Sierra View Homes

Based on observation, interview, and record review, the facility failed to follow the policy and procedure (P&P) to ensure the care plans (CP) were reviewed and revised for one of eight sampled residents (Resident 39) when:The CP for Resident 39 was not reviewed and revised after Resident 39 had a change in physician's order for oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy from 2 liters per minute (L/min- a unit of measurement for the flow rate of oxygen) to 4L/min on 9/23/25.Findings:During a concurrent observation and interview on 2/5/2026 at 12:16 p.m., Resident 39 was seen in the hallway in front of her room and sitting in her wheelchair with a nasal cannula (NC- thin plastic tube that delivers oxygen directly into the nose through two small prongs) in her nostrils, and an O2 tank attached to her wheelchair. The O2 tank was set to 4L/min.During a review of Resident 39's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure services were provided to restore or improve normal bladder function and bowel function to the extent possible for one of eight sampled residents (Resident 6), when Resident 6's bowel and bladder training (a behavioral technique used to help individuals regain control over their bladder and bowel function) for incontinence (lack of voluntary control over urination or defecation) was not implemented.This failure had the potential to place Resident 6 at risk for urinary tract infections (UTI -infection of any part of the urinary system), pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and not maintaining or improving Resident 6's Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). Findings:During a concurrent observation and interview on 02/04/2026 at 3:16 p.m. in Resident 6's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet state/federal laws and professional standards of practice for labeling and storage of drugs and biologicals (medical products or agricultural agents derived from living organisms such as humans, animals, or microorganisms) for two of eight sampled residents (Resident 11 and Resident 47) when:1. Resident 11's controlled medication (medications that are highly regulated by the government because of the significant risk of abuse and dependence they pose) record sheet did not indicate the Administration Instructions (specific directions, including dosage form, route (e.g., by mouth), and frequency (e.g., 1-tab daily) for use of the medications.This failure placed Resident 11 at risk of being administered the wrong dosage of the medication at the wrong time and the route. 2. Resident 47 was administered a controlled medication on 1/3/26 and the Controlled Drug Record (CDR) was not signed by the licensed nurse (LN) according to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents' call light was within reach for three of eight sampled residents (Resident 9, 11, and 55), when:1. Resident 9's call light was on the floor and not within his reach.2. Resident 11 and Resident 55's call lights were on their dressers and not within their reach. These failures had the potential to cause harm to Resident 9, Resident 11, and Resident 55 when these residents were not able to call for assistance with the use of their call lights in the event of an emergency.Findings:1. During an observation on 2/4/2026 at 3:35 p.m. in Resident 9's room, Resident 9 was observed dressed and lying in bed with eyes closed. Resident 9's call light was observed to be on the floor at the head of the bed and was not within Resident 9's reach.During a review of Resident 9's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASRR) when 2 (Resident #19 and Resident #39) of 2 sampled residents reviewed for PASRR were diagnosed with a new serious mental illness. Findings included: A facility policy titled, PASRR Policy and Procedure, dated 04/04/2023, revealed, The PASRR consists of a Level I Screening, a Level 2 evaluation (if needed), and a determination, The PASRR is divided into two components, the Preadmission Screening (PAS) and the resident review (RR). The PAS process is completed by the hospital prior to an individual discharging to a skilled nursing facility (SNF). A SNF can also complete the PAS process, but only when the individual is being admitted directly from the community. The RR process is completed for current SNF residents, readmissions, or inter-facility transfers when there is a significant change in the individual's physical or mental condition. In the case of an RR, the NF…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for 2 (Resident #19 and Resident #38) of 14 sampled residents. Findings included: A facility policy titled, Minimum Data Set, dated 08/17/2015, revealed, To provide an accurate assessment of all residents through clinical competence, observational, interviewing, and critical thinking skills, combined together to develop individualized plan of care for each individual. 1. An admission Record revealed the facility admitted Resident #19 on 03/17/2022. According to the admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease. A significant change in status MDS, with an Assessment Reference Date (ARD) of 04/02/2025, revealed Resident #19 was rarely/never understood. The MDS Coordinator was interviewed on 04/09/2025 at 1:25 PM. The MDS Coordinator stated that it was important for the MDS to be accurate because the MDS reflected the resident's condition. The MDS Coordinator reviewed the MDS for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan that addressed hospice care for 1 (Resident #38) of 1 sampled resident reviewed for hospice and end of life. Findings included: A facility policy titled, Comprehensive Individualized Resident Care Plan (Activities) Isolation, dated 01/01/2024, indicated Comprehensive Individualized resident care plans provide a past and current history to current issues, illnesses, medication use, and another other factors. An admission Record revealed the facility admitted Resident #38 on 09/22/2023. According to the admission Record, the resident had a medical history that included an anxiety disorder and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/2025, indicated Resident #38 had a Staff Assessment for Mental Status (SAMS) that revealed the resident had modified independence in cognitive skills for daily decision making. The MDS indicated that the resident received hospice care. Resident #38's Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when: 1. Two of three sampled Certified Nursing Assistants (CNAs) placed clean linen on top of the personal protective equipment (PPE-equipment worn to minimize exposure to illnesses) cart in the hallway while donning (putting on) their PPE. These failures had the potential to cause an outbreak of the COVID-19 virus (a serious contagious respiratory [Lung] infection transmitted from person to person) outbreak (a sudden rise in the number of cases of a disease) throughout the facility. 2. One of three sampled CNAs exited a room marked red zone (rooms with residents testing positive for COVID-19) with PPE on and walked down the hallway. These failures had the potential to spread the COVID-19 virus throughout the hallway. 3. One of three sampled CNAs exited a red zone room and placed her face shield contaminated side down on top of the PPE cart. These failures had the potential to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer 53 of 54 residents the Covid 19 (a disease caused by a virus named SARS-CoV-2) vaccine (an injection that teaches the immune system how to recognize and fight off specific diease or virus) when it became available to them and did not educate residents, or their designated responsible parties (a person, not the resident, who are responsible for that residents care), on the risks and benefits of Covid-19 vaccination (injection into the body to produce protection from a specific disease). This failure resulted in the Covid-19 vaccine not being available to residents and had the potential to put the residents safety at-risk. Findings: During a review of the facility's Residents Covid Vaccination Status- Resident Directory (RCVS), dated 12/11/23, the RCVS indicated 53 out of 54 Residents were unvaccinated in regard to Covid-19. During a review of the facility's [Pharmacy Store]- Screening Questionnaire and Consent (permission from resident) Form (SQ),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive resident - centered care plans for 12 of 37 sampled residents (Residents 7, 17, 24, 26, 28, 31, 33, 34, 35, 37, 42 and 43) when Social Service Director (SSD) and Activity Director (AD) did not develop activity care plans for Residents 7, 17, 24, 26, 28, 31, 33, 34, 35 37, 42 and 43 since they were admitted to the facility. These failures resulted in Residents 7, 17, 24, 26, 28, 31, 33, 34, 35, 37, 42 and 43 not having activities they could engage in, which could lead to boredom, loss of interest, inactivity, depression, feelings of isolation, decreased socialization opportunities with others, and loss of control over their lives while residing at the facility. Findings: During a review of Resident 7's Record of admission (ROA, (a document with patient information, past medical history, allergies, insurance status or other pertinent information) dated 12/13/23, the ROA indicated Resident 7 was admitted to the facility on [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide services which met professional standards of quality of care for four of ten sampled residents (Resident 3, 28, 353 and 23) when: 1. The oxygen (a colorless, odorless, tasteless gas essential to living organism) flow rate (the amount of oxygen being delivered to the body) for Resident 3, 28 and 353 was not administered according to the physician order (an order given for a specific patient/resident by a healthcare provider. This failure resulted in Resident 3, 28 and 353 to not receive the ordered amount of oxygen via the oxygen concentrator (a machine that pulls in the air around you), which could lead to breathing problems that include shortness of breath, headache, and confusion. 2. The nasal cannula and humidifier for Resident 3 had the incorrect date and the nasal cannula and humidifier for Resident 28 and Resident 353 were undated. These failures placed Resident 3, 28 and 353 at risk for respiratory infection which could lead…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide on-going activities program to support residents in their choice of activities for 11 of 14 sampled residents (Residents' 17, 26, 28, 31, 33, 34, 35, 37, 42, 43 and 48) when Residents' 17, 26, 28, 31, 32, 33, 34, 35, 37 and 43 were not provided individual and independent activities designed to meet their interests since facility started quarantine (staying away from others for a period of time in order to prevent the spread of the disease) on 12/7/23 due to COVID (disease caused by a virus named SARS-CoV-2. It can be very contagious[spread easily] and spreads quickly) positive test results of several staff and residents. These failures resulted in Residents' 17, 26, 28, 31, 33, 34, 35, 37, 42, 43 and 48's inactivity (lack of activity) which could potentially affect their physical, mental and psychosocial well-being. Findings: During a review of Resident 17's Minimum Data Set (MDS, a federally mandated process for clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the nurse staffing information was posted on a daily basis at the beginning of each shift from 11/06/23 to 12/12/23. This failure resulted in facility staffing information not readily accessible to residents and visitors. Findings: During a concurrent observation and interview on 12/12/23 at 3:15 p.m., with licensed vocational nurse (LVN) 3 and Medical Records Director (MRD), in the East wing near the nursing station across the activity room, there was a nursing staff information posted dated 11/05/23. LVN 3 stated the night shift nurse was responsible in completing the form and made sure there was one posted everyday. The MRD stated it was the responsibility of the Director of Nursing (DON) to make sure the posted Census and Nursing Home per Patient Day (NHPPD) form was up to date. The MRD stated, . There was probably an error of the date, but the number of census was also not correct . The MRD stated she was not familiar with the form and was not sure why the form was not up to date. The MRD stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have an adequate system in place for receipt and periodic reconciliation that would determine an account of all controlled drugs received in the facility. These failures increased the potential for all residents' controlled substances to be diverted. Findings: During an observation on 12/12/23 at 9:25 a.m. with Licensed Vocational Nurse (LVN) 3, the medication cart for west wing was observed to contain two medications; one for Resident 38 for Lorazepam (medication used to treat anxiety) 0.5 miligrams (mg) tablet with 19 tablets remaining and one for Resident 44 for hydrocodone/APAP (controlled medication for pain) 5-325 mg tablet with 9 tablets remaining. During a review of Resident 38's Controlled Drug Record sheet, dated 4/11/23, the sheet indicated, . Lorazepam Tab 0.5 mg take one tablet by mouth every 6 hours as needed, Quantity 30 tablets . During a review of Resident 44's, Controlled Drug Record Sheet, dated 11/8/2023, the sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three out of three sampled residents (Resident 38, Resident 26, and Resident 44) were safely administered and appropriately prescribed antipsychotic medications when: 1. For Resident 38, the facility did not determine appropriate indication for use prior to administration of Quetiapine (an antipsychotic medication for mental illness), did not implement resident specific non-pharmacological interventions for the use of Quetiapine), did not adequately monitor behaviors for the use of Quetiapine, did not adequately monitor side effect and laboratory monitoring for the use of Quetiapine and did not complete an Abnormal Involuntary Movement Screening (AIMS- screen to assess abnormal movements that may occur as a result of patients taking antipsychotic medications). 2. For Resident 26, the facility did not develop and implement resident specific non-pharmacological interventions for the use of Quetiapine, did not adequately monitor side…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles, for six out of six sampled residents (Resident 4, Resident 254, Resident 10, Resident 38, Resident 40 and Resident 253) when: 1. Discontinued medications for Resident 4, Resident 254, Resident 10 and Resident 253 were found stored in the medication cart with with currently used medications. This failure placed Residents 4, 254, 10, and 253 at risk for receiving unecessary and potentially expired medications that could cause the residents to experience symptoms of adverse side-effects or drug interactions such as nausea, vomiting, loose stools, and drowsiness. 2. Licensed Nurses (LN) did not apply discard by date labels and resident names on inhaler medications for Resident 38 and Resident 40. This failure could result in Resident 38 and Resident 40 to receive potentially expired and ineffective breathing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident were treated with dignity and respect for two of four sampled residents (Residents 40 and 7) when: 1. Licensed Vocational Nurse (LVN) 3 did not close the privacy curtain and administered medication to Resident 40 in front of other residents and visible to staff and visitors walking by in the hallway. This failure resulted in Resident 40's stomach to be exposed and viewed by other residents, staff, and visitors and violated Resident 40's right to privacy and dignity. 2. Resident 7 was served lunch tray and was seated at the edge of the bed, Resident 7 was almost laying in bed and not able to sit up straight to see her food placed on top of over the bed table and feed self. This failure had the potential for Resident 7 to not consume enough food which could lead to weight loss and also put her at risk for choking and aspiration which could lead to serious medical condition. Findings: 1. During a concurrent observation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a clean and homelike environment for two of seven residents (Residents 4 and 44), when three privacy curtains in room [ROOM NUMBER] were found with scattered brownish red discoloration. This failure resulted in violation of resident's right to live in a clean and homelike environment. Findings: During a concurrent observation and interview on 12/11/23 at 12:20 p.m. with Resident 4 in room [ROOM NUMBER], the privacy curtains separating beds A, B and C were observed with scattered brownish red discolored areas. Resident 4 stated, . The stains in the curtains are blood and had been there for a long time . One privacy curtain between A and B bed was also observed with a large tear. During a review of Resident 4's Record Of Admission dated 12/12/23, the Record of Admission indicated Resident 4 was admitted in the facility on 11/6/23, with diagnoses which included, myocardial infarction (blood clots that blocks blood flow to the heart)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 21) received an influenza (flu-a contagious respiratory infection which can be deadly in high-risk groups) vaccination for the 2023-2024 flu season (from October 1st-March 31st). This failure placed Resident 21 at risk of becoming infected with influenza. Findings: During a review of the Record of Admission, (ROA) undated, the ROA indicated Resident 21 was admitted on [DATE] with diagnoses which included encounter for palliative care (specialized care for a serious illness), pleural effusion (buildup of fluid around the lungs) and Alzheimer's Disease (progressive disease affecting memory, thinking and behavior). During a concurrent interview and record review on 12/12/23 at 9:47 a.m. with the Infection Preventionist (IP), Resident 21's flu consent was reviewed. The consent was signed by Resident 21's responsible party on 8/22/23. The flu consent had a handwritten note on the bottom of the form which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.