Sierra Winds

Based on personnel file review, staff interviews, and policy review, the facility failed to ensure that one Dietary Aide’s (#28) record included certification required for the position.

Based on record review, facility documentation, staff interviews the facility failed to ensure that a policy was established/implemented regarding CPR (Cardiopulmonary Resuscitation) training requirements for staff. Â

The facility failed to ensure that a level 1 PASARR for conducted for one resident (#7).

The facility failed to ensure that medications were stored in accordance with professional standards to protect the health and safety of 2 residents (#12 and #25)

Based on observations, clinical record review, staff interviews and review of facility policy and procedures, the facility failed to ensure the indwelling catheter tubing was not dragging and touching the floor for one resident (#31).Findings include:

Based on documentation, staff interviews, and facility policies the facility failed to ensure that one staff member (#43) completed Dementia Care training and four staff members (#24, #43, #6, & 30) received Disaster training. Â

Based on personnel file review, staff interview, and policy review, the facility failed to ensure that one Housekeeper’s (staff #6) personnel record included documentation of fingerprint clearance.

Based on documentation, staff interviews, and facility policies the facility failed to ensure that one staff member (#43) was educated on abuse, and that two staff members (#43, & #6) received Elder Justice Act (EJA) training.  Â

Based on documentation, staff interviews, and facility policies the facility failed to ensure that two staff members (#43 & #6) are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents. Â

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the recreational activities program was directed by a qualified professional.Â

Based on clinical record review, staff interviews and review of facility documentation, policy and procedures, the facility failed to ensure medications were administered following physician-ordered parameters for one resident (#31).

Based on observations, staff interviews, review of facility policy and procedure, the facility failed to ensure that a raw shelled eggs were stored in accordance with a professional food safety standards.Findings include:

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided for two residents (#6) and (#7) to prevent further resident to resident altercations. Findings include: Regarding residents #6 and #7: -Resident #6 was admitted to the facility February 1, 2024 with diagnosis including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, diabetes mellitus due to underlying condition with unspecified complications. A care plan initiated in April 2023 and revised July 2023 revealed the resident had a focus for communication problems related to dementia and wandering and impaired cognitive function/dementia or impaired thought processes related to short and long-term memory loss and dementia. Interventions included frequent visual checks, when conflict arises, remove residents to a calm safe environment and allow to vent/ share feelings. The quarterly MDS (minimum data set) assessment dated November 26, 2024 revealed a BIMS (Brief Interview for Mental Status) score of 06, indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood or behaviors. The progress notes dated December 20, 2024 documented an alert note that revealed CNA reported that resident #6 was sitting in wheelchair at nurses' station. Resident #7 was sitting near her and they were conversing and holding hands. It was reported that as resident #6 wanted to wheel off to use the bathroom when resident #7 would not let go of the wheelchair, staff needed to intervene. No injury or harm noted to resident #6. Provider made aware and message with contact information for this nurse left for resident #6 family. -Resident #7 was admitted to the facility December 21, 2024 and discharged December 30, 2024 with diagnosis including urinary tract infection, site not specified, altered mental status, unspecified, encephalopathy, unspecified, hallucinations, unspecified, depression, unspecified, unspecified hearing loss, unspecified ear. The admission care plan initiated in December 2024 revealed the resident had a focus for behavior problems (verbal aggression) related to altered mental status and episodes of hallucinations and wandering/elopement related to cognitive impairment. Interventions included identifying if there is a pattern and purpose of wandering, administer medications as ordered. Monitor/document for side effects and effectiveness, intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed The admission MDS (minimum data set) assessment dated December 23, 2024 revealed a BIMS (Brief Interview for Mental Status) score of 10 indicating moderate cognitive impairment. Further review of the MDS revealed indicators for behaviors which included verbal behavioral sympto

Based on clinical record review, interviews, review of policies, the facility failed to ensure that one resident (#1) is free from preventable falls. Findings include: -Regarding resident #1 Resident #1 was admitted on January 11, 2023 with diagnoses including: Muscle weakness (generalized), Neuromuscular dysfunction of bladder, unspecified, Nonrheumatic aortic (valve) stenosis, unspecified atrial fibrillation, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, fall, unspecified lack of coordination A review of the Minimum Data Set (MDS) dated January 11, 2023 revealed a Brief Interview Mental Status (BIMS) score of 13, indicated being cognitively intact. No behaviors were noted and was always continent of bladder and bowel. It was noted that the resident did have a fall prior to entry and since admission. The resident was assessed to be a partial/moderate assistance (meaning helper does less than half the effort. Helper lifts, hold, or supports trunk or limbs, but provides less than half the effort) for toilet transfers (the ability to get on and off a toilet or commode). A review of the care plan revealed that the resident was a fall risk and had a goal to maintain current level of mobility with no increase in the incidence of falls/injuries. Interventions included to assist the resident to wear non-slick footwear that fits, engage in activities that improve strength, balance and posture, instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails), keep areas free of obstructions to reduce the risk of falls or injury, keep nurse call light within easy reach. Instruct to use call bell or call out for assistance. Keep personal items within easy reach; bed to be in lowest position with wheels locked. Review of Clinical Notes dated January 16, 2023 0732 a.m. revealed the resident was fond prone, laying on right side between the toilet and shower in the bathroom. The resident's head was resting on their right arm. The resident complained of pain to the right arm, hip and neck. Resident was transferred from the floor to a wheelchair and started to have a seizure and that lasted 2.5 minutes. A second seizure lasted 1 minute. The resident was then transferred from the wheelchair to bed. 911 was called since no previous history of seizures. Resident was alert and oriented times 3 when paramedics were asking questions. Vitals were blood pressure 111/76, pulse 131, temperature 98.3 and oxygen saturation 87%. Review of Clinical Notes dated January 19, 2023 at 1:09 p.m. revealed that a registered nurse placed a call to the hospital to follow up on resident's diagnosis post fall. The hospital and family member reluctant to release any information regarding her fall other than the resident is in the Intensive Care Unit (ICU). An interview was conducted on December 11, 2024 at 2:19 p.m. with staff member #3 Certified Nursing Assistant (CNA