Sierra Post Acute

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#2 and #3) of five residents reviewed for abuse were kept free from abuse. Specifically, the facility failed to protect Resident #3 and Resident #2 from physical abuse by Resident #1.

Inspectors wroteBased on observations record review and interviews the facility failed to ensure that the resident environments remained free from accidents hazards as was possible and that each resident had adequate supervision to prevent accidents for for one resident (#10) of three residents reviewed for falls out of sample 34 residents. Resident #10 was admitted on [DATE] for long term care with diagnoses of emphysema (shortness of breath), dementia (impaired memory and thinking), paranoid personality disorder (mental health condition), epilepsy (neurological disorder) and repeated falls. Resident #10 was identified as a high fall risk. Resident #10 sustained eight falls in three months (October 2025 to January 2026). On 10/25/25, Resident #10 sustained a fall where he hit his head. He was sent to the hospital and was diagnosed with a closed head injury. [...]

Inspectors wroteBased on observations, record review and interviews, 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. Specifically the facility failed to:-Ensure food was labeled and dated appropriately in the main kitchen and in the nourishment room refrigerators; and,-Ensure food was disposed of timely.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases on two out of three units. Specifically, the facility failed to:-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers performed hand hygiene while cleaning resident rooms;-Ensure housekeepers cleaned high touch areas; -Ensure dwell times were followed during resident room cleaning; and,-Ensure hand hygiene was conducted appropriately during wound care. I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls could be made without being overheard on two of three units. Specifically, the facility failed to have a private area for residents to make and receive telephone calls and inform the resident of these areas on the Prasada and Legacy units.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication carts. Specifically, the facility failed to ensure there were no loose pills in the medication cart.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident was treated with respect and dignity and care was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life and recognized the resident for one of three units for dignity. Specifically, the facility failed to treat the resident with dignity during meals.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#21 and #32) of five residents reviewed were kept free from abuse out of 34 sample residentsSpecifically, the facility failed to protect Resident #21 from physical abuse by Resident #32.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that two residents (#1 and #23) of the three residents reviewed for oxygen received proper respiratory care and services in accordance with professional standards of practice, the residents' care plan, and the residents' choice out of 34 sample residents. Specifically, the facility failed to:-Ensure Resident #1 was provided with continuous oxygen supplementation per the physician's orders; and, -Ensure Resident #23's nebulizer was cleaned appropriately.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures related to influenza immunizations for one (#5) of five residents reviewed for immunizations out of 34 sample residents. Specifically, the facility failed to provide the influenza 2025/2026 vaccine to Resident #5.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#3 and #1) of five residents were kept free from physical abuse out of five sample residents. Resident #3, was admitted on [DATE] with diagnoses of malignant neoplasm of left lung, heart failure, closed nondisplaced intertrochanteric fracture of left femur, unspecified dementia, pulmonary emphysema and post-traumatic stress disorder (PTSD). Resident #4, was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia with psychotic disturbance, cognitive communication deficit, hypertensive chronic kidney disease, and obstructive pulmonary disease. On [DATE] Resident #3 wandered into Resident #4's room. Resident #4 reacted and pushed Resident #3, which caused Resident #3 to fall. Resident #3 sustained a left femur fracture. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#3) of three residents received adequate supervision to prevent accidents out of eight sample residents. The facility failed to develop and implement a person-centered care plan upon Resident #3's admission to the facility that identified the resident's fall risk and put effective interventions into place to reduce falls and prevent injury. Resident #3 fell on [DATE] (10 days after his admission to the facility. Hospital notes documented a vertebral fracture which required surgical intervention. The facility failed to ensure Resident #3 was assessed by a qualified person, a registered nurse (RN), prior to Resident #3 being moved off the floor.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible, affecting one (#1) out of three residents reviewed for accident hazards of three sample residents. The facility failed to provide adequate supervision during a smoking break to a resident, who required the use of oxygen. On 8/21/24 Resident #1 exited the behavioral health secured unit door and entered the smoking patio with his oxygen tank and nasal cannula on his face. Certified nurse aide (CNA) CNA #1 and CNA #2 were present to supervise the resident smoking session. CNA #1 was handing out the cigarettes to the residents and CNA #2 was lighting the cigarette for the residents. Resident #1 reached over other residents for his cigarette and CNA #1 handed him a cigarette. Resident #1 proceed to the line to get his cigarette lit. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to: -Take the appropriate measures to mitigate mice populations in the facility including failing to eliminate or minimize food sources; and, -Attempt to eliminate mice from entering the facility through door gaps and holes.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents resided in a sanitary and comfortable environment for three of three units observed for cleanliness. Specifically the facility failed to: -Ensure resident rooms, dining rooms, hallways, kitchen floors and furniture were free from debris, food, and mice droppings (cross reference F925 pest control); and, -Mitigate unpleasant odors on the Legacy unit.

Inspectors wroteBased on record review and interview, the facility failed to ensure all grievances were followed up on and resolved timely and appropriately. Specifically, the facility failed to investigate and provide feedback for grievances made by residents and their family members.

Inspectors wroteBased on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis. Specifically, the facility named the DON to also function in the role of the facility ' s nurse home administrator (NHA) and the infection preventionist (IP); delegating all three responsibilities to one individual employee in a facility with an average census of 92 residents.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to implement a method for pest control to control the rodent population throughout the facility that was effective and sanitary. Cross-reference F584 failure to maintain a clean and sanitary homelike environment. I. Professional references According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (1/1/19) page 186, retrieved on 10/25/23, from https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: Routinely inspecting the premises for evidence of pests; [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide a comfortable environment and homelike environment in three out of three units. Specifically, the facility failed to ensure: -Residents were not subjected to foul odors in their rooms and common hallways for two of three units; -Resident rooms were clean and in good repair on two of three units; -Common areas and dining room were clean and maintained in good repair; and, -Outside areas were maintained.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide activities designed to support residents' physical, mental and psychosocial well-being were provided for the resident on the behavioral secured unit and four (#59, #39, #1 and #54) of five residents reviewed for meaningful activity programming activities out of 41 sample residents. Specifically, the facility failed to ensure: -Consistent meaningful activity programming to include group activities, individual activities and one-to-one visits were provided to resident on the secured behavioral unit; -Resident #59 was provided meaningful activities; and, -That activities on the skilled/long-term care were not canceled without advanced notice; were provided as scheduled; and as requested by residents affecting Resident #39, #1 and #54.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure essential equipment was in proper working order. Specifically, the facility failed to maintain the water system boiler in working order to ensure the resident had hot water for showering and the kitchen dishwasher maintained proper water temperature to clean and sanitize resident dishware.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide reasonable accommodation necessary to accommodate mobility and accessibility in the resident's environment for one (#39) out of one resident reviewed for mobility out of 41 sample residents. Specifically, the facility failed to: -Ensure Resident #39 had an appropriate assistive device to aid the resident in proper balance while walking; -Ensure Resident #39 has a clear path in which to walk from her side of the room to the hallway; -Ensure Resident #39's bathroom accommodated her toileting needs by removing her roommate's toilet seat riser from the toilet so she could continue to use the toilet independently without having to wait for staff assistance; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who require urostomy, services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. for one (#293) of one resident reviewed for urostomy care out of 41 sample residents. Specifically, the facility failed to ensure: -Resident #293's urostomy bag was maintained per physician's guidance and professional standards of practice; -Ensure orders for Resident #293's urostomy care; and, -Ensure the comprehensive care plan documented a care plan focus for urostomy care with interventions for Resident #293's urostomy care needs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#392) of two residents reviewed for medication errors out of 41 sample residents. Specifically, the facility failed to ensure that Resident #392 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that drugs/biologicals were stored and disposed properly upon expiration in one of two medication storage refrigerators. Specifically, the facility failed to dispose of expired medications.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#15) of one resident reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 41 sample residents. Resident #15 was admitted to the facility on [DATE]. His admission weight on 9/30/19 was188.4 pounds (lbs). The resident maintained a weight between 180 lbs to 200 lbs between January 2022 and June 2023. The resident was hospitalized in July 2023. When he returned to the facility, the facility failed to weigh the resident until August 2023. The facility did not attempt to weigh the resident after he refused one weight. The registered dietitian (RD) recommended weekly weights in July 2023 and no weights were obtained. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for two (#61and #75) of four residents out of 41 sample residents. Specifically, the facility failed to -Ensure the ordered medication was held when Resident #61's blood pressure and heart rate were out of range of the ordered parameters; and, -Ensure Resident #75 received a prescribed medication for treatment of a pressure injury.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure three (#60, #41 and #27) of four residents received adequate supervision to prevent accidents out of 31 sample residents reviewed. Specifically, the facility failed to develop and implement a person-centered care plan that identified the resident's current medical status, fall risk status and put effective interventions into place to reduce falls and prevent injury for Resident #60. Resident #60, who was admitted to the facility on [DATE], was an identified to be at high risk for falls upon admission due to a recent fall at another facility, which resulted in a subdural hematoma (blood collection on the brain). The facility failed to implement effective person-centered interventions, which considered the resident's compromised medical status to prevent further falls and major injuries. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#6) of three residents reviewed received the care and services necessary to meet their nutrition needs and maintain their highest physical well-being level out of 31 sample residents. Specifically, the facility failed to consistently monitor weights, identify significant weight loss, and timely address Resident #6's nutritional needs. Resident #6 experienced a significant, unplanned weight loss of 13% in six months. The facility failed to implement appropriate interventions timely to address Resident #6's significant weight loss.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide activities of daily living (ADL) to dependent residents for four (#25, #27, #62 and #89) of nine out of 31 sampled residents. Specifically, the facility failed to provide nail care for Resident#25, #27, #62 and #89.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide all residents on the secured behavioral unit and including one resident (#6) of seven with an ongoing program to support residents in their choice of activities, through organized group activities, individual activities and independent activities, to meet the interests of and support the physical, mental, and psychosocial well-being of each resident on a consistent basis out of 31 sample residents. Specifically, the facility failed to implement individualized approaches for activities for Resident #6 and ensure the facility provided a consistent meaningful activity programming to include group activities, individual activities and one-to-one visits on the secured behavioral unit.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases and infections. Specifically, the facility failed to: -Ensure resident rooms were cleaned appropriately; and, -Ensure nurse staff performed appropriate hand hygiene during medication pass. I. Failed to appropriately clean resident rooms A. Professional reference Centers for Disease Control and Preventions: Healthcare-Associated Infections (HAIs) 4.1 General Environmental Cleaning Techniques was reviewed on 4/21/2020 and was retrieved on 9/22/22 at https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html. [...]

Inspectors wroteBased on interviews and record review, the facility failed to honor resident choices for one (#340) of four out of 31 sample residents. Specifically, the facility failed to provide showers according to Resident #340's preference.

Inspectors wroteBased on record review and interviews the facility failed to protect two (#90 and #14) of six residents out of 31 sample residents from abuse. Specifically the facility failed to: -Prevent resident to resident altercation between Resident #90 and Resident #76; and, -Prevent a resident to resident altercation between Resident #14 and Resident #23.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure one (#51) of one residents reviewed for activities of daily living of 31 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure Resident #51's facial hair was maintained for a female resident.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#36) out of 31 sampled residents. Specifically, the facility failed to: -Ensure a physician ordered treatment was in place for a newly discovered lesion to Resident #36's right ear,, upon discovery of a lesion to Resident #36's right ear; -Ensure the comprehensive care plan was updated; -Ensure the lesion was assessed and monitored; and, -Ensure an appointment with a dermatologist was scheduled as directed by the physician.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide assistive devices to residents upon waking for one (#89) of two out of 31 sample residents. Specifically, the facility failed to ensure Resident #89, who was extremely hard of hearing, received his hearing devices from the nurse upon waking.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure two (#41 and #13) of three residents reviewed for respiratory care were provided care in accordance with professional standards of practice out of 31 sample residents. Specifically, the facility failed to:: -Administer oxygen therapy as ordered by the physician for Resident #13; and, -Label/date oxygen tubing for Resident #41 and #13.

Inspectors wroteBased on interviews and record review, the facility failed to ensure three (#60, #37 and #6) of five out of 31 sampled residents received the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to: -Ensure Resident #60 and #37 were provided psychosocial support upon the recent passing of a family member and close friend; and, -Ensure Resident #6's behavior was acknowledged and effective interventions put into place.

Inspectors wroteBased on on record review and interviews, the facility failed to ensure two (#43 and #14) of seven residents reviewed out of 31 sample residents were as free from unnecessary drugs as possible. Specifically, the facility failed to ensure Resident #43 and #14 were not administered a psychotropic medication prior to consent being obtained.