Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sierra Vista Healthcare during CMS and state inspections, most recent first.
A resident with acute encephalopathy, severe cognitive impairment, and a history of wandering eloped from the facility after staff failed to respond promptly to a triggered security bracelet alarm at the front door. The resident, who was independently mobile and assessed as high risk for elopement and falls, was later found at a family member's home and returned to the facility with the security bracelet still in place. Facility leadership confirmed that the alarm was not answered immediately, and several other residents at high risk for elopement were also present in the facility.
A resident with a fractured ankle and suspected surgical site infection did not receive a prescribed antibiotic because the physician's order, received via fax, was not provided to clinical staff as required. The breakdown in communication led to the resident missing the ordered treatment.
A resident with cognitive and physical impairments fell and fractured his hip after attempting to self-transfer from a bed with unlocked wheels. The bed had been moved by a CNA to assist the resident's roommate, and the wheels were not locked afterward. Staff interviews confirmed that bed wheels should be locked when residents are in bed.
The facility did not post the most recent survey results in an accessible location for residents and their representatives. A binder labeled CDPH Survey Results was missing the last recertification survey results. Interviews with the DON and ADM revealed a misunderstanding about the requirement to include survey results from 2022. The facility's policy on Resident Rights states that residents have the right to examine survey results, which was not met.
The facility failed to properly store and label medications, with two medication carts found unlocked and unattended, posing a risk of unauthorized access. A bottle of polyethylene glycol 3350 was left unattended on a cart, and an expired bottle of Lactulose was found in another cart, indicating lapses in adherence to storage and expiration policies.
The facility failed to maintain an infection prevention and control program, with deficiencies in sharps storage and oxygen equipment maintenance. Sharps containers were improperly stored in an accessible room, posing a risk of injury. Oxygen concentrator filters for several residents were dirty, and there was confusion about cleaning responsibilities. Additionally, a resident's oxygen tubing was not labeled with the change date, risking infection. These issues indicate a lack of adherence to infection control policies and inadequate staff training.
Five residents experienced a delay of up to 30 minutes in receiving their lunch trays while watching others eat, due to a lack of communication between nursing and dietary staff. This affected their dining experience and violated their right to dignity. The facility's policy emphasizes treating residents with dignity and respect, which was not upheld in this instance.
The facility failed to implement resident-centered care plans for three residents, leading to potential risks and unmet medical needs. A resident lacked a care plan for prescribed medication, another had exposed bedrail padding despite a seizure risk, and a third had no care plan for a change in condition related to diarrhea. Staff acknowledged these oversights, which were confirmed through observations and interviews.
A resident with a fluid restriction order was allowed to consume more fluids than prescribed during a meal, leading to a deficiency in care. Staff acknowledged the oversight, and the facility's policy to check trays for correct diets was not effectively followed.
The facility exceeded the acceptable medication error rate with two incidents involving improper administration. An LVN gave a resident glucophage and methenamine without food, against instructions, risking GI distress. Another LVN mixed Polyethylene Glycol with insufficient water, leading to potential discomfort. Both errors were acknowledged by staff and highlighted the need for adherence to medication instructions.
A dietary staff member failed to check the internal temperature of pork loins before serving, as observed during a survey. The staff member admitted to not knowing the required temperature, and both the Dietary Service Manager and Dietitian confirmed the importance of this step to prevent foodborne illness. Facility policies and professional guidelines emphasize the necessity of using a food thermometer for safety.
The facility failed to ensure sanitary food preparation and storage, affecting 87 residents. A serving cart was found with a white powdered substance and other items, while a kitchen storage room had dirt, debris, and a missing baseboard. The Dietary Manager Supervisor, Registered Dietitian, and Administrator acknowledged the importance of cleanliness to prevent contamination and pest attraction.
A resident's POLST form was not completed and signed by a physician for over eleven days after admission, contrary to facility policy. Staff interviews indicated the form should have been completed upon admission and signed within 72 hours. The resident, with multiple diagnoses and moderate cognitive impairment, was automatically considered full code due to the incomplete form.
A resident's personal information was exposed when an LVN left a computer screen open and unattended, violating privacy protocols. Facility staff confirmed that this action breached HIPAA regulations and contradicted the facility's policy on maintaining residents' confidentiality.
Two residents experienced an unclean and cluttered environment due to one resident's food hoarding habits. Despite being cognitively intact, the resident continued to store various food items improperly, leading to potential risks of pest infestation and foodborne illness. Facility staff attempted to manage the situation through education and alternative storage solutions, but the resident often refused assistance.
A facility failed to accurately complete the PASRR for a resident admitted with unspecified psychosis and depression, who was on psychotropic medications. The PASRR from the hospital inaccurately indicated no need for Level II screening and no mental illness diagnosis, which was not corrected by the facility. The DON acknowledged the oversight, which could affect the resident's psychiatric care.
A resident with diabetes and other conditions had long, thick, and crooked toenails due to the facility's failure to ensure proper foot care. Despite the resident's refusal of podiatry visits, staff did not take further action to address the issue, which was contrary to the facility's foot care policy.
A resident with no cognitive impairment did not have his meal preferences documented, leading to him not eating his lunch due to a dislike for Italian food. Despite the facility's policy to accommodate preferences, staff failed to ensure meal tickets were accurate, resulting in the resident not receiving a meal he would eat.
A resident with psychosis and muscle weakness was not provided with the necessary built-up utensils on her meal tray, as required by her care plan. Despite the facility's policy and staff responsibilities, the dietary aides failed to ensure the correct utensils were placed, leading to the deficiency.
A resident with dementia, known for wandering, exited a facility unsupervised and was found in a rose garden during extreme heat, resulting in second-degree burns and an acute kidney injury. The resident, who had severe cognitive impairment and was a fall risk, required hospitalization for treatment. Staff interviews confirmed the resident needed constant supervision, which was not provided, leading to the incident.
Failure to Respond to Elopement Alarm Results in Resident Leaving Facility
Penalty
Summary
A deficiency occurred when staff failed to respond promptly to a security elopement alarm, resulting in a resident eloping from the facility. The resident had been admitted with acute encephalopathy, severe impairment affecting judgment, and a history of wandering and elopement. Assessments indicated the resident was independently mobile, at high risk for both elopement and falls, and had a physician's order for a security bracelet to be worn on the right ankle. The care plan included interventions such as applying the security bracelet and checking its function and placement per protocol. On the day of the incident, the resident was last seen by staff outside his room during breakfast service. When the resident could not be located, a search was initiated inside and outside the facility. The security bracelet alarm at the front door was triggered, but staff did not respond to the alarm in a timely manner. The resident was eventually found at a family member's home approximately one mile away and was returned to the facility. At the time of his return, the security bracelet was still in place and functioning. Interviews with facility leadership confirmed that the alarm at the front door was sounding but was not answered immediately, as the receptionist who typically monitors the area was not on duty at the time. The facility had six other residents identified as high risk for elopement, all with physician's orders for security bracelets due to wandering or exit-seeking behaviors. Facility policies required adequate supervision and timely response to alarms for residents at risk of elopement, but these protocols were not followed during the incident.
Failure to Administer Prescribed Antibiotic Following Physician Order
Penalty
Summary
A deficiency occurred when a resident who was admitted for aftercare following a fractured left ankle did not receive a prescribed antibiotic for a suspected surgical site infection. The surgeon ordered Bactrim DS to be administered twice daily for ten days, starting on 3/3/25, after a follow-up visit raised concerns about infection. However, the antibiotic was not administered as ordered. The failure was traced to a breakdown in the facility's process for handling physician orders received via fax. The surgeon's progress note, which included the antibiotic order, was faxed to the facility and received by medical records staff, but it was not provided to the clinical staff as required. The Director of Nursing confirmed that the process in place to start antibiotics within four hours of receiving an order was not followed, resulting in the resident not receiving the medication as prescribed.
Resident Falls Due to Unlocked Bed Wheels
Penalty
Summary
The facility failed to ensure a resident was free from injury when he attempted to self-transfer out of his bed with the bed's wheels unlocked, resulting in a fall and fracture to his left hip. The resident, who was cognitively intact but had impairments in both lower extremities and required substantial assistance for transfers, attempted to transfer himself to his wheelchair. During this attempt, the unlocked wheels caused the bed to move, leading to the fall. The resident had been admitted to the facility with diagnoses including neurocognitive disorder with Lewy bodies, bipolar disorder, and dementia. Despite being wheelchair-bound and needing maximal assistance for transfers, the resident attempted to transfer himself after a CNA had moved his bed to assist his roommate and forgot to lock the bed's wheels. This oversight was confirmed by the resident, who stated that the CNA had asked for permission to move the bed but did not lock the wheels afterward. Interviews with staff, including CNAs and nurses, confirmed that the bed's wheels should have been locked when the resident was in bed. The bed was found moved from its normal position, and the resident was discovered on the floor by a nurse. The staff acknowledged that the bed would not have moved if the brakes were locked, indicating a failure to follow safety protocols regarding bed wheel locks.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that was easily accessible to all 91 residents, their families, and legal representatives. During an observation, a binder labeled CDPH Survey Results was found in a hallway near the main entrance, but it did not contain the results of the last recertification survey conducted on September 22. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that the survey results were not included in the binder. The ADM mistakenly believed that only results from the previous year needed to be stored, and since the survey was conducted in 2022, it was not included. The facility's policy on Resident Rights, dated August 22, indicated that residents have the right to examine survey results, which was not upheld in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional standards. Two of four medication carts were found unlocked and unattended by licensed nurses, which posed a risk of unauthorized access by residents, staff, and visitors. During observations, Licensed Vocational Nurses (LVNs) were seen leaving medication carts unlocked while attending to residents in their rooms, acknowledging that the carts should have been locked to prevent access to medications by unauthorized individuals. Additionally, a bottle of polyethylene glycol 3350 was left unattended on top of a medication cart, creating a potential risk for unauthorized access and misuse. The LVN responsible admitted to leaving the medication unattended and acknowledged the risk of it being accessed by residents, staff, or visitors. The Director of Nursing (DON) confirmed that leaving medications unattended on top of carts was against facility policy and posed a risk of unauthorized access and potential harm. Furthermore, an expired bottle of Lactulose was found in a medication cart, indicating a failure to adhere to the facility's policy of checking expiration dates before administering medications. The LVN and Assistant Director of Nurses (ADON) acknowledged that expired medications should not be present in the cart and could lead to ineffective treatment or harmful side effects. The facility's policies clearly stated that expired medications should be removed and destroyed, highlighting a lapse in adherence to these procedures.
Infection Control Deficiencies in Oxygen Equipment and Sharps Storage
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the improper storage of sharps containers in a room accessible to residents. The room contained five full sharps containers, one of which was uncovered, posing a risk of injury and cross-contamination. The room was used by an outside lab company, but the facility staff did not monitor or report the unsafe condition, despite the potential for residents to access the room and harm themselves. Another deficiency involved the maintenance of oxygen concentrators for multiple residents. Resident 58's oxygen concentrator filter was found covered in dirt, dust, and lint, which could introduce contaminants into the oxygen supply. Similarly, the oxygen concentrator filters for Residents 61 and 3 were covered with grayish-white material, indicating they were not cleaned regularly. There was confusion among staff about who was responsible for cleaning these filters, leading to a lack of proper maintenance and increased risk of respiratory issues for the residents. Additionally, Resident 345's oxygen tubing was not labeled with the date it was changed, which is necessary to ensure timely replacement and prevent respiratory infections. The facility's policies required nasal cannula tubes to be changed weekly and labeled with the date, but this was not adhered to, putting the resident at risk. These deficiencies highlight a lack of adherence to infection control policies and procedures, as well as inadequate staff training and communication regarding responsibilities for maintaining medical equipment.
Delayed Meal Service Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure a dignified dining experience for five residents, as they were made to wait up to 30 minutes for their lunch trays while observing other residents eat. This incident involved Residents 68, 81, 245, 246, and 350, who were left without their meals in the dining room on two separate occasions. The delay in serving these residents was attributed to a lack of communication between the nursing and dietary staff, as the lunch trays for these residents were mistakenly sent to their rooms instead of the dining room. Resident 68, who has a severe cognitive deficit, and Resident 81, with a moderate cognitive deficit, were among those affected. Resident 245, with no cognitive deficit, and Resident 246, with a severe cognitive deficit, also experienced the delay. Additionally, Resident 350, who has no cognitive deficit, was affected, and a family member expressed discomfort with the situation. The staff's failure to communicate effectively resulted in these residents being served significantly later than others, impacting their dining experience. Interviews with various staff members, including CNAs, the Dietary Service Manager, the MDS Coordinator, and the Director of Nursing, revealed that the standard practice was to serve one table at a time. However, due to a lack of communication, the dietary staff was not informed of the residents' presence in the dining room, leading to the delay. The facility's policy emphasizes treating residents with dignity and respect, which was not upheld in this instance.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for three residents, leading to potential risks and unmet medical needs. For Resident 31, there was no care plan for the use of clotrimazole medication, which was prescribed for a fungal infection on the toenails. This oversight was identified during a review of the resident's order summary and confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that a care plan should have been initiated immediately upon receiving the order. Resident 1's care plan was not properly implemented, as the padding on the left bedrail was not intact, exposing a metal bar. This was observed during room inspections and interviews with Certified Nursing Assistants (CNAs) and a Registered Nurse (RN). The care plan indicated the need for padded side rails due to the resident's history of seizures, but the nursing staff failed to ensure the padding was maintained, potentially putting the resident at risk of injury during a seizure. For Resident 53, there was no care plan developed for a change in condition related to diarrhea, which was documented in the SBAR communication form and progress notes. Despite the physician ordering tests to rule out C-Diff, the DON and other staff members confirmed that a care plan should have been created to address this change in condition. The absence of a care plan meant that the resident's medical needs might not have been adequately met.
Failure to Follow Fluid Restriction Order
Penalty
Summary
The facility failed to adhere to professional standards of quality care for a resident by not following the physician's fluid restriction order. The resident, who was admitted with diagnoses including psychosis and muscle weakness, was observed consuming more fluids than the prescribed limit during a meal. Specifically, the resident was allowed to consume 28 ounces of fluid in one meal, exceeding the allowed 10 ounces per meal as per the physician's order. This oversight was confirmed by multiple staff members, including a CNA, the Assistant Dietary Service Manager, and the Dietary Service Manager, who acknowledged that the resident received more fluid than ordered. Interviews with staff revealed a lack of compliance with the fluid restriction order, which was crucial to prevent potential health issues such as fluid overload. The Director of Nursing noted that the resident was confused and frequently requested more coffee, indicating a need for staff to consistently explain the fluid restriction to the resident. The facility's policy required the Food Service Manager or designee to check trays for correct diets before distribution, but this protocol was not effectively followed, leading to the deficiency.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11.54%. This deficiency was observed in two separate incidents involving medication administration. In the first incident, an LVN administered glucophage and methenamine to a resident without food, contrary to the medication instructions that specified administration with food. The LVN acknowledged the error, noting that the resident had eaten breakfast earlier, but did not provide food at the time of medication administration. The Assistant Director of Nursing and the Director of Staff Development confirmed that the medication orders should have been followed to prevent gastrointestinal distress. In the second incident, another LVN did not adhere to the medication instructions for administering Polyethylene Glycol to a different resident. The LVN mixed the medication with only four ounces of water instead of the prescribed eight ounces, resulting in a more concentrated solution. This deviation from the prescribed method was acknowledged by the LVN and confirmed by the Director of Staff Development, who noted that the error could lead to gastrointestinal discomfort and inefficient absorption. The facility's policy on medication errors emphasizes the importance of following physician orders and manufacturer instructions to prevent adverse consequences.
Failure to Ensure Competency in Food Temperature Checks
Penalty
Summary
The facility failed to ensure that a dietary staff member was competent in carrying out the functions of the food and nutrition services safely and effectively. During an observation, the dietary staff member was seen removing a baking tray containing three pork loins from the oven without checking their internal temperature. The staff member then proceeded to the prep area to slice the pork loins for service without verifying if they were cooked to the required temperature. In an interview, the staff member admitted to not checking the internal temperature and was unsure of what it should have been, acknowledging that he should have checked it upon removal from the oven. Further interviews with the Dietary Service Manager and the Dietitian confirmed that the staff member should have checked the temperature to ensure the pork loins were properly reheated, as per the facility's policy. The Dietary Service Manager stated that the pork loins were precooked but emphasized the importance of verifying the temperature to prevent foodborne illness. The Dietitian reiterated the necessity of following the recipe's temperature requirements and indicated that the Dietary Service Manager was responsible for training the staff member. The facility's policy and professional references reviewed highlighted the importance of using a food thermometer to ensure food safety.
Sanitation Deficiencies in Food Preparation and Storage
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices, affecting 87 of 91 residents. During an observation, a serving cart was found with a white powdered substance scattered across its surface, alongside items such as serving trays, gloves, aprons, garbage bags, and a utensil holder. The Dietary Manager Supervisor (DMS) acknowledged that the cart should be cleaned daily to prevent contamination and infection, and that it was the responsibility of the dietary aide to maintain its cleanliness. Additionally, a storage room in the kitchen was observed to have dirt and debris on the floor, with a missing baseboard on one wall. The DMS stated that maintenance was responsible for fixing the floors and baseboards, and acknowledged that the area was not clean. The Registered Dietitian (RD) and the Administrator (ADM) both confirmed the importance of maintaining cleanliness to prevent cross-contamination and pest attraction. The facility's policy and the USFDA Food Code emphasize the need for cleanliness in food-contact and non-food-contact surfaces, as well as proper storage of maintenance tools.
Failure to Timely Complete POLST Form
Penalty
Summary
The facility failed to ensure that a resident's code status was documented upon admission on the Physician Order for Life Sustaining Treatment (POLST) form. The POLST form for the resident was not completed and signed by the physician for more than eleven days after admission, which was not in accordance with the facility's policy and procedure. This oversight had the potential to result in the resident's wishes not being honored and unnecessary medical interventions being administered. Interviews with staff revealed that the POLST form should have been completed upon admission, with the physician or nurse practitioner required to sign it within 72 hours. The admission nurse was responsible for completing the POLST form and communicating the resident's wishes to the physician. However, the form was not signed by the physician until much later, and the resident was automatically considered a full code due to the incomplete POLST form. The resident involved was admitted with diagnoses including COVID-19, polyneuropathy, depression, hypertension, and constipation. The resident was moderately cognitively impaired but was her own responsible party. The facility's policy stated that the POLST form is not valid until signed by both the resident and a physician, and the failure to complete this process in a timely manner was a clear deficiency in the facility's adherence to its own procedures.
Privacy Breach Due to Unattended Computer Screen
Penalty
Summary
The facility failed to protect the privacy of a resident's personal information when a Licensed Vocational Nurse (LVN) left her workstation computer open and unattended, exposing the resident's information to public view. This incident involved Resident 34, whose personal and medical information was left visible on the computer screen outside their room. The LVN acknowledged that leaving the computer screen open was inappropriate and that it allowed any passing residents, staff, or visitors to potentially view the resident's private information. Interviews with facility staff, including the Assistant Director of Nursing (ADON), the Director of Staff Development (DSD), and the Director of Nursing (DON), confirmed that the facility's practice and expectation were to always close computer screens when not in use to protect residents' information. The DSD identified this incident as a violation of the Health Insurance Portability and Accountability Act (HIPAA), which mandates the protection of sensitive health information. The facility's policy and procedure document also emphasized the residents' rights to privacy and confidentiality, which were not upheld in this instance.
Failure to Maintain a Clean and Homelike Environment Due to Food Hoarding
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents, Resident 16 and Resident 39, due to the improper storage of personal food items. Resident 16 had a collection of fresh produce, canned goods, and various food items stored in their room, including on the floor and shelves, which created clutter and an unclean environment. This situation was observed during multiple visits, and Resident 39, who shared the room, expressed that the clutter made it impossible to use the shared sink. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), Resident 16 continued to hoard food despite repeated discussions and education from facility staff, including the Infection Preventionist, Director of Staff Development, and Registered Dietitian. The staff explained the risks of food hoarding, such as pest infestation and foodborne illness, but Resident 16 and their family persisted in bringing food into the facility. The facility staff attempted to manage the situation by checking expiration dates and offering to store food in a refrigerator, but Resident 16 often refused these measures. Housekeeping staff were observed cleaning the room but stated that their responsibilities did not include managing the food clutter. The Director of Nursing and other staff members acknowledged the ongoing issue and the potential risks it posed to the facility. Despite efforts to educate and offer alternative solutions, Resident 16's preference to remain in the facility with friends and continue their habits contributed to the deficiency in maintaining a clean and homelike environment.
Inaccurate PASRR Completion for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accurate completion of the Level I Preadmission Screening and Resident Review (PASRR) for a resident upon admission. The resident, who was admitted with diagnoses of unspecified psychosis and depression, was also on psychotropic medications. However, the PASRR completed at the general acute care hospital inaccurately indicated that the resident did not require a Level II screening and did not have a diagnosis of mental illness or prescriptions for psychotropic medications. This discrepancy was not identified or corrected by the facility upon the resident's admission. During a review, the Director of Nursing (DON) acknowledged that the PASRR assessment was not accurate and should have been reviewed and updated to reflect the resident's mental health diagnoses and medication needs. The facility's policy required confirmation and review of PASRR documentation from the hospital, which was not adequately followed in this case. This oversight had the potential to impact the resident's receipt of necessary psychiatric treatment and evaluation.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident 3, whose toenails were observed to be long, thick, and crooked. This condition was noted during an observation and interview with a registered nurse, who acknowledged that the toenails were not in an acceptable condition and should have been reported by certified nursing assistants (CNAs). Despite being aware of the condition, CNA 1 stated that Resident 3 had refused nail care, and no report was made to the nurse. The resident's refusal of podiatry visits was documented in the podiatry notes, and the Social Services Director indicated that if staff had alerted her, alternative arrangements could have been made. Interviews with various staff members, including a licensed vocational nurse, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing, revealed a consensus that the resident's refusal of nail care should have prompted further action. The staff acknowledged the potential risks associated with the resident's diabetic condition, which could lead to complications such as skin breakdown or infection. The facility's policy on foot care emphasized the importance of maintaining foot health, particularly for residents with medical conditions like diabetes, but the policy was not effectively implemented in this case.
Failure to Document and Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to document and accommodate a resident's meal preferences, resulting in the resident not eating his lunch. The resident, who had no cognitive impairment, expressed a dislike for Italian food, which was not documented on his meal ticket. On the day of the incident, the resident was served a meal consisting of spaghetti and zucchini, which he refused to eat due to his dislike for Italian food. Despite the availability of meal alternatives, the resident's appetite was ruined, and he did not request a different meal. Interviews with facility staff revealed a lack of communication and responsibility in ensuring meal preferences were documented and respected. The Certified Nursing Assistant (CNA) and Registered Nurse (RN) acknowledged their roles in checking meal tray accuracy and addressing resident meal preferences. The Dietary Services Manager and Assistant Dietary Services Manager stated that it was the dietary department's responsibility to document food preferences, and the Registered Dietitian emphasized the importance of providing alternate meals if a resident's meal was untouched. The facility's policy indicated that residents should receive meals according to their preferences, but this was not adhered to in this case.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment for a resident, identified as Resident 68, who required built-up utensils to feed herself independently and safely. During an observation in the dining room, it was noted that Resident 68's meal tray contained regular utensils instead of the prescribed built-up utensils. The resident's admission record and order summary report indicated the need for adaptive equipment, including a divided plate and built-up utensils, due to her diagnoses of psychosis and muscle weakness. Interviews with various staff members, including a Certified Nurse Assistant, Assistant Dietary Service Manager, Dietary Aide, Dietary Service Manager, and Registered Dietitian, revealed that the dietary aides were responsible for ensuring the correct utensils were placed on meal trays. However, the dietary aides failed to perform a final check before sending out the tray cart, resulting in the omission of the necessary adaptive utensils. The facility's policy and procedure on self-feeding devices stated that such devices should be provided with each meal, but this was not adhered to in the case of Resident 68.
Resident with Dementia Sustains Burns Due to Lack of Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accident hazards for a resident with dementia, who was known to independently move around the facility in a wheelchair. The resident, who had severe cognitive impairment and was a fall risk, managed to exit the facility unsupervised and was found in the rose garden exposed to extreme heat. The temperature on that day reached up to 108 degrees Fahrenheit, and the resident was outside for an unknown amount of time. As a result of this lack of supervision, the resident sustained second-degree burns on multiple parts of the body, including the scalp, right ear, neck, left shoulder, and both knees. Additionally, the resident suffered an acute kidney injury, likely due to dehydration from prolonged sun exposure. The resident required treatment at an acute care hospital for these injuries. Interviews with facility staff revealed that the resident had a history of wandering and required constant supervision. Staff members acknowledged that the resident should not have been left unattended outside, especially given the high temperatures. The facility's policy emphasized the importance of making the environment free from accident hazards and providing adequate supervision based on individual resident needs, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fresno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twilight Haven | 1.1 mi | — | 0 | 0 |
| Stonehaven Senior Living | 1.1 mi | — | 0 | 0 |
| Orchard Post Acute | 1.6 mi | — | 2 | 0 |
| Pacific Gardens Nursing And Rehabilitation Center | 1.8 mi | — | 1 | 0 |
| Evergreen Care Center | 1.9 mi | — | 1 | 0 |
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