La Sierra Care Center

Inspectors wroteBased on interview and record review the facility failed to ensure a Registered Dietitian (RD) comprehensively and frequently evaluated the effectiveness of food service operations when lapses in the delivery of services associated with meal accuracy and nutritional value of menus, as well as food safety (cross reference F 803, F 806, and F 812) occurred. This failure resulted in lack of sufficient oversight from the RD, which placed 62 out of 65 residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or altered nutritional intake, both of which had the potential to result in death and/or nutritional related medical complications. During an interview on 1/22/26 at 5:00 p.m. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure five out of five residents on pureed diets (pudding-like consistency food, requiring no chewing and easy to swallow) received the correct serving scoop size for lunch on 1/21/26 when stir fried chicken was served with a #8 scoop (1/2 cup) instead of the required recipe #6 scoop (2/3 cup). This failure resulted in the wrong serving size of a menu item which could result in weight variances, inaccurate nutritional monitoring and lead to serious medical conditions. During a review of the facility's document titled, Diet Type Report, dated 1/22/26, the document indicated five residents at the facility received pureed diet textures. During a review of the facility's menu recipe document titled, Stir Fried Chicken, dated 2026, the recipe indicated, .suggested portion # 6 SCP [scoop]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide appealing and nutritional alternative menu items to 62 out of 65 residents eating at the facility when there was no posted or designated alternative meal menu and the kitchen only designated peanut butter and jelly, grilled cheese and ham and cheese sandwiches as an alternative meal option. This failure resulted in residents having no designated appealing and nutritional alternative meal options, and had the potential to result in decreased satisfaction and resident food intake. During an observation on 1/20/26 at 9:14 a.m. no alternative meal menu was posted outside the kitchen on the menu wall. During an observation on 1/20/26 at 9:16 a.m. no alternative meal menu was posted inside the kitchen. During an observation on 1/20/26 at 11:53 a.m. no alternative meal menu was posted inside the two dining rooms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food and beverages were stored, distributed, and served safely in accordance with professional standards of food service safety for 62 out of 65 residents eating at the facility when: Four 48 fluid ounce (fl oz- a unit of measurement) prune juice bottles were not labeled with a received-on date label. The dry food storage room did not have a temperature record log. The food preparation sink did not have an air gap (space between the end of sink pipe and top of sink to prevent backflow). These failures had the potential to result in the serving of expired, spoiled, or contaminated food and beverage items which could result in foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for three of eight sampled residents (Resident 4, Resident 9, and Resident 31) when Resident 4, Resident 9 and Resident 31's copy of Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete. This failure had the potential for Resident 4, Resident 9, and Resident 31's decisions regarding treatment options and end of life wishes to not be honored.

Inspectors wroteBased on observation, interview, and record review during the survey period of 1/20/26 through 1/23/26, the facility failed to provide the minimum of at least 80 square feet per resident in 19 of 23 multiple resident rooms (rooms 1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 23). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation to meet the needs of one of eight sampled residents (Resident 28) when Resident 28, whose vision was severely impaired (no vision or sees only light, colors or shapes column eyes do not appear to follow objects) and dependent on staff for activities of daily living (ADL- a basic skill needed to carry out tasks of everyday life), call light was not within reach. This failure resulted in Resident 28 to be unable to communicate with facility staff for help when needed and be at risk for falls and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of eight sampled residents (Resident 28) when Resident 28's whose vision was severely impaired (no vision or sees only light, colors or shapes column eyes do not appear to follow objects) and did not have care plan interventions that were specific to her vision needs. This failure resulted in staff not assisting with meal set up, cue (a gentle hint or signal) and prompting (an act of assisting) of meals, and assistance with activities of daily living (ADLs) care and had the potential for Resident 28 specific needs to be unmet. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to meet professional standards of practice for three of seventeen sampled residents (Resident 13, Resident 19 and Resident 35) when:Resident 13 was administered hydrocodone-acetaminophen (opioid pain medication used to treat moderate to severe pain) 12 times outside of ordered administration parameters from 1/15/26-1/22/26. Resident 19 was administered tramadol HCL (opioid pain medication used to treat moderate to severe pain) 48 times outside of ordered administration parameters from 11/1/25-1/22/26. These failures had the potential to result in inadequate pain management practices of Resident 13 and Resident 19 which had the potential to lead to adverse consequences such as complications, overdose, misuse or death. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were stored and labeled in accordance with currently accepted professional standards and practice when one of eight bottles of prescription eye drops (physician prescribed medication used in the eyes) were not labeled with the resident's name, directions for use, or expiration date. This failure placed residents at risk of receiving the wrong medication which could lead to medication adverse (resulting in negative or harmful effect) reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program during medication administration for three of 15 sampled residents (Resident 9, Resident 5, and Resident 35) when:1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan (a personalized, written document that outlines a resident's health needs, goals, and the specific actions and services to be provided) for one of three sampled residents (Resident 1) when Resident 1 was a known elopement (a resident who leaves a nursing facility without authorization or staff knowledge) risk and did not have a care plan in place for elopement. This failure resulted in Resident 1 not having a care plan with interventions in place to prevent elopement and led to Resident 1 eloping from the facility on the evening of 11/16/25. [...]

Inspectors wroteBased on interview and record review the facility failed to follow facility's policies and procedures that meet professional standards of quality when: 1.) One of three sampled Residents (Resident 1) did not have nursing documentation in the progress notes for 346 times that he was found on the floor and head-to-toe assessments were not complete. This failure result in no head-to-toe assessments completed and had the potential for delay in care of for Resident 1 and missed opportunity for updating his care plan. 2.) Two of five Certified Nursing Assistant ' s (CNA) working during the afternoon shift were not wearing any identification badges identifying themselves as staff. This failure had the potential for facility residents to not know who was providing care to them, and if they worked in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess dietary preferences for seven of ten (Resident 1, 3, 6, 7, 8, 9, 10) sampled residents when they were not assessed for food preferences within 48 hours of admission. This failure resulted in Resident 1, 3, 6, 7, 8, 9 and 10's food preferences to not be considered when the facility provided meals.

Inspectors wroteDuring an interview on 08/20/2024 at 12:55 PM, Resident #29 stated they took one look at the lunch meal and could not eat it, so they asked for chicken noodle soup instead. During an interview on 08/20/2024 at 2:02 PM, Resident #58 stated the lunch was cold and the meat was dry but at least they got protein. According to an admission MDS, with an ARD of 06/27/2024, Resident #58 had a BIMS score of 13, which indicated the resident was cognitively intact. Based on observation, interview, and facility document and policy review, the facility failed to provide palatable meals. This failure had the potential to affect all residents who received meals from the facility's kitchen.

Inspectors wroteBased on observation, interview, and facility document and policy review, the facility failed to ensure dietary staff did not document lunch meal service temperatures prior to placing the food items on the steam table for meal service and failed to ensure dietary staff utilized proper hand hygiene during meal service. These failures had the potential to affect all residents who received meals from the facility's kitchen.

Inspectors wroteBased on observation, interview, document review, and facility policy review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 19 (Rooms 1 through 7, Rooms 10 through 20, and room [ROOM NUMBER]) of 23 resident rooms in the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). Observation of medication administration revealed the facility had 3 medication errors out of 28 total opportunities, resulting in a medication error rate of 10.71%, affecting 2 (Residents #9 and Resident #32) of 9 residents observed during medication administration.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure 3 (Residents #9, #32, and #19) of 12 residents reviewed during medication administration and for unnecessary medication were free from significant medication errors. Specifically, the facility failed to ensure physician ordered vital signs were obtained prior to administering medications for Resident #9 and Resident #32 and failed to hold Resident #19's medications when their blood pressure and/or pulse were outside of physician-ordered parameters for administration.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 (Resident #46 and Resident #69) of 17 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) was submitted for 1 (Resident #35) of 3 residents reviewed for PASRR.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to revise 1 (Resident #15) of 17 sampled residents' comprehensive care plan.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to provide fortified food intended for nutritional supplement for 1 (Resident #19) of 4 residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide proper monitoring during the administration of a nebulizer treatment for 1 (Resident #35) of 2 residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure prescribed medications were available for 2 (Resident #2 and Resident #29) of 5 residents reviewed for pharmacy services.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders for vital signs were transcribed to medication administration records for 2 (Resident #9 and Resident #32) of 9 residents observed during medication administration.

Inspectors wroteBased on interview and facility policy review, the facility failed to maintain copies of the posted direct care daily staffing numbers. This had the potential to affect all residents that resided in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to implement a comprehensive person-centered care plan for one of four sampled residents (Resident 1) when Resident 1's safety care plan intervention to not have Certified Nursing Assistant (CNA) 1 [staff accused of providing rough care] was assigned to care for Resident 1 on 12/27/22. This failure had the potential for Resident 1 ' s safety to be compromised and potentially increase his emotional distress manifested by restlessness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance Committee performed annual review of the infection control manual . This failure has the potential for caregivers to lack access to current standards of practice for infection prevention and control needed to provide optimal care to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure grievances identified during Resident Council (a group of residents that meet on a monthly basis to discuss issues/concerns within the facility) were addressed. This failure has the potential for no action and resolution of residents grievances which might affect their overall care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a music activity designed to encourage resident participation and interests was provided for two of three sampled residents (Resident 24 and Resident 34). This facility failure had the potential to result in decreased psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Hot water temperatures in the resident's environment was safely monitored and maintained. 2 . Accident hazards in a resident accessible area for four of four sampled residents (Resident 7, 22, 24, and 34) and three unsampled residents (Resident 5, 36, and 39) were identified. These failures had the potential to cause accidents and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 19 of 23 resident bedrooms (room [ROOM NUMBER], 2, 3, 4, 5, 6, 7, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and 23) provided and maintained the required square footage of 80 square feet (Sq. Ft.) per resident. This failure had the potential for residents to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were within residents reach for one sampled resident ( Resident 21) and two un-sampled residents (Resident 33 and 11). This failure had the potential for the residents' calls for assistance to be not timely met.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure acceptable standards of clinical documentation was implemented for one of 14 sampled residents ( Resident 29) when symptoms of depression were not accurately monitored as ordered . This failure has the potential for continued medication administration with no justification.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure unsealed, open medication bottle with the open date/time and expiration date was labeled. This failure has the potential for staff to continue using the medication beyond its' expiration date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the refrigerator designated for food had documented temperatures with in the acceptable range per policy and procedures. This failure had the potential to lead to growth of micro-organisms, which could lead to foodborne illnesses in the vulnerable population residing in this facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dining area used during meal times for one sampled residents (Resident 21) and one un-sampled residents (Resident 36) was well lit. This failure had the potential for Residents 21 and 36 to have decreased enjoyment of dining experience with risk to affect the residents' nutritional intake and well-being.