Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sierra Vista during CMS and state inspections, most recent first.
Unsanitary kitchen conditions and damaged foodservice equipment were observed throughout the dietary area. A sink used to fill pitchers for resident drinking water lacked an air gap, a walk-in refrigerator had shelves with fuzzy white material and grime, and dust/debris was seen on kitchen surfaces, racks, the dishwashing room door frame, and the ceiling above the cook area. Chipped paint was noted in the janitor closet and dry storage room, two frying pans had scraped interior coating, two plastic spatulas were damaged, black substance was found in the ice bin, and a microwave used for resident food had brown splatter on the ceiling.
Improper Dumpster Waste Disposal: Three dumpsters outside the hallway leading to the kitchen were observed filled above the brim with trash bags, and all three lids could not fully close. The CDM stated the dumpsters were in horrible condition and noted that lids are supposed to close because otherwise they bring rodents and flies. Facility policy stated garbage and refuse will be collected and disposed of in a safe and efficient manner.
Resident Council Snack Requests Not Addressed: A resident council reported that residents were receiving only one nighttime snack daily, wanted more frequent snacks, and requested a greater variety of healthier options. Staff told residents to speak with dietary, but the DON/Administrator was not informed, no written response was provided, and the RD said she had not been told of the request. Facility policy required resident council feedback to be addressed in writing and stated that snacks and additional beverages would be available upon request.
Resident Names and Room Numbers Visible to Unauthorized View: A whiteboard listing the full names and room numbers of all residents on a unit was posted in a back room near the nursing station with the door propped open, allowing the information to be read from the common hallway. RN and DON confirmed the names and room numbers were visible, and the DON acknowledged residents’ right to privacy regarding their accommodations.
Medication Error and Unidentified Controlled Substances: A resident with schizoaffective disorder received 400 mg of clozapine instead of the ordered 200 mg when an LPN administered two tablets from a mislabeled bubble pack without verifying the physician order. Surveyors also found two controlled medications stored in unlabeled plastic bags in a locked medication drawer, preventing proper reconciliation and documentation of disposal. The DON and Admin confirmed the medication error and the controlled-substance handling issues.
Medication storage was disorganized in a Unit 1 med room when an RN and DON observed three cabinets with injectables, oral OTC meds, liquids, tablets, sublingual meds, rectal meds, breathing treatments, eye drops, and test kits all intermingled on the shelves. The DON, pharmacist consultant, and Admin confirmed the meds were not stored in accordance with facility P&P, which requires medications to be kept separate by route and type.
Therapeutic Snack Orders Not Followed: The facility provided the same bedtime snack list to all residents, including residents with physician-ordered controlled carbohydrate diets, without offering therapeutic alternatives. The RD stated there were no established substitutions or snack options for those diets, and the Admin and DON acknowledged that the facility’s Snacks policy was not followed.
Food service staff did not follow required cleaning and sanitizing procedures, including the rinse step for food-contact surfaces, the correct 10-second sanitizer test-strip method, or the manufacturer’s sanitizer ppm ranges for both general sanitizing and the dish machine. A cook also did not know how to calibrate a thermometer correctly and could not demonstrate the cooling process for tuna salad, while the RD and CDM identified the correct procedures and ranges.
Controlled Carbohydrate Diet residents were served the same frosted chocolate cake portion as regular diet residents instead of the ordered 1/2 portion of plain cake listed on the therapeutic spreadsheet. A Dietary Aide prepared only the regular dessert, and the CDM acknowledged the CC dessert was not prepared. The RD and CDM stated staff should follow the spreadsheet when preparing and serving food, and the RD noted the extra carbohydrates could cause blood sugar to spike.
Improper Storage of Medications and Personal Care Items: A medication room on Unit 1 contained a tub of personal care items, including colognes and razors, stored with resident meds, and most items were unlabeled. A bag of discontinued topical Rx meds awaiting disposal was also stored on a cabinet shelf next to discarded items, trash, and disinfectant spray. RN, DON, PC, and Admin all acknowledged the storage practices were not sanitary and that non-medication items should not be kept with resident medications.
The facility failed to keep essential kitchen equipment in proper working order when a handwashing sink near the dietary office provided water that was first cold at 63 F and then too hot at 114 F, rather than the expected 85 F to 110 F range. Staff, including the CDM and RD, stated the water temperature was not appropriate for handwashing and could be scalding when too hot. The facility also had ice condensation buildup on the ceiling inside the Veggie reach-in freezer, which the CDM said should not be present and the RD identified as an early sign of freezer malfunction that could affect food quality.
Cracked and stained tiles were observed in two communal shower rooms on unit 1 during a surveyor observation with the IP, MS, and Administrator. The IP stated shower surfaces should be intact and cleanable to prevent infection control issues, while the MS said he was unaware of the condition and had been trying to get a remodel. The Administrator confirmed both showers were old and needed a remodel without a tile surface, and the facility's Maintenance Service policy required the building to be kept in safe, operable, and good repair.
The facility failed to develop comprehensive care plans for two residents. One resident had a history of seizures and multiple falls, but no active fall-risk care plan was in place despite repeated fall and seizure events and DON acknowledgment that a plan was needed. Another resident was identified as a tobacco user, yet the care plan did not address smoking supervision, safe storage or use of smoking materials, or other individualized smoking safety interventions, even though the DON stated the resident should have had a smoking plan.
A resident with paranoid schizophrenia and vitamin D deficiency was supposed to receive weekly weights after admission, then monthly, due to nutritional risk and planned weight loss. Staff did not document weights as ordered, with missed weekly weights noted in the EHR and on a paper chart, and the DON confirmed the ordered monitoring was not completed.
A CNA physically restrained a resident with schizophrenia by holding him against a wall during a verbal altercation in a room with a vending machine. The restraint was used despite the resident not posing a danger to himself or others, and this action was not consistent with facility policy, which only allows physical restraint in emergency situations.
The facility failed to maintain food safety and sanitation standards, as observed during a survey. A toaster with food residue was improperly stored, and the floor under the industrial mixer had grime and paint splashes. Additionally, the shelf under the cook's prep area had crusted food, and the Unit 2 kitchen's refrigerator handle and steam table compartment were dirty. The facility's policy requires all food areas to be clean, which was not adhered to.
The facility failed to follow its policies for medication administration, resulting in expired medications being found in the medication carts for two residents. Clozapine and Vitamin B6 tablets were discovered past their expiration dates, contrary to the facility's procedures for removing and disposing of outdated medications. The DON and Pharmacy Consultant confirmed the policy breaches.
The facility failed to secure medications in Unit 2, where a medication room door was not fully closed, and two medication carts were left unlocked and unattended by a PT. This oversight occurred while the PT assisted a resident, leaving medications vulnerable to unauthorized access. The DON confirmed that the facility's policy requires carts to be locked unless in use and under direct observation.
A resident with a dysphagia puree diet order received a meal with visible lumps, contrary to the required smooth texture. The Dietary Supervisor and Registered Dietician confirmed the meal should have been pureed, as per the resident's dietary needs due to missing teeth. The facility's policy on menu preparation was not followed.
The facility failed to maintain the walk-in refrigerator in safe operating condition, with corrosion on the walls and visible expanding foam from a previous repair. The Dietary Supervisor and Registered Dietician confirmed these issues, and the Facility Administrator acknowledged non-compliance with the facility's policy. The FDA Food Code highlights the importance of maintaining equipment to prevent health risks.
A resident with paranoid schizophrenia was abused by a CNA who kicked his leg and threw water on his face after the resident refused to drink water. The incident was witnessed by a Primary Counselor and confirmed by the resident. The facility's Quality Assurance representative recognized the actions as abuse according to the facility's policy.
Unsanitary kitchen conditions and damaged foodservice equipment
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen. During observation, a sink in the cook area that dietary staff used to obtain tap water for residents did not have an air gap. A Dietary Aide was observed filling a pitcher with water from that sink and carrying it to an adjacent prep counter to fill resident drinking glasses. The Registered Dietician and Certified Dietary Manager acknowledged the need for the air gap and stated that if the sink were contaminated with sewage water, use of pitchers in the sink could create cross contamination of residents’ drinking water. In the walk-in refrigerator, four storage shelves were observed with a fuzzy white material and black and brown grime build-up underneath them while food items including gallons of milk, breads, bell peppers, and ground beef were stored on the shelves. The Certified Dietary Manager admitted the shelves were unsanitary and stated staff were only wiping the surface of the shelves rather than performing deep cleaning. The facility policy stated that all foodservice equipment would be clean and sanitary. Multiple other kitchen sanitation and equipment issues were observed. Brown debris described as dust was seen on the rear guard of a fan blowing into cleaned kitchenware, on racks where clean kitchenware was stored, on the half cylinder wall behind the ice machine, behind the rack storing cleaned kitchenware, and on the dishwashing room door frame. Chips and peeling paint were observed on the janitor closet door and in the dry storage room wall. Two frying pans had scraped-off black interior coating, and one was later observed being preheated for cooking resident food. Two plastic scraping spatulas had damaged tips and were discarded after observation. Five brown spots were seen on the ceiling above the cook area, black substance was found inside the ice storage bin of the ice machine, and a brown substance was observed splattered on the ceiling of a microwave used to heat residents’ outside food. The facility policies stated that food preparation areas and foodservice equipment were to be maintained in clean, sanitary, and proper working order.
Improper Dumpster Waste Disposal
Penalty
Summary
Dispose of garbage and refuse properly was cited after observation, interview, and record review showed three dumpsters on the side of the facility outside the hallway leading to the kitchen were filled above the brim with trash bags and the lids could not fully close. During an interview at the dumpsters, the Certified Dietary Manager stated the condition of the dumpsters was "Horrible" and said the lids are supposed to close because if they do not, they bring rodents and flies. Review of the facility policy titled "Dispose of Garbage and Refuse," dated August 2017, stated that all garbage and refuse will be collected and disposed of in a safe and efficient manner.
Resident Council Snack Requests Not Addressed
Penalty
Summary
The facility failed to respond to and act upon grievances and recommendations from the Resident Council regarding dietary services for seven sampled residents. During a combined Resident Council meeting, residents stated that the facility provided only one nighttime snack per day, that residents were hungry during the day, and that they wanted more than one snack daily. The residents also stated that the snacks were repetitive and requested a greater variety of snack items, including healthier options such as a small chef’s salad. Resident Council members explained that when they asked for more snacks or different snack choices, they were told to speak with dietary staff, but they did not know when the contracted dietary staff member was present or how to reach that person. The facility’s posted snack list showed the same limited snack offerings repeated across the week, with items such as Krispie Treats, Cheezits, fruit punch, fresh fruit, cookies, corn chips, and chips. The group collectively requested snacks between breakfast and lunch, between lunch and dinner, and at bedtime. During interviews, the Administrator stated she was responsible for ensuring a written response to Resident Council grievances and requests within 30 days, but she had not been made aware of the snack request and no written response was given. The Social Services Assistant stated she had not heard the residents wanted more than one snack per day and did not bring the issue to the Administrator because she believed the residents needed to speak directly with dietary. The Registered Dietitian stated she had not been informed of the Resident Council’s request for three snacks per day or for healthier snack options. Facility policy stated that all feedback and requests from Resident Council were to be addressed in writing, and that snacks would be provided for all residents with additional snacks and beverages available upon request.
Resident Names and Room Numbers Visible on Whiteboard
Penalty
Summary
The facility failed to protect residents’ privacy and confidentiality by leaving a whiteboard with the full names and room numbers of all residents on Unit 1 visible to unauthorized individuals and other residents. During an observation on Unit 1 at Nursing Station 1, a door marked Chart Room was propped open, and the room led into the medication storage room. On the upper right wall inside the Chart Room, a whiteboard listed the first and last names and room numbers of all residents on Unit 1, and it could be read from the common hallway. RN 1 stated the Chart Room door was always propped open because it provided access to the medication storage room and staff were coming and going throughout the day. RN 1 also stated the Chart Room was not being used as a chart room, but as a place to store items. RN 1 and the DON stood in the common hallway and confirmed that the resident names and room numbers were visible from that location. The DON verified that residents had a right to personal privacy and privacy regarding their accommodations. A review of the facility policy stated the facility would protect and safeguard resident confidentiality and personal privacy, including privacy regarding accommodations, and limit access to resident personal and medical records to authorized staff and business associates.
Medication Error and Unidentified Controlled Substances
Penalty
Summary
The facility failed to provide comprehensive pharmaceutical services by not ensuring a medication error-free system and by not maintaining proper accountability, reconciliation, and witness documentation for controlled substances. The deficiency involved 71 residents on Unit 2. Surveyors identified that Resident 4, who had schizoaffective disorder and a history of paranoid delusions, received 400 mg of clozapine instead of the physician-ordered 200 mg dose. During medication administration observation, an LVN removed a bubble pack labeled for clozapine 200 mg, gave two tablets from the pack, and the resident took the medication. Later review confirmed that the resident had received twice the ordered dose. The medication error occurred because the pharmacy label on the bubble pack did not match the physician’s order, and the required checks were not completed. The DON stated the LVN should have compared the medication label with the physician’s order when the medication was received and again before administration, but those checks were not done. The LVN stated she believed each tablet was 100 mg and did not review the physician’s order before giving the medication. The DON and Administrator confirmed that the resident received twice the prescribed amount of clozapine. Surveyors also found two controlled medications in separate unlabeled plastic bags inside the double-locked controlled medication drawer on a medication cart. One bag contained a capsule with smeared writing and only a date visible; the other contained an unidentified tablet with no label. The LVN stated the medications could not be reconciled or wasted properly because the resident, medication, and dose could not be determined. The DON stated controlled medications were supposed to be reconciled and signed off before destruction, but that process could not be completed because the medications were unidentified. The Pharmacist Consultant stated that refused controlled medications should be wasted immediately by two licensed nurses and should not be placed in unlabeled bags to wait for destruction.
Medication Storage Not Organized by Route
Penalty
Summary
Medications were not stored in an organized and safe manner in the Unit 1 medication storage room for 45 sampled residents. During an observation with an RN and the DON, three cabinets in the medication room were found with medications stored haphazardly on the shelves, with injectables, oral over-the-counter medications, liquid medications, tablets, sublingual medications, rectally applied medications, breathing treatments, eye drops, and test kits intermingled together. There was no apparent order or organization to the medications, and the RN stated that over-the-counter medications were kept in the cabinets so staff would not have to go downstairs for more when they ran out. The DON reviewed the condition of the medication storage area and confirmed that the medications were not stored appropriately or in accordance with the facility's policy and procedure. The pharmacist consultant stated that medications should be stored separated by route, with each route kept together on one shelf or in a specific container or drawer, and that different routes should not be intermingled. The administrator and DON later agreed with the pharmacist consultant and acknowledged that the medications in the Unit 1, Nursing Station 1 medication room were not stored in accordance with the facility's policy and procedure.
Therapeutic Snack Orders Not Followed
Penalty
Summary
The facility failed to ensure that snacks provided to residents with physician-ordered controlled carbohydrate diets met their specific clinical and therapeutic needs. A review of the facility’s Diet Type Report dated February 23, 2026 showed that Residents 1 through 35 had current orders for a controlled carbohydrate diet. However, a snack list posted outside the Dietary Supervisor’s office showed the same bedtime snack items being provided to the entire resident population, including items such as Krispie Treats, Cheezits, fresh baked chocolate chip cookies, corn chips, Lays chips, fruit punch, ice water, and fresh fruit. During interview, the RD stated that the posted snack list represented the nighttime snacks provided to all residents and that the snacks did not change unless a specific request was made. The RD stated there were no established substitutions for the listed snack items and no established snack options for residents with controlled carbohydrate diets, and that she had not provided a therapeutic alternative for those residents. The Admin and DON stated that residents with orders for a controlled carbohydrate diet should have been offered a snack aligned with the ordered diet, and they acknowledged that the facility’s Snacks policy dated September 2017 was not followed.
Food Service Staff Did Not Follow Required Cleaning, Sanitizing, and Food Safety Procedures
Penalty
Summary
Food and nutrition service employees did not safely and effectively carry out required sanitation and food safety functions. During observation and interview, cooks demonstrated cleaning food-contact work surfaces by using soap and water and then sanitizer, but did not describe the required rinse step between washing and sanitizing. The Certified Dietary Manager stated that food service employees should wash soil from work surfaces with soap and water, rinse away the soap, and then sanitize, and explained that skipping the rinse could prevent effective sanitizing and allow microorganisms to cross-contaminate foods. Multiple dietary staff also did not follow the manufacturer’s directions for testing sanitizer concentration. The sanitizer poster and facility in-service materials stated the test strip should be placed in the diluted sanitizer solution for 10 seconds, but one Dietary Aide dipped the strip for 1 second and a cook stated it should remain in the solution for 1 minute. Staff also gave incorrect sanitizer concentration ranges, stating values of 200-500 ppm and 400-500 ppm, while the manufacturer’s guideline and the CDM identified the correct range as 150-400 ppm. For the dish machine, a Dietary Aide stated the sanitizing concentration should be 100-200 ppm, while the facility log and the RD identified the manufacturer-recommended range as 50-100 ppm. Additional food service competency concerns were identified with thermometer calibration and cooling procedures. A cook demonstrated calibrating a thermometer in ice water but stated it should be calibrated at 40 F, while the RD stated it should be calibrated at 32 F. The same cook was unable to demonstrate the cooling process for tuna salad even after being provided the cooling log. The RD stated the cook should know the cooling process for tuna salad and identified the risk as a foodborne illness outbreak.
Controlled Carbohydrate Diet Dessert Not Served as Ordered
Penalty
Summary
The facility failed to ensure that residents on a Controlled Carbohydrate Diet received the dessert portion specified on the therapeutic spreadsheet. During observation in the kitchen, a Dietary Aide was seen preparing lunch dessert by slicing two sheet pans of cake into even portions, frosting all slices, and placing them on dessert plates; no separate or different-sized chocolate cakes were prepared for residents on the Controlled Carbohydrate Diet. During lunch service in the dining room, all residents, including those on the Controlled Carbohydrate Diet, were observed being served the same size chocolate cake with frosting as residents on the regular diet. Record review and interviews confirmed that the therapeutic spreadsheet for February 23, 2026 directed residents on the Controlled Carbohydrate Diet to receive a 1/2 portion of chocolate cake, plain without frosting, for lunch. The Certified Dietary Manager acknowledged that the Dietary Aide did not prepare the Controlled Carbohydrate Diet dessert and that residents on the diet were served the regular dessert. The Registered Dietitian and Certified Dietary Manager stated that food service employees should follow the spreadsheet when preparing and serving food, and the Registered Dietitian stated that giving Controlled Carbohydrate Diet residents the regular dessert portion could cause blood sugar to spike because they would receive more carbohydrates.
Improper Storage of Medications and Personal Care Items
Penalty
Summary
The facility failed to maintain a sanitary and orderly medication storage room for 45 residents on Unit 1 when a tub of personal care products was stored in a medication cabinet alongside resident medications. During the observation, the tub contained 10 different colognes, one electric razor, and one disposable razor. RN 1 stated that residents were not allowed to keep breakable or sharp objects in their rooms, so these items were kept at the nursing station for staff to assist and monitor use. RN 1 acknowledged that not all of the items were labeled with a resident’s name, which created a risk of giving an item to the wrong resident and increasing the risk of transmitting an infection. The DON also observed that most of the personal care products were unlabeled and stated they should have been labeled and not stored with medications in the medication room. The facility also stored a bag of discontinued prescription topical medications awaiting disposal on the bottom shelf of a medication cabinet next to discarded items, disinfectant spray, and trash. RN 1 acknowledged that this did not provide a sanitary environment for storing medications, and the DON stated that discontinued medications should not be stored alongside discarded items, trash, or disinfectant spray. The PC stated that medications awaiting disposal should be stored in an area dedicated solely to that purpose and that it was not appropriate to store prescription medications on top of discarded items and next to a disinfectant chemical spray. The facility’s policy stated that medications and biologicals are to be stored safely, securely, and properly, that disinfectants are stored separately from medications, that outdated or contaminated medications are immediately removed from stock and disposed of, and that medication storage areas are kept clean, well-lit, and free of clutter.
Improper Temperature Control and Ice Buildup in Kitchen Equipment
Penalty
Summary
The facility failed to ensure proper maintenance of essential kitchen equipment when the handwashing sink near the dietary office did not consistently provide water at the required temperature. During observation, the surveyor turned on the hot water at the sink and found the water was cold; after running it for approximately one minute, the thermometer measured 63 F. A follow-up observation a few minutes later showed the water was too hot, and the thermometer measured 114 F. In interviews, the Certified Dietary Manager stated handwashing water should be at least 85 F to 110 F, and the Registered Dietitian agreed that water below 85 F may result in ineffective handwashing and water that is too hot may scald food service employees. The facility also failed to maintain the Veggie reach-in freezer in proper working order. During a concurrent observation and interview in the kitchen, ice condensation buildup was seen on the ceiling inside the freezer. The Certified Dietary Manager stated the freezer was not supposed to have ice condensation buildup, and the Registered Dietitian stated that this was an early sign of freezer malfunction and could affect the quality of foods stored in the freezer. The facility policy titled Equipment stated that all foodservice equipment will be in proper working order and routinely maintained.
Cracked and stained shower room tiles
Penalty
Summary
The facility failed to ensure that two communal shower rooms on unit 1, identified as the blue and green shower rooms, were maintained in good repair and in a safe and sanitary condition. During a concurrent observation and interview with the Infection Preventionist, multiple cracked and stained tiles were observed in both shower rooms, and the Infection Preventionist stated that shower surfaces should be intact and cleanable to prevent infection control issues. During a later concurrent observation and interview, the Maintenance Supervisor also observed the multiple cracked and stained tiles in both shower rooms and stated he was not aware of the condition, although he had been trying to get a remodel for both shower rooms. The Administrator then verified that both shower rooms had multiple cracked and stained tiles and stated that the two showers were old and needed a remodel without a tile surface. Review of the facility's Maintenance Service policy showed that the maintenance department is responsible for keeping buildings, grounds, and equipment in a safe and operable manner at all times and for maintaining the building in good repair and free from hazard; the Administrator stated the facility did not follow the policy.
Incomplete Care Plans for Falls and Smoking Safety
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two sampled residents. Resident 14 was admitted with diagnoses including schizophrenia, unspecified convulsions, and hypo-osmolality and hyponatremia. The record showed multiple falls and seizure-related events, including a seizure in the recreation room on November 11, 2025, a fall in the hallway on November 13, 2025, a collapse and convulsion during a community smoke break on November 14, 2025, and another episode where the resident was found on the floor and then had a seizure on November 18, 2025. The record also showed an IDT discussion on November 20, 2025 related to seizures resulting in falls and that the resident was on Q15 monitoring, with a later witnessed fall without injury on January 15, 2026. Despite this history, there was no active care plan for falls or fall risk for Resident 14. During interview and record review, the DON stated the resident had a history of seizures with falls and should have a care plan for fall risk or fall history, but she was unable to find an active care plan and stated she needed to create one. The facility policy for Fall Management required residents at risk for falls to receive appropriate interventions and an individualized plan of care, and the comprehensive care plan policy required measurable objectives and timetables to meet the resident’s needs. Resident 34 was admitted with diagnoses including schizoaffective disorder, bipolar type, and vitamin D deficiency. The MDS indicated the resident currently used tobacco, and a smoking evaluation documented that the resident did not require special equipment during smoking and was independent for smoking. However, the comprehensive care plan did not include a smoking plan addressing the resident’s smoking assessment, measurable goals, or individualized interventions for safe smoking. The DON stated the resident did not have a smoking care plan but should have one to address smoking needs and safety, and the facility’s smoking policy required an individual plan for safe storage and use of smoking materials, assistance, and required supervision if necessary.
Failure to Follow Ordered Weight Monitoring
Penalty
Summary
Nursing staff failed to follow the physician’s order for Resident 19’s weight monitoring after admission. The resident was admitted with diagnoses including paranoid schizophrenia and vitamin D deficiency, and the care plan identified the resident as at nutritional risk with planned gradual weight loss toward a long-term goal of 166 pounds. The care plan included weekly weights to monitor progress and assess for no more than 2% weight loss per week or 5% per month, and the physician ordered weekly weights for four weeks after admission, then monthly. The resident’s electronic health record showed weights documented on February 25, 2025, and March 4, 2025, but no weights were recorded for the weeks of March 9, 2025, and March 16, 2025. During interview and record review, the DON stated staff were supposed to weigh the resident weekly for four weeks starting February 24, 2025, then monthly, but this was not done. The DON also stated the person responsible for weighing and documenting residents was no longer at the facility and had sometimes used a paper chart; the paper chart reviewed was blank for the missed weeks. The MDS assessment indicated the resident had significant weight loss and was not on a prescribed weight loss program.
Improper Use of Physical Restraint by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) physically restrained a resident by placing his arm over the resident's shoulders and holding him against a wall, restricting the resident's movement. The incident took place in a room with a vending machine, where the resident, who had a history of schizophrenia and functional dyspepsia, was found unsupervised. The CNA attempted to escort the resident out after a verbal altercation, during which the resident became agitated and used derogatory language. The CNA's actions escalated to physically restraining the resident, despite the resident not posing an imminent danger to himself or others. Facility records, including the nurse's progress notes and an event summary report, confirmed that the CNA's use of physical restraint was not consistent with facility policy, which only permits such interventions as emergency measures to protect from injury. The administrator acknowledged that the CNA did not follow proper procedures, as the situation did not warrant physical restraint. The facility's policy requires restrictive behavioral interventions to be used only when necessary for safety, which was not the case in this incident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food safety, as observed during a survey. A toaster with an accumulation of food residue was improperly stored in the dry storage area, which was acknowledged by the Dietary Supervisor (DS) as not being in use and needing cleaning. Additionally, the floor under the industrial mixer was found to have black grime, food crumbs, and paint splashes, which the DS attributed to a recent painting job and a missed deep-cleaning session. Further observations revealed that the shelf under the cook's preparation area, which stored clean pans, had crusted food and debris. The DS confirmed that the pans and trays were supposed to be cleaned daily by the cooks. In the Unit 2 kitchen area, the refrigerator door handle had crusted food and smudges, and the compartment under the steam table contained black grime and food debris. The DS acknowledged these conditions as unacceptable and requiring cleaning. The facility's policy and procedure, revised in September 2017, mandates that all food preparation, service, and dining areas be maintained in a clean and sanitary condition. The Registered Dietician (RD) and the Facility Administrator both stated that the expectation was for the kitchen to be cleaned regularly, with no presence of grime or debris. The FDA Federal Food Code sections cited in the report emphasize the importance of keeping food-contact and nonfood-contact surfaces clean to prevent the accumulation of pathogenic microorganisms and to avoid attracting insects or rodents.
Expired Medications Found in Facility's Medication Carts
Penalty
Summary
The facility failed to ensure medications were administered according to its policies and procedures for two residents. For one resident, 11 tablets of Clozapine, a medication used to treat severe mental illness, were found in the medication cart with an expiration date that had passed 124 days prior. The Registered Nurse confirmed the expired status of the medication during an observation and interview. The facility's policy requires that outdated medications be immediately removed from stock and disposed of, which was not followed in this instance. For another resident, five tablets of Vitamin B6, used to treat movement disorders, were found in the medication cart with an expiration date that had passed 8 days prior. A Licensed Vocational Nurse confirmed the expired status of the medication during an observation and interview. The facility's policy mandates that expired medications be marked, stored separately, and destroyed according to the Medication Destruction policy, which was not adhered to. The Director of Nursing acknowledged that the policy was not followed, and the Pharmacy Consultant emphasized that expired medications should not be left in medication carts.
Medication Security Lapse in Unit 2
Penalty
Summary
The facility failed to ensure the secure storage of medications in Unit 2's medication room and on two medication carts. During an observation, it was noted that the medication room door was not fully closed, and both medication carts were left unlocked and unattended by a Psych Tech (PT 1). This lapse in security occurred while PT 1 left the medication room to assist a resident across the hall, leaving the medications vulnerable to unauthorized access. Upon inquiry, PT 1 acknowledged the oversight, stating that the carts should have been locked when unattended to prevent unauthorized access. The Director of Nursing (DON) confirmed that the facility's policy requires medication carts to be locked at all times unless they are in use and under direct observation. The failure to adhere to this policy posed a risk of unauthorized individuals accessing medications, affecting a population of 71 residents.
Failure to Provide Properly Prepared Dysphagia Diet
Penalty
Summary
The facility failed to prepare food in a form designed to meet the needs of a resident with dysphagia, identified as Resident 28. During an observation, it was noted that Resident 28's lunch tray contained chicken potpie and carrots with visible lumps, despite the resident's diet ticket specifying a dysphagia puree diet, which requires a smooth texture. Interviews with the Dietary Supervisor and the Registered Dietician confirmed that the meal should have been pureed to a smooth consistency, as per the resident's dietary order. A review of Resident 28's physician orders and nutritional assessment indicated that a dysphagia puree diet was necessary due to the resident's difficulty with chewing and swallowing, attributed to seven missing teeth. The facility's policy and procedure on menu preparation, which mandates that meals be served as written unless substitutions are necessary, was not adhered to in this instance. The Facility Administrator acknowledged that the staff should have followed the established policy and procedure.
Refrigerator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain equipment in safe operating condition, specifically the walk-in refrigerator in the kitchen. During an observation, corrosion was noted on the bottom walls of the refrigerator, and yellow expanding foam was visible from behind the posterior wall. The Dietary Supervisor acknowledged that the foam was from a previous maintenance repair and should not have been visible, and that there should not be corrosion on the walls. The Registered Dietician also confirmed that the refrigerator should not have had corrosion or visible expanding foam from repair. The facility's policy and procedure, revised in September 2017, stated that all foodservice equipment should be clean, sanitary, and in proper working order, and all non-food contact equipment should be clean and free of debris. However, the Facility Administrator admitted that the facility did not follow this policy. Additionally, the FDA Federal Food Code, section 4-501.11, emphasized the importance of maintaining equipment in good repair to ensure proper operation and prevent health risks. The failure to maintain the refrigerator in proper condition had the potential to result in unsafe temperature control for safety foods and the accumulation of bacterial growth.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a Certified Nursing Assistant (CNA) threw water on the resident's face and kicked his right leg. This incident was witnessed by a Primary Counselor who reported that the resident, diagnosed with paranoid schizophrenia, refused to drink water after taking his medication. The CNA reacted to the resident's sudden movement by kicking him and pouring water on his face. The resident confirmed the incident during an interview, indicating the location of the kick on his right lower leg. The facility's Quality Assurance representative acknowledged that the CNA's actions constituted abuse, as defined by the facility's Abuse Prohibition policy. The policy, reviewed during the investigation, includes physical abuse such as hitting, slapping, pinching, and kicking. The resident's cognitive function was assessed as normal, with a score of 15/15 on the BIMS assessment, suggesting that he required minimal cognitive aid and memory support from staff.
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What surveyors actually found near you
We read the 688 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Highland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Del Rosa Villa | 1.1 mi | ★★★★★ | 14 | 0 |
| Highland Palms Healthcare Center | 1.7 mi | ★★★★★ | 9 | 0 |
| Haven Post Acute | 1.8 mi | ★★★★★ | 1 | 0 |
| Waterman Canyon Post Acute | 2.9 mi | ★★★★★ | 2 | 0 |
| Valley Healthcare Center | 2.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.