Sierra View Homes

Inspectors wroteBased on interview record review, the facility failed to have a qualified, full-time certified dietary manager (CDM) for oversight of the Food and Nutrition Services. This failure had the potential of compromising the safety and nutritional status of residents through potential transmission of foodborne illnesses (illness that comes from eating contaminated food) and decreased quality of food for 52 of 52 residents who received food from the kitchen and could negatively affect the resident's quality of life and health.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure Dietary Aide (DA) 1, DA 2 and Maintenance (MAINT) 1 were trained to carry out the functions of the food and nutrition services safely and effectively for 52 of 52 residents when:1. DA 1 did not demonstrate and DA 2 did not verbalize the proper use of a test strip (paper that measures the concentration of quaternary ammonium compounds [chemicals that kills germs on surfaces] for the sanitizing bucket (a container used to store and mix a chemical solution that reduces germs on surfaces). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed for 52 of 52 residents when:1. Two bags of cabbage with a used by dated 2/2/26, a bag of celery with a used by date of 1/30/26 and a bag of daikon with a used by date of 2/2/26 were stored on the shelves next to other produce in the walk-in refrigerator.2. Two cartons of apple cobbler with a received date of 7/22/25 with no used by date were on the top self in a freezer.3. Two packs of unlabeled cooked chicken with no pulled-out date and used by date were on a tray next to the deli ham in refrigerator 3.4. Black and pink substances inside and white substances were found outside the ice machine.5. One staff member stored their lunch bag inside the resident refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' water pitcher was within reach for five of eight sampled residents (Resident 9, 11, 13, 39 and 55), when the water pitcher was observed to be placed on the residents' dressers and were not accessible to the residents. This failure had the potential to violate Residents 9, 11, 13, 39, and 55's right to respect and dignity by neglecting their basic need for hydration, and undermining their autonomy and their right to person centered dignified care.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet professional standards of practice for five of ten sampled residents (Resident 8, Resident 13, Resident 29, Resident 39 and Resident 47) when:1. Resident 39's physician orders for Oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy was incomplete on 9/23/25. This failure had the potential for Resident 39 to be administered incorrect O2 treatment.2. Resident 39's O2 tank was found empty on 2/5/26, and Resident 39 did not receive O2 therapy as ordered by the physician on 2/5/26. This failure placed Resident 39 at risk for experiencing shortness of breath (SOB) and respiratory distress (difficulty breathing).3. Resident 13 and Resident 47's medication from 2/1/26, 2/2/26, and 2/5/26 were not administered according to physician's orders and were still in the medication cart on 2/6/26. [...]

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 eight of 16 sampled residents (Resident 9, Resident 11, Resident 36, Resident 39, Resident 55, Resident 6, Resident 7, and Resident 38), when Resident 9, Resident 11, Resident 36, Resident 39, Resident 55, Resident 6, Resident 7, and Resident 38's copy of the 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for three of eight sampled residents (Resident 9, Resident 11, and Resident 49) when:1. Resident 9 was on Droplet Precautions (infection control measures designed to prevent the spread of germs (viruses/bacteria) transmitted through large respiratory droplets created by coughing, sneezing, or talking that usually travel short distances (less than 6 feet) and facility staff did not put on appropriate Personal Protective Equipment (PPE- wearable gear and clothing designed to protect individuals from workplace injuries, illnesses, and infections) when entering Resident 9's room.2. A urinal (a portable, handheld, or bedside container used by patients to receive urine) was seen on Resident 11's dresser close to Resident 11's water pitcher.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were in place for unnecessary medications for two of eight sampled residents (Resident 2, and Resident 7), when:1. Pharmacy recommendations to include resident specific symptoms and/or behaviors which should indicate the reason these residents were being treated with the prescribed antipsychotic (a medication that affects brain activities associated with mental processes and behavior used to treat a collection of symptoms that affect your ability to tell what's real and what is not) and psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications were not listed in Resident 2 and Resident 7's physician's orders for the medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 2), received a Level II Pre-admission Screening and Resident Review (PASRR - an evaluation for individuals suspected of having a Serious Mental Illness [SMI] or Intellectual/Developmental Disability [I/DD]/Related Condition [RC]- to determine if they needed specialized services, ensuring placement in the least restrictive setting) evaluation by the designated entity to determine if SMI, ID/DD/RC conditions were present when, Resident 2, who had a diagnosis of schizophrenia (a mental illness that affects a person's ability to think, feel, and behave clearly) and had a PASRR Level I screening indicating Resident 2 had no diagnosis of schizophrenia which resulted in a negative Level I result for SMI.This failure resulted in Resident 2 not receiving the required PASRR level II [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a tailored document summarizing a person's health conditions, care needs, medications, and goals to ensure consistent care and improve quality of life) was developed and implemented for one of five sampled residents (Resident 49), when Resident 49 had an oxygen (a prescribed treatment that provides supplemental oxygen to individuals with low blood oxygen levels) order that started on 4/18/25. This failure had the potential for Resident 49's oxygen needs not be monitored, revised, and met which could cause increase in shortness of breath.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.