur between the greater and lesser trochanter [part of the femur near its joint with the hip bone]) fracture to the left hip.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order to apply an immobilizer (or sling to reduce or eliminate motion of the body or a part of the body) for one of three sampled residents (Resident 1). This failure had the potential to result in worsening of Resident 1 ' s fracture (broken bone) of the right upper arm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five dietary aides (DA) performed handwashing upon entering the kitchen. This failure had the potential to result in contamination of residents' food which may lead to foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff have competencies necessary to care for two of 33 sampled residents (Resident 32, Resident 46) based on the resident's needs. This failure had the potential for the resident's unmet care needs and delay in provision of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for two of 33 sampled residents (Resident 17 and Resident 71) when: 1. Licensed Vocational Nurse (LVN) 3 did not pull the privacy curtain while administering medication to Resident 17's gastrostomy tube (G-tube - tube inserted through the stomach that brings nutrition directly to the stomach). 2. Resident 71's urinary catheter drainage bag (bag that collects urine) was not covered with a privacy bag. These failures had the potential for Resident 17 and Resident 71 to have a decrease in feelings of self worth and self esteem.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for a diabetic ulcer (injury to the skin) for one of 33 sampled residents, (Resident 296). This failure had the potential for not providing the appropriate care and adversely affect Resident 296's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders were followed for two of 33 sampled residents (Resident 32 and Resident 71). These failures had the potential for adverse outcomes of residents care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to ensure residents maintain the highest level of range of motion (ROM - measurement of movement around a specific joint or body part) and mobility (the ability to move or be moved freely and easily), for two of 33 sampled residents, (Resident 46, and Resident 36). These failures had the potential for a decline in ROM and an avoidable change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing information was posted daily, readily accessible and visible to all residents and visitors for one of three nursing stations (Nursing Station One). This failure had the potential to result in data regarding the number of staff and the actual hours worked of staff was not accurate, accessible and posted visibly by residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist psychotropic medication (drug that affects brain activities associated with mental processes and behaviors) recommendation was acted upon for one of 33 sampled residents (Resident 66). This failure had the potential for adverse drug reactions, excessive duration, excessive dose and/or unnecessary use of psychotropic medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention and control standards, when a certified nursing assistant (CNA) 1 did not don (put on) the proper personal protective equipment (PPE - protective clothing designed to protect the wearer's body from injury or clothing). This failure had the potential to result in spreading infection to residents, other staff, and visitors.

Inspectors wroteBased on observation and record review, the facility failed to provide the minimum square footage as required by regulations in 19 of the facility's bedrooms. This had the potential to affect the care the residents receive in these rooms.