Sierra Basin Post Acute

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF609Mar 12, 2026

  Based on interview, clinical record review, and document review, the facility failed to report an allegation of staff-to-resident physical abuse for 1 of 18 sampled residents (Resident #24). This deficient practice could allow allegations of abuse to occur and not be reported for investigation resulting in continued or worsening abuse of vulnerable residents throughout the facility.Findings include:Resident #24Resident #24 was admitted to the facility on [DATE], with diagnoses including fracture of left femur, fracture around internal prosthetic left hip joint, and chronic obstructive pulmonary disease.On 03/09/2026 at 12:00 PM, Resident #24 verbalized a Certified Nursing Assistant (CNA) had handled the resident roughly and the resident was concerned the CNA would cause further injury to… […]

• No harm, potential for more than minimal, patternF943Jan 16, 2025

  Based on interview, personnel record review and document review, the facility failed to ensure staff were trained on the prevention of elder abuse prior to engaging with residents for 8 of 20 sampled personnel records reviewed (Employee #1, #10, #13, #14, #15, #16, #19, and #20). Findings include: On 01/15/2025 at 11:40 AM, the Business Office Coordinator (BOC) and the Administrator participated in an interview to confirm the accuracy of the Personnel Records Checklist completed by the facility for 20 employees. On 01/15/2025 at 11:40 AM, the BOC and the Administrator verbalized elder abuse training was required upon hire, annually, and as needed (PRN). Employee #1 Employee #1 was hired as the Administrator with a start date of 05/28/2024. […]

• No harm, potential for more than minimal, patternF690Jan 16, 2024

  Based on interview, observation, clinical record review, and document review the facility failed to ensure a process was developed and implemented to assess/screen residents for participation in a bowel and bladder retraining program with the potential to affect the facility's entire resident census of 48 and 1 of 12 sampled residents (Resident #9) was assessed to determine if the resident was a candidate for a bowel and bladder retraining program. Findings include: Bowel and Bladder Program 01/09/24 at 12:03 PM, the Director of Nursing Services (DNS) explained the initial resident assessment drove a resident's plan of care. A bowel and bladder assessment were done upon admission as part of the required Minimum Data Set 3.0 (MDS) assessment. […]

• No harm, potential for more than minimal, patternF642May 20, 2021

  Based on clinical record review and interview, the facility failed to ensure the Minimum Data Set (MDS) Resident Assessment and Care Screening was coordinated and completed by a Registered Nurse (RN) for 8 of 13 sampled residents (Resident #25, #28, #34, #29, #6, #8, #10, and #91). Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section Z: Assessment Administration of an MDS Assessment for Resident #25, documented Section C: Cognitive Patterns and Section D: Mood were signed as completed by a Licensed Practical Nurse (LPN) on 04/27/21. Resident #28 Resident #28 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF658May 20, 2021

  Based on clinical record review, interview and document review the facility failed to meet professional standards related to the completion of resident Minimum Data Set (MDS) assessments by a Licensed Practical Nurse. Findings include: On 05/18/21 at 12:56 PM, and on 05/19/21 at 8:27 AM, a Licensed Practical Nurse (LPN), confirmed having completed and electronically signed Section C: Cognitive Patterns and Section D: Mood of the MDS assessments for 8 of 13 sampled residents (Resident's #25, #28, #34, #29, #6, #8, #10, and #91), to include interviewing each of the residents. The LPN verbalized the LPN did not always consult with Department Heads unless the LPN, finds an issue. […]