Sierra Post Acute

Penalty

Inspection fine: $28,350

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in the facility’s failure to maintain a resident environment free from accident hazards and to provide adequate supervision and consistent implementation of fall-prevention interventions for one high fall-risk resident. The facility’s own Falls and Fall Risk, Managing Policy required staff to identify and implement resident-specific interventions, adjust them if falls recurred, and monitor/document responses. Resident #10, an individual over age 65 with emphysema, dementia, paranoid personality disorder, epilepsy, and a history of repeated falls, was assessed as having moderate cognitive impairment and needing staff supervision for toileting, dressing, and ambulation. The comprehensive care plan, initiated and updated over several months, identified the resident as at risk for falls with and without injury and listed multiple interventions, including call light and personal items within reach, traction strips and reminder signs, bed in low position, room relocation closer to the nurses’ station, hipsters, a low-profile fall mat, and offering a scrum cap when out of bed. Despite these identified risks and planned interventions, the resident sustained eight falls within a three‑month period, including several unwitnessed or unexplained falls and a significant fall resulting in a closed head injury. Documentation showed falls on multiple dates, including events where the resident was found on the floor near his wheelchair, bed, or in the bathroom, and one witnessed fall when he turned too fast and lost balance. On one occasion, a nurse documented being informed after the fact that the resident had fallen on a previous shift without a corresponding report or injury documentation at the time of the event. Emergency room records from one fall documented a closed head injury with periorbital and parietal scalp hematomas, and a later physician note referenced MRI findings of a subdural hematoma, while the facility reported the resident remained neurologically stable. During on-site observations, surveyors found that key fall-prevention interventions were not consistently in place for this resident. On multiple occasions, the resident was observed lying in bed in a different bed position (bed A) than his assigned bed (bed B) without a fall mat in place and without the call light within reach, contrary to the care plan and physician orders. The resident’s bathroom lacked traction strips despite this being a listed intervention. Staff interviews revealed inconsistent awareness and implementation of fall precautions: one CNA stated the resident was not a fall risk and was unaware of his fall history, could not locate his hipsters, and believed the bed did not need to be low. An LPN, who acknowledged the resident was a high fall risk, confirmed that the fall mat was placed by the wrong bed side and that the resident’s hipsters and scrum cap, along with other personal belongings, remained in the resident’s old room more than a week after a permanent room move. The DON confirmed that fall interventions should be used at all times and that staff were expected to use the care plan, Kardex, and intervention binders to guide resident safety, but the resident’s interventions and belongings had not been properly transferred or consistently applied.

Penalty

Inspection fine: $28,350

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain an effective infection prevention and control program on two of three units, specifically in housekeeping practices and hand hygiene during resident care. Professional references cited in the report emphasize the importance of cleaning and disinfecting high-touch surfaces, following proper cleaning sequences from cleaner to dirtier areas, and adhering to disinfectant contact (dwell) times to prevent healthcare-associated infections. Facility policies on cleaning and disinfecting resident rooms and on hand hygiene require regular cleaning of environmental surfaces, appropriate selection and use of disinfectants, changing soiled cleaning materials, and performing hand hygiene at key moments, including before and after resident contact and after glove removal. During observations of housekeeping practices, a housekeeper was seen cleaning a double-occupancy room using a single Clorox hydrogen peroxide disinfectant wipe on surfaces for both sides of the room, contrary to hygienic practice and without allowing the surfaces to remain wet for the manufacturer-required one-minute dwell time. The housekeeper sprayed the toilet with Spic and Span disinfectant and then used a toilet brush and a red rag to wipe the toilet rim, seat, and lid in a sequence that did not proceed from the cleanest to the dirtiest areas. Without changing gloves or performing hand hygiene after cleaning the toilet, the housekeeper then reached into the mop bucket twice to wet mop pads, thereby contaminating the cleaning solution, and proceeded to mop the bathroom and resident room. The housekeeper did not clean high-touch areas such as call lights, light switches, bed controls, or the resident sink area, and did not perform hand hygiene between rooms before donning new gloves. In a triple-occupancy room, the same housekeeper again used Spic and Span to spray the toilet and collected trash, then used two Clorox hydrogen peroxide wipes to clean bedside tables and nightstands for two beds, leaving one bed’s nightstand and bedside table uncleaned and not maintaining the required dwell time, as the surfaces dried in about 30 seconds. The housekeeper used Spic and Span and a single rag to clean the sink area and mirror, wiping the mirror first and then the sink handles, bowl, and countertop, again not following a clean-to-dirty sequence. After scrubbing the toilet bowl with a toilet brush, the housekeeper touched the bathroom light switch, items on the cleaning cart, and then placed toilet paper in the bathroom while still wearing soiled gloves used for toilet cleaning. Although gloves were later changed, hand hygiene was not performed between glove changes. The report also documents a failure to perform appropriate hand hygiene during wound and catheter-related care by the facility’s infection preventionist (IP). While providing suprapubic catheter care to a resident, the IP performed initial hand hygiene, donned PPE, removed the resident’s adult disposable brief, removed the old drain sponge, and cleansed and dried the suprapubic area using multiple clean washcloths before placing a new drain sponge and reattaching the brief. After removing PPE and washing her hands, the IP donned gloves and handled the resident’s garbage bag, used PPE, and an old Foley catheter bag to take them to the garbage disposal area. The IP did not change gloves and perform hand hygiene immediately after removing the soiled drain sponge, and the old Foley catheter bag, which was contaminated with bodily fluids, was not placed into a red biohazard bag. In interviews, the IP acknowledged that gloves should be changed after removing a dirty dressing, and the DON confirmed that the correct procedure would include removing the old dressing, removing gloves, washing hands, donning clean gloves, and discarding a dirty Foley catheter bag in a red biohazard bag.

Penalty

Inspection fine: $28,350

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and in three of three unit nourishment refrigerators/freezers. Surveyors observed multiple food items in the walk-in freezer and refrigerator that were unlabeled, undated, or past their use-by dates, including opened egg rolls with no labeling or dating, ground beef dated 1/14/26 with a use-by date of 1/18/26, lemon bars dated 10/16/25, pizza flat breads with no label or date, opened ice cream bars with no label or date, a bucket of mixed meats with no label or date, and grilled cheese sandwiches with no label or date. The dietary director stated several of these items would be discarded because they were too old or could not be identified. In the nourishment areas at the nurses’ stations, surveyors found additional food storage problems. One nourishment refrigerator/freezer had melted chocolate ice cream streaks in the freezer. Another had an opened square metal container of yellow creamy food with plastic wrap partially covering it and a serving spoon inside, with no label or date. The same area also contained an overcrowded refrigerator with an opened coffee creamer, chili in a Tupperware container, a half-full plastic container of soda with a straw, and an opened container of yogurt, all without names or dates. In a separate nourishment refrigerator/freezer, three resident snack and beverage items were found without labels or dates, including an unknown beverage in a plastic cup, an opened sports drink, and a snack in a plastic bag. The dietary director and activities assistant stated that kitchen staff and dietary leadership were responsible for cleaning out old food and maintaining the kitchen and nourishment refrigerators/freezers. The dietary director said food delivered on Tuesdays and Thursdays was supposed to be reviewed, labeled, and dated, and that she and the dietary manager were responsible for cleaning and discarding outdated food and beverages. She also stated there were no cleaning logs for the kitchen or nourishment refrigerators/freezers, that the areas should be cleaned weekly, and that items in these storage areas should be labeled and dated. She further stated it had been over three months since she had cleaned one of the nourishment refrigerator/freezer areas.

Penalty

Inspection fine: $28,350

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents had reasonable access to private telephone use on two of three units, Prasada and Legacy. The facility policy stated residents should have reasonable access to telephones and private telephone conversations, and that residents should be informed of the provisions made for access and privacy in communications. However, surveyors observed that both secured units had only a public landline telephone located at or near the nurses' station, with no private area available for calls on those units. On the Prasada unit, an unidentified resident was observed making a personal call to his mother from the nurses' station/dining area during lunchtime, and the conversation was overheard by residents seated in the dining room. Resident #21 stated he made calls at the nurses' station/dining room area because it was the only phone available and there was no portable phone, and he said private phone calls would be great but were not an option. Resident #56 said he had spoken with his grandma at the nurses' station on his birthday and would have preferred a more private conversation, and he did not know whether private calls were an option. On the Legacy unit, Resident #5 was observed making a personal call on speakerphone at the nurses' station while three residents and a CNA were nearby and able to hear the conversation. Residents interviewed on the unit said the phone was located at the nurses' station and there was no room or phone available for private calls. The social services director acknowledged that the other two units had only a landline at the nurses' station, that there should be a place on each unit where calls could be made without being overheard, and that some residents were not aware that private phone conversations were an option.

Penalty

Inspection fine: $28,350

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Drugs and biologicals were not properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication carts. The facility policy stated that medications are to be stored in a safe, secure, and orderly manner and kept in the packaging, containers, or dispensing systems in which they are received. During observation, medication cart B contained three loose pills in the drawers, and an LPN identified one of the pills as Advil. Medication cart A contained twenty loose pills in the drawers, and an RN was unable to identify any of the loose pills. During interviews, the LPN stated that night nurses were responsible for cleaning the medication carts, although all nurses were responsible for ensuring the cart was clean. The RN stated that all nurses were responsible for ensuring the medication carts were clean. The DON stated that the unit manager nurse was overseeing cleaning of the medication carts and that the carts were assigned to be cleaned once a week by the nurse manager, but nurses should also be cleaning the carts on their shifts. The DON stated, "The task was not getting done," and that a resident could find a loose pill and take it.

Penalty

Inspection fine: $28,350

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect one resident from physical abuse by another resident during an unwitnessed altercation in a shared room. The facility’s abuse prevention policy states that residents have the right to be free from abuse, including physical abuse, and that they must be protected from harm. On the date of the incident, a resident with schizoaffective disorder left his room and reported to a CNA that he had hit his roommate in the head multiple times because voices told him to do so. The altercation was not witnessed by staff, and the facility’s own investigation confirmed that the assault occurred based on the statements of both residents. The resident who committed the assault was younger than 65 and had documented diagnoses including unspecified schizoaffective disorder, unspecified affective mood disorder, and hallucinations, with a history of behavioral symptoms such as physical and verbal aggression. His MDS showed he was cognitively intact and independent in mobility, and his care plans documented targeted behaviors including internal stimuli, auditory hallucinations, delusions, and aggression. The behavior and schizoaffective disorder care plans also documented that he had been recently involved in two separate resident-to-resident altercations, and staff interviews confirmed he had a history of such altercations, including punching a prior roommate. Despite this known history and identified risk for aggressive behavior toward peers, he remained in a shared room where he was able to physically assault his roommate while the roommate was in bed. The victim of the assault was over 65 with diagnoses including intracranial injury, dementia, post-traumatic stress disorder, and major depressive disorder, and had moderate cognitive impairment per his MDS. He required varying levels of assistance with ADLs and had a trauma-informed care plan identifying him as at risk for decreased psychosocial well-being and emotional distress. On the day of the incident, nursing documentation recorded that the assailant admitted to hitting this resident two to three times in the head while he was sleeping. When assessed, the victim denied pain, loss of consciousness, and fear, and stated his roommate had “just went crazy.” Staff interviews indicated that the assailant was known to be easily agitated and had a history of resident-to-resident altercations, and that a room change for him had been delayed. The combination of the assailant’s known aggressive behaviors, his documented history of altercations, and the continued placement in a shared room led to the failure to keep the victim free from physical abuse. Staff interviews further showed gaps in awareness and implementation of behavior management interventions. A CNA reported that the assailant had been involved in a prior altercation two to three weeks earlier, also self-reported by the resident, and that the victim was only moved to a different room after the current altercation. An RN stated that the resident’s triggers included hearing voices and that care plan updates were important for safety, but she was unsure why there was a delay in changing the assailant’s room. The social services director acknowledged the resident’s history of altercations and stated that previous root causes were related to auditory hallucinations, and that a room change was delayed due to another resident occupying the room and the need for a five-day room change notification. The NHA was unable to state what specific interventions were in place to manage the resident’s anger-related outbursts after the altercation. These circumstances, combined with the known behavioral history and risk factors, resulted in the facility’s failure to ensure that the victim was protected from physical abuse by his roommate. The facility’s investigation concluded that the altercation was substantiated, with both residents confirming the incident. Documentation indicated that the incident did not cause injury or psychosocial stress according to the facility’s assessment, but the core deficiency remained that a resident with known aggressive behaviors and hallucinations was able to physically assault his roommate in their shared room. The facility’s own records and staff interviews demonstrate that the assailant’s behavioral risks and prior altercations were known, yet he remained in a situation where he could and did inflict physical abuse on another resident, contrary to the facility’s abuse prevention policy and the residents’ right to be free from abuse.

Penalty

Inspection fine: $28,350

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident was treated with dignity during meals. The facility’s Dignity policy stated that residents are to be cared for in a manner that promotes well-being, self-worth, and self-esteem, and that residents are to be provided with a dignified dining experience. The Assistance With Meals/Mealtime policy stated that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals. During lunch observations on the memory care unit, CNA #4 was seen assisting Resident #26 by spoon-feeding him while standing between him and another resident, and when a resident told her to sit down, she replied that there were no chairs available even though an open chair was observed at another table. LPN #4 was also observed standing next to Resident #40 while assisting with the meal despite an unused chair being available at the table. On a later observation, CNA #3 was seen standing next to Resident #5 and then standing over him while assisting him to eat, and she continued standing while assisting Resident #40 and Resident #42 with meals. In interviews, CNA #3 stated staff should be seated when assisting residents to eat, LPN #3 stated staff should assist residents while sitting at eye level, and the DON stated staff were to sit at eye level and communicate with residents while providing meal assistance.

Penalty

Inspection fine: $28,350

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen and nebulizer services. Resident #1 had diagnoses including COPD, CHF, vascular dementia, diabetes, kidney disease, muscle weakness, and wheelchair dependence, and the MDS indicated continuous oxygen at 2 LPM via nasal cannula. During observations, the resident was seen in the dining room multiple times without a portable oxygen tank and, at times, without a nasal cannula, despite the physician’s order for continuous oxygen. The resident stated she did not have a portable oxygen tank and only needed oxygen in her room, while staff later stated she had the right to refuse a portable tank and that one had been obtained and set up for her. Resident #23 had diagnoses including vascular dementia, COPD, diabetes, sleep apnea, dependence on supplemental oxygen, and long-term use of inhaled steroids. The resident’s nebulizer equipment was observed sitting on the TV stand with the mask and tubing connected and left out on the table, with no storage bag present. The resident stated that after nebulizer treatments, which occurred four times a day, the nurse left everything on the TV stand and that she had never seen the nurses clean it. The MAR/TAR did not show documentation that cleaning was completed, and the care plans did not include cleaning frequency or cleaning instructions for the nebulizer unit or accessories. Staff interviews showed inconsistent practices and a lack of clear direction for nebulizer cleaning. An RN said she hung the mask on the machine after treatment and thought night shift washed the accessories, while the DON said nurses were responsible for cleaning the mask with running water and placing it on a bedside table to air dry, and that she thought sanitizing was done with sani-wipes. The DON also reviewed the record and stated there was no guidance or physician order for cleaning the nebulizer unit/accessories and nothing in the care plan. The manufacturer’s instructions provided to the surveyor stated that nebulizer parts should be washed after each use, dried, and disinfected daily after the last treatment of the day.

Penalty

Inspection fine: $28,350

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its policies and procedures related to influenza immunizations for one resident reviewed for immunizations. Resident #5, who was over age 65 and admitted with diagnoses including dementia, hypertension, atrial fibrillation, and epilepsy, had a BIMS score of 3 out of 15 and was severely cognitively impaired. The resident’s MDS indicated the influenza vaccine had been received outside the facility, but review of the electronic medical record did not show documentation that the 2025/2026 influenza vaccine had actually been administered. Record review showed Resident #5 had signed a consent form requesting the influenza vaccine upon admission, but the physician order record did not include an order for the vaccine on multiple reviews. The influenza vaccine order was not present until during the survey, when the resident was administered the vaccine by the facility. Staff interviews with the IP and DON confirmed the facility tracked vaccines through the state immunization portal and resident records, and that the resident had been included in the annual flu vaccine process; however, after review, staff determined there had been an error and that the resident had not previously received the vaccine from an outside provider.

Penalty

Inspection fine: $40,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from physical abuse, resulting in two separate incidents involving resident-to-resident altercations. In the first incident, a resident with severe cognitive impairment and multiple medical conditions, including dementia and a recent femur fracture, wandered into another resident's room. The second resident, also severely cognitively impaired with a history of behavioral symptoms and a preference for personal space, pushed the first resident, causing a fall and a subsequent femur fracture. Staff interviews and care plan reviews indicated that the resident who pushed had known behavioral triggers related to personal space, and interventions such as a stop sign on the door and staff redirection were in place, but these measures were not sufficient to prevent the incident. In the second incident, a resident with moderate cognitive impairment and schizoaffective disorder was sitting on a couch when another resident, who was cognitively intact but had a history of hallucinations and behavioral outbursts, approached and struck him in the face. The altercation was witnessed by another resident and confirmed by video footage. The victim sustained a small bruise near the eye but did not retaliate or express fear. Staff and resident interviews revealed that the assailant had a history of unpredictable aggression, often without clear triggers, and had been involved in several previous altercations with different residents. Both incidents demonstrate that the facility did not adequately prevent physical abuse between residents, despite having policies and care plans addressing behavioral risks. Staff were aware of the behavioral histories and triggers of the residents involved, and interventions such as increased monitoring and environmental cues were in place, but these were not effective in preventing the physical altercations that resulted in injury and distress among the residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision and accident prevention for a resident, leading to a significant injury. Upon admission, the resident, who had a history of falls and cognitive impairments, was not provided with a person-centered care plan that addressed his high fall risk. Despite being identified as high risk for falls, the facility did not implement effective interventions such as a low bed or fall mat, nor did they install recommended bed rails. On the day of the incident, the resident fell out of bed and sustained a T12 to L1 fracture, which required surgical intervention. The fall was unwitnessed, and the resident was not assessed by a registered nurse before being moved, contrary to facility policy. Additionally, there was a delay in notifying the resident's family about the fall, and the facility did not document a comprehensive assessment following the incident. Interviews with staff revealed that the facility's interventions were not person-centered, and there was a lack of documentation regarding the ordering of a larger bed or the installation of bed rails. The director of nursing acknowledged the failure to implement appropriate fall prevention measures and the absence of a documented assessment by a registered nurse immediately following the fall.

Penalty

Inspection fine: $10,358

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe environment for a resident who required supervision during a smoking break while using oxygen. On the day of the incident, the resident exited the behavioral health secured unit with an oxygen tank and nasal cannula still in place. Two CNAs were present to supervise the smoking session, but neither noticed that the resident was still wearing his oxygen. As a result, when the resident's cigarette was lit, his hair caught fire, leading to burns on his face. The resident, who was cognitively intact and independent in activities of daily living, had a history of schizophrenia, substance abuse, COPD, and nicotine dependence. Despite being aware of the facility's smoking policy, the resident forgot to remove his oxygen before entering the smoking area. The CNAs, responsible for supervising the session, failed to ensure the resident's oxygen was removed, which was a violation of the facility's smoking policy. The incident resulted in the resident sustaining burns to his forehead, nose, lips, and cheeks. The CNAs involved were not attentive to the resident's condition, as they were focused on distributing and lighting cigarettes for other residents. This lack of supervision and failure to adhere to safety protocols directly contributed to the accident, highlighting a significant deficiency in the facility's supervision practices during smoking sessions.

Removal Plan

• The facility corrected the deficient practice.
• The NHA, police department, DON, ombudsman, and resident's legal guardian were notified of the incident.
• Resident #1 was transferred to the hospital for evaluation and treatment of his burns.
• The two employees involved were educated on the smoking policy and suspended pending an investigation.
• All staff working in the facility were provided reeducation on the smoking policy.
• The remainder of facility staff were reeducated on the smoking policy with return demonstration.
• The facility reviewed their current smoking policy to ensure appropriate procedures were in place to prevent harm/potential harm.
• All staff were reeducated on the smoking policy.
• The NHA ensured that all newly hired staff would receive education on safe smoking and the facility policy.
• The facility initiated random audits of all three units to monitor residents who required supervision for smoking.
• The DON or designated supervisor was to continue the audits.
• Every resident was reassessed for smoking safety.
• The smoking policy was revamped to include that the supervised monitor was responsible for removing the oxygen and oxygen tubing at the nurses station before the smoking session.
• The facility requested the local fire marshal to assess the smoking area at the facility.