Health inspection·July 24, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based 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. Findings: During a review of Resident 1's Care Plan (CP) , dated 5/16/17, the CP indicated, [Resident 1] is at risk for falls with or without injury related to poor safety awareness. Interventions: Bed alarm, ensure in proper working order, answer promptly. During an observation on 7/19/24 at 11:30 a.m. in Resident 1's room, Resident 1 did not have a bed alarm on his bed. During an interview on 7/19/24 at 12:35 p.m. with Assistant Director of Nursing (ADON), ADON stated Resident 1 is at risk for falls. ADON stated, [Resident 1] will hang his feet on the side of the bed. He will attempt to transfer. During an interview on 7/19/24 at 12:39 p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated, [Resident 1] tries to get out of bed occasionally. During a review of Resident 1's Fall Risk Observation/Assessment (FROA), dated 7/5/24, the FROA indicated Resident 1 had a score of 24 (score of 16-42 means high risk for falls). During an interview on 7/19/24 at 12:52 p.m. with ADON, ADON stated Resident 1's care plan was not followed and she expects Resident 1 to have a bed alarm. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Page 1 of 2 055568 055568 07/24/2024 Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few Findings: During a concurrent observation and interview on 7/24/24 at 11:46 a.m. with Resident 5 in Resident 5's room, Resident 5 was lying in bed and his call light was hanging on the wall behind his bedside drawer. Resident 5 stated he cannot find his call light. He stated, Where is it [call light]? During an interview on 7/24/24 at 11:50 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 5's call light was not within his reach. CNA 2 stated Resident 5's call light should have been placed within his reach. During a review of Resident 5's Minimum Data Set (MDS – an assessment tool), dated 5/17/24, the MDS indicated Resident 5 had a BIMS (Brief Interview for Mental Status) of 7 (score of 0-7 means severe cognitive impairment). The MDS indicated Resident 5's both lower extremities have limitation that interfered with daily functions. During a review of Resident 5's Care Plan (CP), CP indicated, [Resident 5] has an ADL [Activities of daily living – activities related to personal care] self care performance deficit r/t [related to] general weakness/impaired balance/transfer, bilateral AKA [Above the knee amputation- both lower limbs were surgically removed], need assistance for personal care. Interventions: Bed Mobility: dependent. Dressing: dependent. Personal Hygiene: dependent. Toileting: dependent. During a review of the facility's policy and procedure (P&P) titled, Call Light, Use of, dated 2018, the P&P indicated, Be sure all call lights are placed within the reach of each resident, never on the floor or bedside stand. 055568 Page 2 of 2