Sidney Health Center Extended Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective fall prevention program; failed to follow the established fall policy and failed to identify and address the direct root causes of resident falls with and without major injury. Additionally, the facility did not ensure staff received updated fall-prevention training or education on newly implemented fall prevention interventions. These failures negatively affected 4 (#s 4, 7, 9, and 46) residents out of 5 residents sampled for falls with injuries, to include: - Resident #4 experienced a fall on 9/8/25 and sustained a rib fracture;- Resident #7 experienced multiple falls, with three individual falls on 2/13/25, 6/17/25, and 11/13/25, where she sustained injuries to include head lacerations and bruising. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was held at safe temperatures in the steam table1. The failure placed all residents who are served food from the steam table at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Director participated in the Quality Assurance and Performance Improvement meetings, in order to meet the minimum requirements for the meeting attendees and frequency. This failure could affect any resident when or if a care system was effectively addressed or corrected for a deficient practice. Refer to F689 Accidents and Hazards, with an Immediate Jeopardy cited related to falls; F880, Infection Control; F883 Influenza Vaccines; and F887 Covid-19 vaccines, all system failures related to direct care.

Inspectors wroteBased on interview and record review, the facility failed to maintain adequate infection surveillance and documentation within the facility over a four-month period for the early identification and monitoring of infections and safe infection control practices. This failure increased the risk for all residents in the facility and staff, related to the transmission and prevention of infectious agents.

Inspectors wroteBased on Interview and record review, the facility failed to submit a report to the State Survey Agency within the required timeframe for reportable events for 5 (#s 9, 25, 30, 39, and 46) of 10 residents sampled for facility-reported events.

Inspectors wroteBased on Interview and record review, the facility failed to complete a thorough investigation and comprehensive corrective action following facility-reported events for 3 (#s 9, 39, and 46) of 10 residents sampled for facility-reported events.

Inspectors wroteBased on interview and record review, the facility failed to update resident care plans based on individual resident needs for 4 (#s 4, 8, 9, and 25) of 19 sampled residents. This deficient practice placed residents at risk for injury, unmet needs, and decline in overall function and health.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for 1 (#25) of 6 residents sampled for abuse. The failure resulted in a violation of the resident's right to be free of physical restraint and placed the resident at risk for serious harm. The facility identified the abuse, addressed and corrected the deficient practice before the survey; therefore, it was past non-compliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate documentation was completed and maintained for the education provided to the resident or their responsible party, related to the risks and benefits of the seasonal influenza vaccination, for 3 (#s 6, 7, and 13) of 5 residents sampled for vaccinations.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was completed and maintained to show education was provided to the resident or their representative related to the risks and benefits of the COVID-19 vaccination, for 4 (#s 6, 7, 13, and 14) of 5 residents sampled for vaccinations.

Inspectors wroteBased on interview and record review, the facility failed to provide a resident with necessary respiratory care and services in accordance with professional standards of practice and the resident's physicians orders, which caused the residents to have insufficient oxygen saturations for 2 (#1 and #10) of 14 sampled residents.

Inspectors wroteBased on observations and interview, the facility failed to ensure a Director of Nursing (DON) was working full-time for 35 or more hours per week, in the facility. This failure increased the risk of negative outcomes for all residents in the facility related to nursing care and services, due to the lack of onsite oversight provided by the DON to ensure completion of all necessary resident cares and treatments in the facility. During this survey, harm was identified related to respiratiry care and services, which was identified to be a system concern, and affected 2 (#1 and #10) of those who were sampled for respiratory care.

Inspectors wroteBased on interview and record review, the facility failed to adequately respond to allegations of abuse (bruises of unknown origin) and have evidence the alleged violation unknown bruising was investigated thoroughly; and the facility failed to show the allegation was reported to the required officials, for 1 (#94) of 14 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for oxygem use within 48 hours of admission, and the resident had a hypoxic event, for 1 (#1) of 3 recently admitted sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent enhanced barrier precautions were provided for 2 (#s 16 and 37) of 24 sampled residents; and the facility failed to provide documentation of infection surveillance and mandatory communicable disease reporting for six consecutive months which had an increased risk to the entire facility population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan was created for 1 (#31) of 24 sampled residents who utilized oxygen. From admission, the resident had three MDS assessments completed, all showing oxygen therapy was provided, but the care plan was never updated, showing a repeated pattern for the failure.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the individualized resident care plans with interventions, for 2 (#s 4 and 10) of 24 sampled residents, showong.

Inspectors wroteBased on interview and record review, the facility failed to ensure Provider Orders for Life-Sustaining Treatment (POLST) forms were completed for 3 (#s 2, 7, and 36) of 24 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to fully investigate and resolve a reported concern and grievance for 1 (#34) of 24 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the monthly drug regimen review process was used to identify and report irregularities to the attending physician, for 1 (#33) of 24 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an as needed psychotropic medication was reviewed or discontinued after 14 days for 1 (#33) of 24 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide standard infection control practices through provision of Pnemococcal immunization for 1 (#34) of 24 sampled residents.