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. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055568 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Valley Rehab Center 301 West Putnam Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)