Sierra Post Acute

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Ensure residents have reasonable access to and privacy in their use of communication methods.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

A complaint survey, prompted by #CO39038, #CO39095, #CO39097 and Incident #37889 was conducted on 2/25/25 to 2/26/25. One deficiency was cited. 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 12/23/24 (10 days after his admission to the facility. Hospital notes documented a vertebral 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. Facility policy and procedureThe Fall Prevention Program policy and procedure, implemented March 2020, was provided by the nursing home administrator (NHA) on 2/26/25 at 12:08 p.m. It revealed in pertinent part, "Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls."A fall is an event in which an individual unintentionally comes to rest on the ground, or other level, but not as a result of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere."Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident' s level of fall risk. The nurse will indicate the resident' s fall risk and initiate interventions on the resident' s baseline care plan, in accordance with the resident' s level of risk. The nurse will refer to the facility' s high risk or low/moderate risk protocols when determining interventions."High risk protocols: the resident will be placed on the facility' s fall prevention program: indicate fall risk on care plan, place fall prevention indicator on the name plate to the resident' s room and place fall prevention indicator on resident' s wheelchair; implement interventi..

A complaint survey, prompted by #CO39441 was completed on 2/25/25 to 2/26/25. One deficiency was cited. 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 12/23/24 (10 days after his admission to the facility. Hospital notes documented a vertebral 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. Facility policy and procedureThe Fall Prevention Program policy and procedure, implemented March 2020, was provided by the nursing home administrator (NHA) on 2/26/25 at 12:08 p.m. It revealed in pertinent part, "Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls."A fall is an event in which an individual unintentionally comes to rest on the ground, or other level, but not as a result of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere."Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident' s level of fall risk. The nurse will indicate the resident' s fall risk and initiate interventions on the resident' s baseline care plan, in accordance with the resident' s level of risk. The nurse will refer to the facility' s high risk or low/moderate risk protocols when determining interventions."High risk protocols: the resident will be placed on the facility' s fall prevention program: indicate fall risk on care plan, place fall prevention indicator on the name plate to the resident' s room and place fall prevention indicator on resident' s wheelchair; implement interventi..

A complaint survey, prompted by #CO35326 #CO37318 and Incident #37319 was conducted on 9/4/24 to 9/5/24. One deficiency was cited. 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. Resident #1 reached over other residents for his cigarette and CNA #1 handed him a cigarette. Resident #1 proceed to the line to get his cigarette lit. CNA #2 lit his cigarette but did not observe that the resident' s oxygen was in place. Resident #1 proceeded to a chair in the corner of the smoking patio and began smoking his cigarette. CNA #1 and CNA #2 saw another resident running towards Resident #1 and patting his hair which was on fire. Both CNAs ran to Resident #1 and the fire had already been extinguished. CNA #2 immediately removed the resident' s nasal cannula and oxygen tank. CNA #2 turned the oxygen off and both CNAs escorted the resident to the nurse' s station. The nurse immediately called 911 and sent Resident #1 to the hospital related to the burns on his face. Due to the facilities failure to ensure adequate supervision while residents were smoking, Resident #1 sustained burns to his forehead, tip of his nose, both nostrils, upper and lower lip and his cheeks. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/4/24 to 9/5/24, resulting in the deficiency being cited as past noncompliance with a correction date of 8/21/24.I. Accident investigationThe 8/20/24 accident investigation was provided by the NHA on 9/4/24 at 1..