Sierra Post Acute

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 5, 2024

  Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible, affecting one (#1) out of three residents reviewed for accident hazards of three sample residents. The facility failed to provide adequate supervision during a smoking break to a resident, who required the use of oxygen. On 8/21/24 Resident #1 exited the behavioral health secured unit door and entered the smoking patio with his oxygen tank and nasal cannula on his face. Certified nurse aide (CNA) CNA #1 and CNA #2 were present to supervise the resident smoking session. CNA #1 was handing out the cigarettes to the residents and CNA #2 was lighting the cigarette for the residents. […]

• Actual harm, isolatedF689Jan 29, 2026

  Based on observations record review and interviews the facility failed to ensure that the resident environments remained free from accidents hazards as was possible and that each resident had adequate supervision to prevent accidents for for one resident (#10) of three residents reviewed for falls out of sample 34 residents. Resident #10 was admitted on [DATE] for long term care with diagnoses of emphysema (shortness of breath), dementia (impaired memory and thinking), paranoid personality disorder (mental health condition), epilepsy (neurological disorder) and repeated falls. Resident #10 was identified as a high fall risk. Resident #10 sustained eight falls in three months (October 2025 to January 2026).On 10/25/25, Resident #10 sustained a fall where he hit his head. […]

• Actual harm, isolatedF600Oct 20, 2025

  Based on observations, record review and interviews, the facility failed to ensure two (#3 and #1) of five residents were kept free from physical abuse out of five sample residents.Resident #3, was admitted on [DATE] with diagnoses of malignant neoplasm of left lung, heart failure, closed nondisplaced intertrochanteric fracture of left femur, unspecified dementia, pulmonary emphysema and post-traumatic stress disorder (PTSD). Resident #4, was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia with psychotic disturbance, cognitive communication deficit, hypertensive chronic kidney disease, and obstructive pulmonary disease.On [DATE] Resident #3 wandered into Resident #4's room. Resident #4 reacted and pushed Resident #3, which caused Resident #3 to fall. […]

• Actual harm, isolatedF689Feb 26, 2025

  Based on record review and interviews, the facility failed to ensure one (#3) of three residents received adequate supervision to prevent accidents out of eight sample residents. The facility failed to develop and implement a person-centered care plan upon Resident #3's admission to the facility that identified the resident's fall risk and put effective interventions into place to reduce falls and prevent injury. Resident #3 fell on [DATE] (10 days after his admission to the facility) and sustained a T12 to L1 fracture, which required surgical intervention. The facility failed to ensure Resident #3 was assessed by a qualified person, a registered nurse (RN), prior to Resident #3 being moved off the floor. Findings include: I. […]

• Actual harm, isolatedF692Oct 24, 2023

  Based on observations, record review and interviews, the facility failed to ensure one (#15) of one resident reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 41 sample residents. Resident #15 was admitted to the facility on [DATE]. His admission weight on 9/30/19 was188.4 pounds (lbs). The resident maintained a weight between 180 lbs to 200 lbs between January 2022 and June 2023. The resident was hospitalized in July 2023. When he returned to the facility, the facility failed to weigh the resident until August 2023. The facility did not attempt to weigh the resident after he refused one weight. The registered dietitian (RD) recommended weekly weights in July 2023 and no weights were obtained. […]