Sierra Vista Healthcare

In the surveyor’s words

From the most serious findings on record at Sierra Vista Healthcare, in the surveyor’s own words.

• Immediate jeopardy, widespreadF801Sep 6, 2022

  Based 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 Cook 1, who was not trained or qualified to perform the duties of a CDM. […]

• Actual harm, patternF692Sep 6, 2022

  Based 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. […]

• Actual harm, isolatedF689Aug 2, 2024

  Based 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. […]

• Actual harm, isolatedF600Feb 8, 2023

  Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse for one of three sampled residents (Resident 1) when Registered Nurse (RN) 1, in response to Resident 1's complaint of abdominal pain and possible constipation, instructed Licensed Vocational Nurse (LVN) 1 and Certified Nursing Assistant (CNA) 1 to physically restrain Resident 1 while RN 1 willfully continued to push her finger into Resident 1's rectum (lower part of the intestine that terminates at the anus [where waste matter leaves the body]) even after Resident 1 cried no and stop. Resident 1 did not agree and consent to RN 1 manually inserting her finger into the rectum to extract feces (waste matter discharged from the bowel). […]

• No harm, potential for more than minimal, widespreadF812Jan 9, 2026

  Based 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. […]