Sierra Vista Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food and ice in accordance with professional standards for food service safety when:1. The kitchen ice machine was observed to have several areas with a removable black substance when wiped with a white paper towel and was not sanitized according to manufacturer's directions.2. The kitchen's sanitizer solution was not the appropriate concentration to sanitize the food preparation area.3. A high calorie/protein nutritional supplement drink was observed in station two's refrigerator, open, and with no open date written on the carton. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional needs of the residents were met when the menus were not followed for three residents (Residents 7, 21, and 55) on a large portion diet when Resident 21 received three ounces of meatloaf (regular portion) instead of four ounces (large portion), Residents 7 and 55 received 4 ounces of meatloaf and should have received 6 ounces during lunch on 1/6/26. These failures had the potential to result in unintended weight loss, weakness, fatigue, or increased fall risk, and decreased quality of life. During a review of the facility's menu titled, Diet Spreadsheet dated Day: 17 - Tuesday [1/6/26], the Diet Spreadsheet indicated, .Large Portion. Lunch. Homestyle Meatloaf. Portion Size 4 oz (ounces). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for five of 22 sampled residents (Resident 4, 38, 58, 71, and 98) when:1. Resident 98's foley catheter drainage bag (a bag connected to a tube that is inserted into the urinary bladder to collect urine) was lying on the floor in his room. LVN 5 proceeded to enter his room and manipulate his catheter and did not put on a gown as specified by enhanced barrier precaution (EBP- standards in place in healthcare facilities to prevent the spread of infection) standards. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's privacy, dignity and respect when two of 12 sampled residents (Resident 95 and 14), foley catheter (an indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag) drainage bags were without a dignity cover (a bag used to the cover and hold the urine drainage and collection bag so it was not visible). This failure violated Resident 95 and Resident 14's privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 95 and Resident 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of seven sampled residents (Resident 96), who self-administered medication, stored their medication safely and securely at bedside when Resident 96 kept nine over the counter medications (OTC) on her bedside table. This failure resulted in Resident 96's OTC medications being accessible to residents, visitors and staff which could result in unauthorized access and unintended use of Resident 96's medication. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure one of six residents (Resident 53) received a level II Pre-admission Screening and Resident Review (PASARR- evaluation for individuals suspected of having a Serious Mental Illness [SMI] or Intellectual/Developmental Disability [I/DD]/Related Condition [RC], triggered by a positive Level I screen, to determine if they need 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 53 had a PASARR level I screening result positive for SMI, and the facility did not ensure a PASARR level II screening was completed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) for one of six sampled residents (Resident 6), when Resident 6 had a known hernia (a sac protrusion of intestine or other tissue through a weakness or gap in the abdominal wall) and the condition was not addressed in the care plan. This failure placed Resident 6 at risk of experiencing severe and serious medical complications, and had the potential to cause unintentional weight loss, pain, and psychological harm when resident reported discomfort and bloating after eating, and the hernia was not addressed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure professional standards of practice for one of seven sampled residents (Resident 96) who self-administered medication at bedside when:Resident 96 was self-administering vitamin D3 (dietary supplemental providing vitamin D) 10,000 IU (International Units (IU- a unit of measurement for drug dosage), and guaifenesin extended-release (thins and loosens mucus in the airway) 1200 mg (milligrams- a unit of measurement for drug dosage) at bedside with no order. Resident 96 had an order for ferrous sulfate (iron supplement) 325 mg, but the order did not indicate it could be self-administered at bedside. This failure resulted in Resident 96 self-administering medication without complete, and accurate provider orders which could lead to inadequate monitoring, duplicate therapy and/or adverse effects. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly follow procedures for medication disposal when two of four medication carts inspected had denture containers being used as medication waste containers. This failure resulted in improper medication disposal during the medication pass and created the potential for medication diversion due to failure to dispose of medications at the required time.

Inspectors wroteBased on observation, interview, and record review the facility failed to label medications in accordance with accepted professional principles for one of two nasal spray medications located in station 1's medication cart 1 when the medication fluticasone propionate (nasal spray medicine used in the nose to reduce swelling and irritation) did not have patient identifier information on the bottle. This failure had the potential for cross-contamination (process of transferring germs and bacteria from one area to another) if another resident who was prescribed the same medication received Resident 102's unlabeled fluticasone propionate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed (food that's been blended into a smooth pudding like consistency) food was prepared in a form designed to meet individual needs for three of five sampled residents (Residents 5, 55, and 84) when Residents 5, 55, and 84's physician ordered pureed lunch meals on 1/6/26 and 1/7/26 did not hold shape or form. This failure had the potential to result in aspiration (food entering the airway or lungs), choking, and inadequate nutrition due to decreased flavor, which may result in weight loss and malnutrition. During a review of the facility's menu titled, Diet Spreadsheet dated Day: 17 - Tuesday [1/6/26], the Diet Spreadsheet indicated, . Pureed . (texture) . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete, accurate, readily accessible and systematically organized for two of thirteen sampled residents (Resident 12 and Resident 10) when:1. Resident 12's consent for the use of bedside rails, was not completed, lacking the indication for use, who the consent was discussed with, licensed nurse signature, and dates of consent, were not present in the medical record. This failure had the potential for improper use of bedside rails and potential injury of resident. 2. Resident 10's Informed Consent for the use of Bed Rails, from 8/24/20-11/3/22, could not be located for over 24 hours and had to be retrieved from an off-site location, was not complete or accurate, and was being used for Resident 10's current bed rail order. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the elopement (when a resident leaves the facility's premises or a safe area without authorization, or necessary supervision) of one of seven residents (Resident 7) when staff did not respond promptly to a security elopement alarm when Resident 7 eloped from the facility. This failure had the potential for Resident 7 to experience injury such as falling or struck by traffic, becoming disoriented and lost due to his unsupervised time away from the facility, and also the potential for six other residents who were identified as elopement risks (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) to elope. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer an antibiotic (a medicine that inhibits the growth of or destroys disease causing microorganisms such as bacteria) as prescribed by a physician for one of three sampled residents (Resident 1). This failure resulted in Resident 1 not receiving antibiotics for an infected left ankle, potentially resulting in worsening infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from injury when he attempted to self-transfer out of his bed with the bed ' s wheels unlocked, resulting in a bedside fall and fracture to his left hip. This failure had the potential to contribute to the fall with fracture when the bed ' s unlocked wheels caused the bed to move when he attempted to transfer out of bed.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the results of the most recent survey in a place readily accessible to 91 of 91 residents, families, and their legal representatives. This failure had the potential to violate the rights of residents and their representatives to be informed of previous survey deficiencies.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with current accepted professional standards of practice when: 1. Two of four medication carts were found unlocked and unattended by Licensed nurses. This failure had the potential for residents, staff, and visitors to access the medication carts. 2. Polyethylene glycol 3350 was left on top of the medication cart 1 unattended in Station 1. This failure had the potential risk of other residents, staff and visitors walking by and gaining access to the medication and could lead to adverse effect when taken without a prescription. 3. An expired bottle of Lactulose ( a non-absorbable sugar used in the treatment of constipation), was observed in the medication cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an infection prevention and control program was maintained for 91 of 91 sampled residents when: 1. A room containing five full sharps containers (a bin used to store needles which have been used on residents) was unlocked and accessible to 91 of 91 residents. The sharps containers were stacked on top of each other. One of those containers was full and did not have a lid covering it. This failure had the potential to cause residents to enter the room and hurt themselves if they touched the exposed sharps. 2. Resident 58's oxygen concentrator (a medical device which provides oxygen to a resident) filter was covered in dirt, dust, and lint like materials. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in an environment that promotes and enhances quality of life for five of 21 sampled residents (Residents 68, 81, 245, 246, and 350,) when Residents 68, 81, 245, 246 and 350 waited up to 20 minutes for their lunch tray while watching other residents eat their meal while in the dining room. This failure violated Residents' 68, 81, 245, 246 and 350 the right to be offered a dignified dining experience.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a resident centered care plan for three of 11 sampled residents (Resident 1, Resident 31, and Resident 53) when: 1. Resident 31 did not have a care plan for the use of clotrimazole (brand name-used to treat fungal infection) medication. This failure placed Resident 31 at risk for complications from not having care needs planned by licensed nurses to determine if nursing intervention needed to be added, changed, or completed. 2. The padding on Resident 1's left bedrail was not fully intact, and the metal bar was exposed This failure had the potential to result in Resident 1 sustaining an injury during a seizure (uncontrolled bursts of electrical activities that change sensations behaviors, awareness and muscle movements) episode. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which met professional standards of quality of care for one of five sampled residents (Resident 68) when Resident 68's fluid restriction order was not followed according to the physician order. This failure resulted in Resident 68 consuming more than the allowed fluid intake which could lead to fluid overload and could result in serious health condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent (11.54%) when: 1. Licensed Vocational Nurse (LVN) 3 administered glucophage (medication used to treat diabetes) medication and methenamine (medication used to treat urinary bladder infection suppression]) without food and did not follow instructions for medication administration with food. This failure had the potential for Resident 44 to develop gastrointestinal upset (GI-gastric upset like diarrhea) which could lead to serious health condition. 2. LVN 1 did not follow medication direction when he administered Polyethylene Glycol (medication used to treat constipation) to Resident 244. This failure had the potential for Resident 244 to develop constipation which could lead to serious health condition.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure Dietary [NAME] (DC) 1 was competent to carry out the functions of the food and nutrition services safely and effectively when DC 1 did not check the internal temperature of three pork loins prior to prepping to serve and was not able to be verbalize the cooking or process of reheating cooked food per the facility's policy. This failure had the potential to result in unsafe food being served, consumed, and could have cause food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed for 87 of 91 residents when: 1. A serving cart was observed with a white powdered substance spilled and scattered throughout the top surface. 2. A storage room in the kitchen was observed with dirt and debris on the floor and the base boards were peeling and missing from one side of the wall. These failures placed residents at risk for foodborne illnesses (illness caused by consuming contaminated food) and had the potential to attract pest and rodents.

Inspectors wroteBased on interview and record review the facility failed to ensure one of six sampled residents (Residents 351), had their code status (resident's instructions to a medical team about the type of treatment they want if their heart or breathing stops) documented upon admission on the Physician Order for Life Sustaining Treatment (POLST). Resident 365's POLST form was not completed and signed by the physician for more than eleven days after admission and not in accordance with the facility policy and procedure. This failure had the potential to result in Resident 351's wishes not being honored and unnecessary medical interventions administered.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the privacy of personal information for one of three sampled residents (Resident 34) when Licensed Vocational Nurse (LVN) 2 left her workstation computer open and unattended with Resident 34's information exposed to public view. This failure resulted in violation of Resident 34's right to confidentiality and the potential for unauthorized access to Resident 34's personal information.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and homelike environment for two of six sampled residents (Resident 16 and Resident 39) when Resident 16 had the following at bedside: 1. A plastic bag of fresh onions, tomatoes and avocados on the floor. 2. On a shelf were multiple cans of soup, bananas, cookies, ramen noodle soup, bottles of spices with broken lids, individual packets of sugar, pepper, mayonnaise and loaves of bread. 3. The sink area had kitchen utensils and under the sink was a small ice chest, loaf of bread and small bottles of spices. These failures provided an unclean and un-homelike environment for Resident 16 and Resident 39 (Resident 16's roommate) and placed them at risk for cross contamination from improper storage of personal food.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Level l Preadmission Screening and Resident Review (PASRR-The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed accurately for one of two sampled residents (Resident 68) when Resident 68 was admitted to the facility on [DATE]. This failure had the potential for Resident 68 not to receive the necessary and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper treatment and care to maintain good foot health was performed for one of six sampled residents (Resident 3) when Resident 3's toenails were long, thick, and crooked. This failure had the potential to cause Resident 3 to receive injuries from her toenails digging into her skin.

Inspectors wroteBased on observation, interview and record review, the facility failed to determine and document resident meal preferences for one six sampled residents (Resident 11) when Resident 11 did not have his dislikes listed on his meal ticket (a document which indicates a resident's diet, allergies, preferences, and dislikes.) This failure resulted in resident 11 not eating his lunch on 9/23/24 and caused him to not receive the nutritional benefits of his meal.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adaptive equipment was provided for one of three sampled residents (Resident 68) when Resident 68 was not provided built-up utensils on her meal tray. This failure had the potential to limit Resident 68's ability to feed herself independently and safely.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accident hazards (an unexpected injury or illness that occurred due to the resident ' s environment) for one of three sampled residents (Resident 1) when Resident 1 who had dementia (condition of progressive loss of memory, language and other thinking abilities which requires increased supervision of the individual) and had a known behavior of moving around in the facility in the wheelchair independently, exited unsupervised to the rose garden outside. Resident 1 was found in an area of the rose garden exposed to the sun for an unknown amount of time on a day temperatures reached up to 108 degree Fahrenheit (unit of temperature measurement). [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the Certified Dietary Manager (CDM) fulfilled her job responsibilities of daily kitchen oversight when: 1. The CDM failed to monitor daily kitchen operations to ensure a) food safety guidelines and standards of practice were followed; b) effective supervision of kitchen employees was conducted; c) proper preparation of pureed items; d) meal palatability and food was prepared to conserve nutrients; e) resident food preferences and intolerances were followed, and f) kitchen equipment was in safe working order (Cross reference to F812, F802, F803, F804, F806, and F908). 2. The CDM delegated daily departmental oversight responsibilities to [NAME] 1, who was not trained or qualified to perform the duties of a CDM. [NAME] 1 performed the CDM's job duties 40 hours weekly which included but not limited to; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement a comprehensive systematic approach to ensure effective monitoring and maintenance of acceptable parameters of nutritional status for three of three sampled Residents (Residents 6, 34, and 79) when: 1. Resident 6 experienced a severe unplanned weight loss of 21 pounds (lbs.) equivalent to 11.8% of total body weight according to weights obtained from 5/13/22 to 8/8/22. Certified Nursing Assistant (CNA) staff obtained weights, but Nursing Staff did not communicate the weight loss to the Physician or Registered Dietitian (RD) until 8/7/22. On 8/7/22, RD 1 noted a nine-pound weight loss (5.4%) for one month but did not note the 21 pound loss over 3 months. [...]

Inspectors wroteBased on kitchen observations, interviews and facility document review, the facility failed to ensure one of two cooks (Cook 2) was competent in position related duties when [NAME] 2 was unable to demonstrate: 1. Adequate handwashing. 2. Prevention of cross contamination of food (measuring scoop use). 3. Cleaning, sanitizing and properly storing food preparation equipment (meat slicer, steam table pans & weighing scale). 4. Manual ware washing of cookware used for resident food preparation. 5. Proper testing of the kitchen sanitizing solution. 6. Preparation of puree food items for according to the recipe for Residents 44, 28, 46, 31, 27 and 17. 7. Preparation of food in a manner that maintained the nutritional value of resident meals. 8. Food prepared for the facility residents was palatable. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food prepared for residents was palatable and cooked to preserve nutritive value when: 1. Residents 6, 80, and 287 complained the food lacked flavor and the vegetables were over cooked. 2. Vegetables were cooked more than two hours prior to meal service in an oven temperature above 400 degrees Fahrenheit (F). These failures could potentially affect the nutritive content of the food and the amount of food residents consume, which could result to decrease residents' food intake and lead to poor nutrition and health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards for food safety guidelines were followed when: 1. [NAME] 2 touched the trash can then failed to wash hands and sanitized kitchen counters. 2. A measuring scoop was placed on a kitchen cart then placed in a plastic bin containing a food product without being sanitized. 3. Expired food items in the walk-in refrigerator, resident refrigerator, and dry storage room were not discarded. 4. Leftover potatoes were not cooled down properly. 5. Steam table pans, three frying pans, four cutting boards and a can opener blade were not safe for use. 6. A meat slicer, mixer, can opener and a weight scale were not clean. 7. Three food items in plastic bins were not labeled and did not have open dates. 8. Milk was stored in crates on the floor of the walk-in refrigerator. 9. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an effective infection control and prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable (contagious) diseases and infections when: 1. Family (FM) was in a contact isolation room for Clostridium difficile (C. diff- bacterial infection that causes life threatening diarrhea) without gown and gloves. This failure place residents, visitors, and staff at risk for transmission (a process on how an infectious agent can be transferred from one person to another) of C. diff infections. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper maintenance of essential equipment when: 1. Five of five freezers (including resident refrigerator [two] and medication refrigerator[two]) had excessive ice build-up. 2. The walk-in refrigerator door in the kitchen was not flush with the door frame exposing a gap. 3. The numbers indicating the temperature of the oven located on the oven dial used to prepare resident food were worn and illegible. These failures had the potential for equipment not functioning in the way they were intended and in turn cause contamination of food and medications which could lead to illnesses for the residents. 4. The two laundry dryers' did not have heat and cool-down time control knobs. This failure placed residents at risk for exposure to mold spores due to laundry not being thoroughly dried.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from misappropriation of residents' property for one of three sampled residents (Resident 26) when the facility did not take action to resolve Resident 26's lost money which was not logged in his belongings inventory list. This failure resulted in the loss of Resident 26's 40 dollars.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for two of six sampled residents (Resident 9 and Resident 20) when Resident 9 and Resident 20's smoking habits was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 9 and Resident 20's care needs not met.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan for two of three sampled residents (Resident 21 and Resident 20) when: 1. Residents 21 did not have a care plan for the use of anticoagulant [blood thinner] medications. This failure placed resident 21 at risk for complications from not having care needs planned by licensed nurses to determine if nursing interventions needed to be added, changed or completed. 2. Resident 20 did not have a care plan for smoking. This failure had the potential to result in Resident 20's smoking needs going unmet.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident-centered comprehensive care plan was revised for two of two non-sampled residents (Residents 80 and Resident 285) when: 1. Resident 80 was lactose intolerant and the care plan focus titled, Impaired nutritional and hydration status, did not reflect lactose intolerance. This failure placed Resident 80 at risk for complications abdominal cramps, bloating, and diarrhea) due to lactose intolerance and not having care needs planned by licensed nurses to determine if interventions needed to be added, changed or completed. 2. Resident 285 preferred her breakfast meal to be served at 7:00 a.m. and there was no documentation in Resident 285's care plan stating Resident 285 requested her breakfast at 7:00 a.m. This failure had the potential to result in Resident 285's mealtime preferences not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provided services which met professional standards of quality of care for one of four sampled residents (Resident 19) when Resident 19's supplemental (added when there is a lack or deficiency) oxygen flow rate was not administered according to the physician order. This failure resulted in Resident 19 not receiving the amount oxygen she needed which could lead to breathing problems.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activities program to support residents in their choice of activities for one of six sampled resident (Resident 61) when Resident 61 was not provided individual and independent activities designed to meet his interest. This failure resulted in Resident 61 inactivity (lack of activity) which could potentially affect his physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an environment free from accident hazards for two of three sampled residents (Resident 21 and 43) when Resident 21 and 43's low air loss (LAL- an air mattress with fluctuating air) mattress prescribed air pressure setting was not set based on the patient' weight. This failure had the potential to cause fall with injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Nurses have the competencies necessary to meet the needs of the residents for two of three sampled residents (Resident 21 and 43) when Licensed Vocational Nurse (LVN) 1 and 5 did not have training and competencies to operate the low air loss (LAL- an air mattress with fluctuating air) mattress. This failure had the potential to cause resident falls and injury due to inaccurate LAL pressure settings.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles when: 1. One Tuberculin (combination of proteins that are used in the diagnosis of tuberculosis [potentially serious infectious bacterial disease that mainly affects the lungs]) vial (small container for liquids) was opened with no indication of used-by date or open date. This failure had the potential to produce inaccurate PPD (purified protein derivatives) Test (skin test is a test that determines if you have tuberculosis) results and or cause harm to a vulnerable population if administered beyond the manufacturer's used by date. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided a diet that accommodated residents preferences for one of one resident (Resident 99) when Resident 99's food preferences and intolerances were not obtained in a timely manner (past 7 days). This failure posed the risk for Resident 99 to not receive the food he preferred and food that he could tolerate which in turn could contribute to decreased intake and meal dissatisfaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the recipes were followed for puree (a smooth creamy substance made of liquidized food) diets when an unmeasured quantity of food thickener was added to puree food items by [NAME] 2. This failure resulted in food recipes not followed which posed the risk to alter the nutritional value and taste of the food being produced which in turn could compromise the nutritional status and meal satisfaction for Residents 44, 28. 46, 31, 27 and 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident food preferences and intolerances were followed for one of one non-sampled resident (Resident 80) when Resident 80 was served milk with his lunch meal. This failure had the potential for Resident 80's meal intake to be inadequate which could compromise his nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records for residents that were complete, accurately documented and readily accessible for two of six sampled residents (Resident 9 and Resident 16) when the Physician Order for Life-Sustaining Treatment (POLST) form (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) was incomplete for Resident 9 and Resident 16. This failure had the potential risk for Resident 9 and Resident 16's decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct regular inspections of bed rails as part of the facility's regular maintenance program for one of three sampled residents (Resident 14) when Resident 14's right side rail appeared bent leaning away from the bed. This failure had the potential to result in an injury or accident to Resident 14.