Health inspection·November 4, 2024

F 0656 Level of Harm - Actual harm stated, During report, I was told that therapy had given CNAs the okay to transfer the resident from walker to bed. I was helping Resident [1] go from the chair to the bed on 9/12/24 when Resident [1] was already standing, and she [Resident 1] stated she was tired, and she started to go down. CNA 2 stated, I assisted her [Resident 1] to the floor. Residents Affected - Few During a review of Resident 1's Interdisciplinary Team Progress Notes (ITPN), dated 9/13/24 at 2:56 p.m., the ITPN indicated interventions for Resident 1: ADL: dependent assist with ADLs and transfers. Anticipate resident needs, provide verbal cue, and safety education. During an interview on 10/22/24 at 1:27 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, She [Resident 1] was assisted by three staff, they used a gait belt [a device that helps with mobility issues to move safely, a thick, woven strap that's placed around a resident's waist and fastened with a buckle] that is why I found a bruise on the left upper arm bicep [a large muscle in the upper arm] area on 9/13/24. During a concurrent observation and interview on 11/4/24 at 10:10 a.m. with Resident 1, in Resident 1 ' s room, Resident 1 was lying in bed with casts (holds a broken bone/fracture in place and prevents the area from moving as it heals) on both lower legs. Resident 1 stated she had two recent falls this month. Resident 1 stated her first fall was on 9/12/24. Resident 1 stated, CNA [2] asked me to stand and use the board. Resident 1 stated she tried to turn her body and fell. Resident 1 stated she had a second fall on 9/20/24. Resident 1 stated every morning the staff has her stand and use the walker from the wheelchair, and the Hoyer lift is never used. Resident 1 stated, CNA [1] asked me to stand. Resident 1 stated she felt weak, and CNA 1 stated, You can do it and next thing I remember is I am on the floor. Resident 1 stated when she was on the floor her knees were bent and she was sitting on her legs. Resident 1 stated a therapist picked her up by her waist and tossed her on the bed. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 8/14/24, the MDS indicated Resident 1 had a Brief for Mental Status (BIMS) score of 14 (score of 13-15 means cognitively intact). During a review of the Resident 1's Progress Notes (PN), dated 9/21/24 at 8:30 a.m., the PN indicated, [Resident 1] had bruising to bilateral lower extremities painful/hot to touch. Pain was 8/10 [using pain scale 0-10, with 0 representing no pain and 10 representing the worst pain possible] and physician was notified, and [Resident 1] was transferred to a local hospital. During a review of the hospital's Image Report (IR), dated 9/23/24, the IR indicated Resident 1 had comminuted displacement fracture (where the bones are broken in several places) to both right and left tibia (inner larger bones between the knee and the ankle on the inside) and fibula (the outer smaller bones between the knee and the ankle). During a review of the hospital's Emergency Department Note (EDN), dated 9/21/24, the EDN indicated, Recommends admission in the hospital and will perform surgery on Monday. During a review of the hospital's Operative Report (OR), dated 9/23/24, the OR indicated, Pre-op diagnosis: Displaced fracture (broken bone not in alignment) right upper tibia (shinbone) and displaced fracture left upper tibia. The OR report indicated (Resident 1) had a surgical procedure for open reduction and internal fixation of the left upper tibia and lateral tibial plateau plate of each leg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055568 If continuation sheet Page 2 of 3 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 11/04/2024 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)

F 0656 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policy and procedure (P&P), titled, Falls - Clinical Protocol, dated 2001, the P&P indicated, Treatment/Management: 1. Will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. During a review of the facility's P&P, Care Plans, Comprehensive Person-Centered, dated 2001, 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. Event ID: Facility ID: 055568 If continuation sheet Page 3 of 3