Sierra View Medical Center

In the surveyor’s words

From the most serious findings on record at Sierra View Medical Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF658Mar 28, 2024

  Based on interview and record review, the facility failed to ensure the Crash Cart (emergency cart used to transport and store emergency medications and supplies) used for 30 of 30 sampled residents, was inspected daily. This failure had the potential to result in necessary supplies and medications to be unavailable in an emergency. Findings: During a concurrent interview and record review on [DATE] at 11:37 a.m. with Registered Nurse (RN) 1, the Crash Cart Integrity Check List (CCICL), dated [DATE] through [DATE] were reviewed. The CCICL was not completed on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. RN 1 stated the crash cart is supposed to be checked every night shift. […]

• No harm, potential for more than minimal, widespreadF680Dec 8, 2022

  Based on interview and record review, the facility failed to ensure a qualified professional directed the activities program from 5/21/22 through the recertification survey, which concluded on 12/8/22 (six and a half months). This failure resulted in 34 of 34 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 334) not receiving activities directed by a qualified professional. […]

• No harm, potential for more than minimal, patternF693Apr 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure five of 28 sampled resident's (Resident 184, Resident 20, Resident 9, Resident 6, and Resident 134) head of bed (HOB) was elevated during G-tube feeding (gastrostomy tube - G tube a small flexible to tube surgical inserted through the abdomen and placed into the stomach to deliver nutrition, fluids, and medication directly into stomach). This failure had the potential to cause aspiration (liquid or food enters into the lungs instead of the stomach) and choking for Resident 184, Resident 20, Resident 9, Resident 6, and Resident 134. Findings: a. During a concurrent observation and interview on 4/6/25 at 11:06 a.m. […]

• No harm, potential for more than minimal, patternF755Apr 10, 2025

  Based on interview and record review, the facility failed to ensure their Policy and Procedure (P&P) titled, Medication Storage was followed when four of six sampled [facility name] Narcotic count check sheets [NCCS-requires two licensed nurses to sign and verify count accuracy], were not consistently completed. This failure had the potential for narcotic count errors, narcotic diversion [illegal use of controlled substance] or theft to not be identified. Findings: During a concurrent interview and record review on 4/8/25 at 10:10 a.m. with Registered Nurse Supervisor (RNS), the NCCS, dated November 2024, December 2024, January 2025, February 2025, March 2025, and April 2025 were reviewed. The NCCS' indicated the following: November 2024: 11/2/24 at 7 p.m. […]

• No harm, potential for more than minimal, patternF812Apr 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure pre-made food items were labeled with the use-by date and opened food items were labeled with the opened date. These failures had the potential to result in decreased palatability (tastiness) and foodborne illnesses for residents. Findings: During a concurrent observation and interview on 4/6/25 at 9:47 a.m. with Nutritional Lead (NL) 1 in the kitchen, 12 individual containers containing approximately one cup of sliced strawberries were in the refrigerator unlabeled and undated. NL 1 stated the strawberries should have been labeled with the prepared and use by date. During a concurrent observation and interview on 4/6/25 at 10:17 a.m. […]