Health inspection·December 30, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow their policy and procedure when a resident-to-resident allegation of abuse was not reported to California Department of Public Health (CDPH-state agency) per facility policy and procedure for two of two sampled residents (Resident 4 and Resident 5). This failure resulted in the allegation of abuse not being reported to CDPH timely. Residents Affected - Few Findings: During a review of the Initial Facility Reported Event (IFRE), (undated), the IFRE indicated, Date/Time Reported: 12/16/24 approx. (approximately) 5 p.m. CDPH.Obtained knowledge 12/16/24 of incident on 12/14/24 at approx. 5:44 p.m. (approximately 48 hours prior to the abuse being reported) .Type of Incident. resident-to-resident physical contact.An incident of resident-to-resident mistreatment occurred between (Resident 5) and (Resident 4). Per staff witness, both residents were initially arguing when (Resident 4) kicked (Resident 5). During a review of Resident 4's Minimum Data Set (MDS-resident assessment tool) dated 12/8/24, the MDS indicated, Brief Interview for Mental Status (BIMS).12 (moderately impaired cognitively). During a review of Resident 5's Minimum Data Set (MDS-resident assessment tool) dated 12/7/24, the MDS indicated, Brief Interview for Mental Status (BIMS). 03 (severe cognitive impairment). During an interview on 12/16/24 at 4:22 p.m. with Administrator (prior to the facility reporting the incident), Administrator stated he was not aware of the resident-to-resident (Resident 4 and Resident 5) altercation on 12/14/24, but it should have been reported to CDPH. During an interview on 12/30/24 at 2:28 p.m. with Social Services Director (SSD), SSD stated when the resident-to-resident (Resident 4 and Resident 5) altercation occurred, the staff should have notified the abuse coordinator right away and it should have been reported to CDPH per facility policy. During a review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating the P&P indicated If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.Immediately is defined as. within two hours of an allegation involving abuse or result in serious bodily injury. 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 5 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 12/30/2024 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)