Sidney Health Center Extended Care

In the surveyor’s words

From the most serious findings on record at Sidney Health Center Extended Care, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 4, 2025

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

• Actual harm, isolatedF695Oct 10, 2024

  Based on interview and record review, the facility failed to provide a resident with necessary respiratory care and services in accordance with professional standards of practice and the resident's physicians orders, which caused the residents to have insufficient oxygen saturations for 2 (#1 and #10) of 14 sampled residents. Findings include: a. During an interview on 10/8/24 at 11:35 a.m., staff member M said resident #1 had been in the tub room without her oxygen on when the resident turned blue and was not responding. Staff member M applied oxygen to resident #1, assessed the resident, and called the physician for orders. Staff member M was unable to remember the exact date this incident occurred. Staff member M said the CNA scheduled to care for resident #1 was new. […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was held at safe temperatures in the steam table1. The failure placed all residents who are served food from the steam table at risk for foodborne illness. Findings include:During an initial observation of the facility's dining room on 12/1/25 at 5:45 p.m., staff member G was observed in the dining room talking with a resident who was seated at a table. A steam table was observed, which contained trays with stuffed peppers, chicken strips, and soup. All trays were uncovered, and the lids were set off to the side of the steam table.During an observation and interview on 12/1/25 at 5:50 p.m., with staff member A, staff member G was prompted to check the holding temperatures of all foods in the steam table. […]

• No harm, potential for more than minimal, widespreadF868Dec 4, 2025

  Based on interview and record review, the facility failed to ensure the Medical Director participated in the Quality Assurance and Performance Improvement meetings, in order to meet the minimum requirements for the meeting attendees and frequency. This failure could affect any resident when or if a care system was effectively addressed or corrected for a deficient practice. Refer to F689 Accidents and Hazards, with an Immediate Jeopardy cited related to falls; F880, Infection Control; F883 Influenza Vaccines; and F887 Covid-19 vaccines, all system failures related to direct care. Findings include:During an interview on 12/3/25 at 8:31 a.m., staff member A stated that sign-in attendance sheets were not used to track attendees who participated in the QAPI meetings. […]

• No harm, potential for more than minimal, widespreadF880Dec 4, 2025

  Based on interview and record review, the facility failed to maintain adequate infection surveillance and documentation within the facility over a four-month period for the early identification and monitoring of infections and safe infection control practices. This failure increased the risk for all residents in the facility and staff, related to the transmission and prevention of infectious agents. Findings include:During an interview on 12/3/25 at 10:27 a.m., staff member A stated she was unable to locate infection surveillance logs for the period of February 2025 through June 2025. Staff member A stated she only had line lists for a norovirus and a COVID outbreak that were tracked earlier in 2025. […]