Sierra Vista

Inspectors wroteBased on interview and record review, the facility failed to ensure staff treated residents with dignity and respect when a Certified Nursing Assistant 1 (CNA 1) verbally abused one of three sampled residents (Resident 1) by calling Resident 1 a derogatory term and inappropriately discussed details of Resident 1's personal sex life with fellow staff members. This failure resulted in Resident 1 feeling humiliated, dehumanized, embarrassed and to experience emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The sink in the cook area which food service workers use to get tap water for residents, did not have an air gap (a vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water). 2. The storage shelves in the walk-in refrigerator had a fuzzy white material and grime build-up. 3. Dust was found in several areas in the kitchen and equipment. 4. Chipped off/peeling paint found in janitor room and dry storage room. 5. Two frying pans were found with part of their black interior coating scraped off. 6. Two plastic scraping spatulas were found to have damage on their tips. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when three dumpsters on the side of facility outside of the hallway that leads to the facility's kitchen were filled beyond the brim with trash, and the lids of all three dumpsters were not closed properly. This failure had the potential to attract pests and rodents and comprise the health and safety of 116 residents who reside in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to respond to and act upon the grievances and recommendations of the Resident Council (a group of residents that acts as a formal body to improve quality of life, discuss concerns, and make recommendations to facility's administrator to improve the quality of daily living and care in the facility) regarding dietary services for seven sampled residents (Residents 12, 34, 45, 55, 60, 88, and 113) when the Resident Council requested to increase the frequency of snacks from once daily to three times daily and provide a greater variety of snacks, including more nutritious options, to address resident hunger; however, the facility failed to provide a written response or implement these requested changes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' privacy and confidentiality by failing to secure personal information from public view for 45 sampled residents (Residents 1 to 45) when a whiteboard containing the full names and room numbers of all residents on Unit 1 was posted in a back room of the nursing station but remained clearly visible to unauthorized individuals and other residents walking in the common hallway. This failure had the potential to cause psychosocial harm by compromising the residents' dignity and their right to exercise control over their personal environment, creating an institutionalized atmosphere that devalues resident individuality and can lead to feelings of embarrassment, vulnerability, and a loss of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide comprehensive pharmaceutical services by failing to ensure a medication error-free system and by lacking proper accountability, reconciliation, and witness documentation for the disposal of controlled substances, for 71 residents on Unit 2 (Residents 1 to 71) when:1. Resident 4 was administered two times the dose (400 mg-milligrams, a unit of measurement) of clozapine (an atypical antipsychotic medication used to treat schizoaffective disorder-a chronic mental health condition that is essentially a combination of two different types of illnesses: schizophrenia (which affects how a person perceives reality) and a mood disorder (which affects how a person feels), instead of the physician-ordered 200 mg dose. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in an organized and safe manner for 45 sampled residents (Residents 1 to 45) when the Unit 1 medication storage room contained injectables, oral over-the-counter medications, liquid medications, tablets, sublingual medications, rectally applied medications, breathing treatments, eye drops and test kits that were intermingled and disorganized. This failure had the potential to cause significant medication errors, as the intermingling of products with different routes of administration increases the risk of nurses selecting and administering the wrong medication to a resident.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that snacks provided to residents (Residents 1 through 35) met their specific clinical and therapeutic needs for 35 residents receiving controlled carbohydrate diets (a consistent, set amount of carbohydrates at each meal and snack to stabilize blood sugar levels) when the facility failed to follow physician-ordered controlled carbohydrate diets by providing a uniform bedtime snack to the entire resident population without offering therapeutic alternatives. This failure had the potential to cause significant fluctuations in blood sugar levels, specifically acute hyperglycemia (high blood sugar) from excessive carbohydrate intake or nighttime hypoglycemia (low blood sugar) if the provided snack did not meet the resident's specific stabilization needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food services employees safely and effectively carried out the functions of food and nutrition services when:1. Cooks did not follow standard of practice Cleaning and sanitizing food contact surfaces by using three separate steps (wash, rinse and sanitize) to clean and sanitize work surfaces.2. Multiple food services employees did not follow manufacturer's guideline time length dipping the test strip into sanitizer (sanitizing solution used for sanitizing food contact surfaces) for testing the concentration of the sanitizer.3. Multiple food services employees did not know the concentration range of sanitizer (a solution used to reduce the number of germs on food contact surfaces to acceptable levels).4. Diet Aide 1 did not know the Dish machine sanitizing concentration.5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Controlled Carbohydrate Diet (a meal plan for diabetic residents) lunch dessert was provided for 34 of 34 sampled residents who are on a Controlled Carbohydrate Diet (CC) when the 34 sampled residents received a regular dessert for lunch on February 23, 2026. This failure had the potential to negatively impact the residents' nutritional status and further compromising residents' medical status.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a sanitary and orderly medication storage room for 45 residents (Residents 1 through 45) when:1. A tub containing various used personal care products-some labeled with resident names and others unlabeled-was stored in a cabinet alongside resident medications.2. A bag of discontinued prescription topical medications awaiting disposal was stored on the bottom shelf of a medication cabinet next to discarded items, disinfectant spray, and trash. This failure had the potential to cause cross-contamination and the transmission of infectious agents for 45 residents who reside in Unit 1 of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper maintenance of essential equipment when: 1. The handwashing sink did not consistently maintained water temperatures in accordance with the standard of practice. This failure had the potential for inadequate water temperature which may result in ineffective handwashing putting residents at risk for food borne illness. 2. The Veggie reach-in freezer had ice condensation buildup. This failure had the potential to cause poor quality of food served to a population of 116 out of 116 sample residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two resident's communal shower rooms (blue and green shower rooms) located on unit 1 were maintained in good repair and in a safe and sanitary condition, when the blue and green shower rooms were both observed to have cracked and stained tile surfaces. This failure had the potential to expose all 45 residents on unit 1 who utilize these shared showers to potential harm, contamination and transmission of healthcare-associated infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans (an individualized plan based on assessment that identifies needs, sets goals, and outlines interventions for the medical care of a resident) for two of 35 sampled residents (Resident 14 and 34) when:1. For Resident 14, who had a documented history of falls, the facility did not create a fall risk care plan to address fall risk factors, individualized interventions, and preventive strategies.2. For Resident 34, who was identified as a smoker, the facility did not create a care plan that addressed smoking supervision, safety precautions, and risk mitigation. These failures had the potential to place Residents 14 and 34 at risk for injury, burns, fire hazards, and recurrent falls with injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff followed physician's orders for one of five sampled residents (Resident 19) investigated for nutrition, when the facility did not have documented weights of Resident 19 in the frequency as ordered by the physician. This failure resulted in Resident 19 not being monitored as ordered by the physician for changes in weight and placed the resident at risk for undetected significant weight loss or gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's rights to be free from physical restraint (a manual method, physical or mechanical device or material that restricts the resident's freedom of movement or normal access to his/her body), for one of one resident (Resident 1), were followed when a Certified Nursing Assistant (CNA 1) placed his arm over Resident 1's shoulders, restricting his movement, on June 8, 2025. This failure had the potential for Resident 1to be at risk for physical and psychological harm (the unpleasant emotional or psychological symptoms that individuals experience when they feel overwhelmed, impacting their quality of life).

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety when: 1. A toaster was stored in the dry storage, and it had an accumulation of food residue. 2. On the floor under the industrial mixer, there was black grime, food crumbs, and paint splashes. 3. The shelf under the cook's preparation area that was storing clean pans had crusted food and debris. 4. In the Unit 2 kitchen area where food is served to the residents, the refrigerator door handle had crusted food and smudges. Under the steam table, there was a storage compartment that had black grime and food debris. These failures had the potential to result in accumulating pathogenic microorganisms (germs or infectious agents that can cause disease) and to attract insects or rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to the facility's policies and procedures (P&P) for two of 71 residents (Resident 22 and 85) when: 1. For Resident 22, 11 tablets of Clozapine (medication used to treat severely ill patients with serious mental illness that have difficulty distinguishing what is real and what is not) 50 mg (milligrams- unit of measurement) were found with an expiration date of August 9, 2024 (expired 124 days) and were available for resident use when stored in Unit 2's medication cart (Cart 2). 2. For Resident 85, five tablets of Vitamin B6 (a vitamin used to treat movement disorder) 100 mg were found with an expiration date of December 3, 2024 (expired 8 days) and were available for resident use when stored in Unit 2's medication cart (Cart 1). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure secure storage of medications when one of two medication rooms (Unit 2's medication room) and two of three medication carts (Medication Cart 1 and 2 in Unit 2's medication room - carts used by licensed nurses and Psych technicians [PT] to hold medications for all residents) were found unlocked and unattended by a licensed nurse and PT. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 71 residents.

Inspectors wroteBased on observation, interview, record review, the facility failed to prepare food in a form designed to meet the need of one resident (Resident 28) when Resident 28's lunch on Monday, December 9, 2024, had visible chunks of food. This failure had the potential to result in Resident 28 choking during the meal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition when the refrigerator had corrosion on the walls and expanding foam visible from behind the refrigerator wall. This failure had the potential to result in unsafe temperature control for safety foods and the accumulation of bacterial growth (germs that can cause illness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one resident (Resident 1), when a Certified Nursing Assistant (CNA 1) threw water on Resident 1's face and kicked his right leg. This failure placed Resident 1 at risk for physical and psychological harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. Three plastic pitchers and three lids were stored wet. It was placed on a rack where clean and dried cookware and serviceware (containers, bowls, plates, trays, cups, utensils) were stored. 2. An unlabeled large plastic container with red liquid was found inside the fridge. 3. The kitchen floors were observed with build-up of dirt, sticky residue, and crumbs. Behind the stove, the floors had buildup of crumbs and one food thermometer. 4. The metal shelf, above the stove, had grease build-up. 5. There was no thermometer inside the Resident Refrigerator, and the Resident Refrigerator Temperature Log was empty. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rights were respected for two of five residents (Residents 59 and 18) reviewed for unnecessary medications (any medications which are in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) when: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the rights of one resident (Resident 43) reviewed for physical restraints (any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff) when Resident 43's physician's order for restraint was not discontinued in accordance with the facility's policy. This failure had the potential to result in Resident 43 to be restraint unnecessarily and without a new physician's order.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS- a computerized assessment instrument) was completed for one of four residents (Resident 8) reviewed for nutrition after severe weight loss and decline in personal hygiene to reflect current resident's status, care, and services was identified . This failure had the potential to delay identification and implementation of Resident 8's care and support needs, which could result on his care plan not being updated and revised to reflect his current status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately to reflect the resident's status, care, and services for one of seven residents (Resident 56) reviewed for skin conditions. This failure had the potential to cause inaccuracy in identifying Resident 56's care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the post fall protocol was implemented in accordance with the facility's policy and procedure for one of four residents (Resident 18) reviewed for falls, when Resident 18's care plans (action plan that outline the type of care and treatment a resident need) was not updated, and the Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines working towards a common goal for a resident) did not conduct a review after Resident 18 had a fall. This failure have the potential for Resident 18 to be at risk of further falls which could increase Resident 18's risk of injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed safe infection control practices when: 1. A Dietary Aide did not perform hand hygiene before serving lunch on March 7, 2023. 2. The Dietary Supervisor (DS) was wearing acrylic nails, longer than the tip of the fingers, while breakfast on March 8, 2023. 3. Resident 23's used towels and linens, with live lice crawling, were not placed in bags. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 116 highly vulnerable residents whose health conditions are already compromised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was being implemented when: 1. There was one live cockroach crawling out from the janitor's closet, close to the Wing 1 dining room. 2. There was one live cockroach found in wing 2 Men's shower room.