Sierra Valley Rehab Center

In the surveyor’s words

From the most serious findings on record at Sierra Valley Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF656Nov 4, 2024

  Based 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). […]

• Actual harm, isolatedF689Feb 14, 2023

  Based on interview and record review, the facility failed to provide the necessary assistance for one of one sampled resident (Resident 1) when Certifed Nursing Assistant (CNA) 1 attempted to transfer the resident with no assistance from another staff resulting in the resident falling to the ground. The facility also failed to complete the Fall Risk Evaluation (FRE - an assessment containing a series of questions which are used to determine if a resident is at risk of falling. […]

• Actual harm, isolatedF689May 17, 2022

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was transferred by two staff. This failure resulted in Resident 1 experiencing an assisted fall resulting in a fracture. Findings: During a review of Resident 1's Progress Notes (PN), dated 2/2/22, at 9:43 AM, the PN indicated, Alerted by staff member, while attempting to transfer resident from bed to wheelchair, she was uanble [sic] to transfer her and slid her down to her bottom onto the floor. Upon entering residents room, resident noted to be by her bed sitting on her bottom with assistance from staff member. […]

• Actual harm, isolatedF580Sep 14, 2021

  Based on interview and record review the facility failed to notify the physician of a swollen hip and pain with movement for one of one sampled residents (Resident 1). This failure resulted in severe untreated pain for Resident 1 and a delay in acute medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: During an interview on 6/24/21, at 1 PM, with Director of Nursing (DON), DON stated, the facility transferred Resident 1 to the acute hospital on 12/13/20 and the hospital diagnosed Resident 1 with a left hip fracture (break in bone). DON stated, Resident 1 did have pain on 12/12/20. During an interview on 6/24/21, at 3 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she worked with Resident 1 on 12/13/20 around 3 AM to 6 AM. […]

• Actual harm, isolatedF697Sep 14, 2021

  Based on interview and record review the facility failed to provide pain medication for one of one sampled residents (Resident 1). This failure resulted in Resident 1 experiencing unresolved pain due to a broken hip for approximately 12 hours during which she would scream and moan with pain, and swat away staff during provision of care. Findings: During an interview on 6/24/21, at 1 PM, with the Director of Nursing (DON), DON stated, the facility transferred Resident 1 to the acute hospital on 12/13/20 and the hospital diagnosed her with a left hip fracture. […]