Inspection Reports for
Sierra Post Acute

The complaint investigation substantiated two incidents of physical abuse: Resident #4 pushed Resident #3 causing a fall and fracture, and Resident #2 hit Resident #1 causing a black eye. Both incidents were investigated with interviews, observations, and care plan reviews.

The facility failed to protect residents from physical abuse by other residents, resulting in actual harm including a femur fracture and a facial injury. Investigations substantiated two separate incidents of resident-to-resident abuse involving multiple residents.

The complaint investigation substantiated physical abuse incidents involving Resident #3 being pushed by Resident #4 causing a fracture, and Resident #1 being hit by Resident #2 causing a black eye. Both incidents were investigated with interviews, observations, and review of care plans and progress notes.

The facility failed to protect residents from physical abuse by other residents, resulting in actual harm including a fractured femur and physical altercations causing bruising. Investigations substantiated the incidents and documented interventions such as 15-minute checks and behavioral care plans.

The complaint investigation focused on Resident #3 who fell out of bed on 12/23/24 and sustained a vertebral fracture. The facility delayed notifying the resident's representative and failed to implement recommended fall prevention measures such as installing bed rails and using a fall mat. The resident was not assessed by a registered nurse immediately after the fall, contrary to facility policy.

The facility failed to develop and implement a person-centered care plan addressing Resident #3's fall risk and did not ensure a registered nurse assessed the resident prior to moving him off the floor after a fall. The resident sustained a vertebral fracture requiring surgical intervention following the fall.

The complaint investigation focused on Resident #3's fall on 12/23/24, delayed family notification, lack of RN assessment post-fall, and failure to implement recommended fall prevention interventions. The resident sustained a vertebral fracture requiring surgery. The facility acknowledged deficiencies in care planning and supervision.

The facility failed to develop and implement a person-centered care plan addressing Resident #3's fall risk, did not ensure a registered nurse assessed the resident immediately after the fall, delayed family notification, and failed to install recommended safety interventions such as bed rails and fall mats. Resident #3 sustained a significant vertebral fracture requiring surgical intervention.

The investigation was triggered by a complaint regarding a resident who was burned when his oxygen ignited during a supervised smoking session on 8/20/24. The incident was substantiated, and the facility was found to have failed in supervision and safety protocols.

The facility failed to ensure adequate supervision during a smoking break for a resident using oxygen, resulting in the resident sustaining burns to his face. The facility took corrective actions including staff education, suspension pending investigation, policy review, and implementation of monitoring audits.

The investigation was complaint-related due to an incident on 8/20/24 where Resident #1's oxygen ignited while smoking, causing burns. The resident was hospitalized and the incident was substantiated. Staff involved were suspended and reeducated. The facility implemented corrective actions including policy review, staff reeducation, and daily audits.

The facility failed to provide adequate supervision during a smoking break for a resident using oxygen, resulting in the resident sustaining burns to his face. The facility corrected the deficient practice prior to the onsite investigation and implemented reeducation and policy revisions to prevent recurrence.

The facility failed to maintain a sanitary and comfortable environment, with multiple observations of debris, food crumbs, mouse droppings, and pest traps in resident areas. The pest control program was ineffective in mitigating mice populations and preventing their entry into the building.

The facility failed to ensure a sanitary and comfortable environment across multiple units, with issues including debris, food crumbs, mouse droppings, unpleasant odors, and gaps allowing pest entry. The pest control program was ineffective in mitigating mice populations, with evidence of ongoing mouse activity and inadequate pest prevention measures.

The facility was found deficient in maintaining a safe, clean, and homelike environment with issues such as foul odors, unclean resident rooms, and poorly maintained common areas. Medication administration was not consistently in accordance with physician orders, including failure to hold antihypertensive medications when vital signs were out of range and failure to provide prescribed zinc supplementation for wound healing. Nutritional care was inadequate, resulting in significant weight loss for one resident due to lack of proper monitoring and interventions. The facility also lacked a full-time registered nurse designated as director of nursing, with one individual performing multiple leadership roles.

The facility was found deficient in multiple areas including failure to accommodate resident mobility needs, inadequate homelike environment, unresolved resident grievances, insufficient meaningful activities, improper urostomy care, lack of full-time director of nursing, medication administration errors, expired medications storage, inadequate hot water supply, and ineffective pest control program.

The facility was found deficient in maintaining a homelike environment free of foul odors and in good repair, ensuring proper medication administration according to physician orders, providing adequate nutritional care to prevent significant weight loss, and designating a full-time registered nurse as director of nursing. Several residents experienced issues including foul odors, unclean rooms, medication errors, significant weight loss, and lack of proper leadership.

The facility was found deficient in multiple areas including failure to accommodate resident mobility needs, inadequate maintenance of a safe and homelike environment, failure to follow grievance procedures, insufficient meaningful activities programming, improper urostomy care, lack of a full-time director of nursing, medication administration errors, expired medications in storage, malfunctioning essential equipment including hot water system and dishwasher, and ineffective pest control with ongoing rodent infestation.

The complaint investigation substantiated that resident to resident physical abuse occurred between Resident #1 and Resident #2 on 4/19/23, with both residents involved in altercations requiring staff intervention and police involvement. The facility concluded insufficient evidence to substantiate abuse due to lack of willful infliction of injury, but the investigation found failures in supervision and monitoring.

The facility failed to protect two residents from physical abuse by each other, resulting in actual harm. The facility documented 15-minute checks but lacked proper one-to-one supervision, and staff presence was reduced during police involvement, leading to a retaliatory incident.

The complaint investigation involved two residents (#1 and #2) who engaged in physical altercations on 4/19/23. The facility failed to prevent the second retaliatory incident despite 15-minute checks. The facility concluded insufficient evidence of willful abuse due to Resident #1's cognitive impairment but did not address Resident #2's aggression. Staff interviews revealed concerns about inadequate supervision and agency staff involvement. The facility did not provide documentation of one-to-one care or identify staff responsible for monitoring.

The facility failed to protect two residents from physical abuse by each other on two occasions within approximately one hour. The facility documented 15-minute checks but lacked documentation of one-to-one supervision as required. The facility concluded insufficient evidence to substantiate abuse due to cognitive impairments of one resident, but failed to address the retaliatory aggression adequately.

The facility was found deficient in multiple areas including failure to honor resident shower preferences, prevent resident-to-resident abuse, maintain residents' activities of daily living such as grooming and nail care, provide meaningful activities, ensure appropriate treatment and care for skin lesions, assist residents with hearing aids, supervise medication administration, prevent falls and injuries, address significant weight loss, provide appropriate respiratory care, manage mental health and psychosocial needs, obtain consent for psychotropic medications, and maintain infection control practices.

The facility was found deficient in multiple areas including honoring resident preferences, preventing resident abuse, maintaining residents' activities of daily living, providing appropriate activities, treatment and care, medication administration, infection control, and ensuring resident safety. Specific failures included inadequate shower accommodations, failure to prevent resident-to-resident abuse, poor grooming and nail care, insufficient activity programming, failure to address a skin lesion, improper medication supervision, failure to provide hearing aids, inadequate respiratory care, failure to address significant weight loss, and deficient mental health and behavioral care.

The complaint investigation substantiated allegations of resident-to-resident abuse involving residents #46, #30, #36, and #31, with actual harm to some residents. Additional complaints involved failure to provide restorative care and inadequate infection control practices.

The facility failed to prevent resident-to-resident abuse resulting in actual harm to residents, failed to provide adequate restorative care to maintain or improve residents' range of motion and mobility, and failed to maintain an effective infection prevention and control program including proper PPE use and resident hand hygiene.

The complaint investigation was triggered by allegations of resident-to-resident abuse involving residents #46, #30, #36, and #31. The investigation substantiated abuse between residents #46 and #30 and between residents #36 and #31. Additional complaints involved failure to provide restorative care and infection control deficiencies.

The facility failed to prevent resident-to-resident abuse resulting in actual harm to residents, failed to provide adequate restorative care to maintain residents' range of motion and mobility, and failed to maintain proper infection prevention and control practices including PPE use and hand hygiene.