Sierra Vista

(Residents 1 to 45) when a whiteboard containing the full names and room numbers of all residents on

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.Findings: During an observation and interview on Unit 1 at Nursing Station 1, conducted with a Registered Nurse (RN 1) and the Director of Nursing (DON) on February 25, 2026, from 8:19 AM to 9:23 AM, a door with a nameplate indicating Chart Room was propped open.

When walking through the Chart Room, one entered through a second door into the medication storage room. On the upper right wall upon entering the Chart Room a whiteboard was hung listing the first and last names and room numbers of all residents on Unit 1.

The board was visible to passersby in the common hallway, where the resident names and room numbers could be read. RN 1 stated the Chart Room door was always propped open because it provided access to the medication storage room, where staff were coming and going all day. RN 1 further stated the Chart Room was not used as a chart room, but rather as a place to store items. RN 1 and the DON stood in the common hallway of Unit 1 at Nursing Station 1 and confirmed that the resident names and room numbers could be read from that location.

The DON verified that the residents had a right to their personal privacy and privacy regarding their accommodations (room numbers).A review of the facility's policy and procedure (P&P) titled, Confidentiality of Information and Personal Privacy, dated February 2021, it indicated, Our facility will protect and safeguard resident confidentiality and personal privacy.

Policy Interpretation and Implementation: 1.

The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2.

The facility will strive to protect the resident's privacy regarding his/her: a. accommodations; . 4.

Access to resident personal and medical records will be limited to authorized staff and business associates.

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Sierra Vista 3455 East Highland Ave Highland, CA 92346

During a concurrent interview and record review on February 25, 2026, at 8:50 AM with DON, the facility's Policy and Procedure (P&P) titled, Smoking, dated August 9, 2022, was reviewed.

The P&P indicated, .I.

Purpose: To provide a safe environment for resident, staff and visitors.III.Procedures: IDT will develop an individual plan for safe storage, use of smoking materials, assistance and required supervision, if necessary, for residents who smoke.

This is documented on the resident's smoking evaluation, the residents plan of care and discussed with the resident and responsible party at the resident care conference meeting. DON stated the facility did not follow the policy.

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Sierra Vista 3455 East Highland Ave Highland, CA 92346

physician's orders for one of five sampled residents (Resident 19) investigated for nutrition, when the

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.Findings: During a review of Resident 19's admission Record (contains medical and demographic information), the admission Record, indicated Resident 19 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a mental disorder characterized by intense paranoia, delusions, and auditory hallucinations), and vitamin D deficiency.

During an interview on February 24, 2026, at 8:45 AM, with Resident 19, Resident 19 stated he had lost 60 pounds since he was admitted to the facility.During a review of Resident 19's care plan titled, Resident is at nutritional risk: overwt [overweight].wt loss planned; is desired w/o [without] sig [significant] changes.goal.gradual wt loss toward long term 166# [166 pounds] wt loss goal. interventions in the care plan included, Weekly weights for monitoring progress to assess for no more than loss of 2% per week or loss of 5% per month.weigh as ordered.During a review of Resident 19's physician's orders, an order dated February 24, 2025, indicated, Weigh weekly x 4 [for four weeks] post admission, then monthly.During a review of Resident 19's Electronic Health Record (EHR), Resident 19 did not have documentation of weights recorded by staff weekly as ordered by the physician.

Weights were recorded as follows: 240 pounds (lbs) February 25, 2025, 238 lbs.

March 4, 2025, but then there was no other weights recorded until March 28, 2025, at 236 lbs.

There was no weights for the week of March 9, 2025, and March 16, 2025.During a concurrent observation, interview, and record review on February 25, 2026, at 2:20 PM, with the Director of Nursing (DON), the DON reviewed Resident 19's EHR and stated staff was supposed to weight the resident weekly for four weeks starting February 24, 2025, and then monthly as ordered by the physician but it was not done.

The DON stated the resident did not have weights recorded in his medical record for the weeks of March 9, 2025, or March 16, 2025.

The DON further stated the individual who was responsible for weighing and documenting resident weights was no longer at the facility and used to document weights on a paper chart sometimes.

The DON then found the paper chart she was referring to and upon review it was blank for the weeks of March 9, 2025, and March 16, 2025, where Resident 19's name was indicated.

The DON stated Resident 19 was not weighed weekly for four weeks as ordered by the physician.During a review of Resident 19's Minimum Data Set Assessment (MDS assessment - a federally mandated, standardized evaluation of a residents functional skills, medical conditions, cognitive and psychosocial status, which is used to guide care planning and quality monitoring) the MDS assessment indicated Resident 19 had significant weight loss and was not on a prescribed weight loss program.During a review of the facility's policy and procedure (P&P) titled, Weight Management, dated August 25, 2021, the P&P indicated, Purpose - To obtain baseline weight and identify significant weight change.Policy - Each individual's weight will be obtained and documented upon admission to the facility.Procedure.2. In nursing facilities, weights will be obtained weekly for 4 weeks after admission.

Subsequent weights will be obtained monthly unless physician's orders or an individual's condition warrants more frequent weight measurements.4.

Staff will follow acceptable procedure to obtain accurate weights.

be placed in a non-labeled bag to wait for the DON to waste them.

This practice will lead to

2:52 PM, the Admin and DON stated they agreed with the statement made by the PC.

The DON stated

nurses.A review of the facility's policy and procedure (P&P) titled, Controlled Medication Storage, dated August 2014, indicated, Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations.

Procedures: The director of nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. A controlled medication accountability record is prepared by the pharmacy or facility for all Schedule II-V medications.

The following information is completed:1) Name of resident2) Prescription number3) Name, strength, and dosage form of medication4) Date received5) Quantity received6) Name of person receiving medication supply7) Dispensing pharmacy informationD. At each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. E.

Any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. I.

The director of nursing in conjunction with consultant pharmacist or designee routinely monitors controlled medication storage, records, and expiration dates during medication storage inspection.

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Sierra Vista 3455 East Highland Ave Highland, CA 92346

Based on observation, interview, and record review, the facility failed to ensure medications were

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.Findings: During a medication storage observation and interview on Unit 1 at Nursing Station 1, conducted with a Registered Nurse (RN 1) and the Director of Nursing (DON) on February 25, 2026, from 8:19 AM to 9:23 AM, there were three cabinets in the medication room where medications were stored. On the shelves of each cabinet, medications were stored haphazardly; intermingled together on each shelf were injectables, oral over-the-counter medications, liquid medications, tablets, sublingual medications, rectally applied medications, breathing treatments, eye drops, and test kits.

There was no apparent order or organization of the medications. RN 1 stated that the over-the-counter medications were in the cabinets, so staff did not have to go downstairs for more when they ran out.

The DON reviewed the disarray of the medications in the three cabinets and confirmed that they were not stored appropriately or per the facility's policy and procedure (P&P).

During an interview with the Pharmacist Consultant (PC) on February 26, 2026, at 11:49 AM, the PC stated the facility should store medications separated by route (the specific way or path a medicine takes to get into the body), with each route kept together on one shelf or in a specific container or drawer.

The PC further stated that medications of different routes should not be intermingled, as it increases the likelihood of making a medication error.

During an interview with the Administrator (Admin) and DON on February 26, 2026, at 2:52 PM, the Admin and DON stated they agreed with the statement made by the PC.

They further agreed that the medications in the Unit 1, Nursing Station 1 medication room were not stored in accordance with the facility's policy and procedure.A review of the facility's Policy and Procedure (P&P) titled, Storage of Medications, dated January 2025, it indicated, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier.

Procedures: . c.

Orally administered medications are kept separate from externally used medications, such as suppositories [a solid piece of medicine that is inserted into a body opening-most often the rectum or the vagina], liquids, and lotions. D.

Intravenously [through a vein] administered medications are kept separate from orally administered medications. E.

Eye medications are kept separate from ear medications. F.

Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area. G.

Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart.

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Sierra Vista 3455 East Highland Ave Highland, CA 92346

nutritional and special dietary needs.

(Residents 1 through 35) met their specific clinical and therapeutic needs for 35 residents receiving

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.Findings: A review of the facility provided Diet Type Report, dated February 23, 2026, indicated Residents 1 to 35 had a current physician's order for a controlled carbohydrate diet.A review of a sign posted to a window outside the Dietary Supervisor's office indicated, Snack List!!! Monday: [NAME] Krispie Treats, Fruit Punch, Tuesday: Cheezits, Ice Water, Fresh Fruit, Wednesday: Scooby Snacks, Fruit Punch, Thursday: Fresh Baked Chocolate Chip Cookies, Ice Water, and Fresh Fruit, Friday: Corn Chips, Fruit Punch, Saturday: .

Fresh Fruit, Sunday: Lays Chips, Fruit Punch.

During an interview with the Registered Dietitian (RD) on February 26, 2026, at 2 PM, the RD stated that the snack list posted outside the Dietary Supervisor's office represented the snacks provided to all residents for their nighttime snack.

The RD stated that the snacks on the list did not change unless a specific request was made for a change.

The RD stated there were no established substitutions for the snack items listed, and there were no established snack options for residents with physician-ordered controlled carbohydrate diets.

The RD stated she had not provided a therapeutic alternative for residents receiving controlled carbohydrate diets.

During an interview with the Administrator (Admin) and Director of Nursing (DON) on February 26, 2026, at 2:39 PM, the DON stated that residents with physician's orders for a controlled carbohydrate diet should have been offered a snack which aligned with the ordered diet.

The Admin and DON stated that the facility's policy and procedure titled Snacks, dated September 2017, was not followed.A review of the facility's P&P titled, Snacks, dated September 2017, indicated, Policy Statement: Snacks and beverages will be provided as identified in the individual plans of care.

Bedtime [also known as HS] snacks will be provided for all residents.

Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times.

Procedures: 1.

The Dining Services department will collaborate with the residents/patients, and nursing and management team to identify necessary beverage and snack items to be provided to each resident/patient. 2.

The Dining Services department assembles on a daily basis snack items (food and beverages) for delivery to each resident/patient care area. 3.

Snacks will be assembled, labeled, and dated in accordance with the individual plan of care for each resident and those items will be delivered to patient care areas in a timely manner. 4.

The Dining Services department will assemble and deliver to each unit the individually planned snack items and bulk snack items to be offered at bedtime. 5.

The Dining Services department provides a listing of the current diet orders and snacks for each resident to each care area. 6.

Nursing Services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. 7.

All snacks will be properly stored for time and temperature control, as appropriate.

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Sierra Vista 3455 East Highland Ave Highland, CA 92346

During an interview on February 25, 2026, at 11:34 AM, with Dietary Aide 1 (DA 1) in the dish washing room, DA 1 was asked to demonstrate how to check the Dish machine sanitizing concentration. DA 1 dipped the test strip into Dish machine sanitizing solution.

The test strip indicated at 100 ppm. DA 1 stated the sanitizer concentration should be between 100 -200 ppm.

During an interview on February 25, 2026, at 7:22 AM, with the Registered Dietitian (RD) and Certified Dietary Manager (CDM), the RD stated according to manufacturer guidelines dish machine sanitizing concentration should be 50 -100 ppm.

The CDM stated sanitizing concentration between 100 -200 ppm was too strong.

The CDM stated using too strong concentration sanitizing solution could result the cleaned kitchenware had strong chlorine odor.During a review of the facility provided document titled, Dish Machine log, undated, the log indicated, Manufacturer Recommended PPM: 50 -100.5.

During an interview on February 23, 2026, at 12:30 PM, with [NAME] 2 (CK 2) in cook area, CK 2 was asked to demonstrate how to calibrate thermometer. CK 2 inserted thermometer into a cup of ice water.

When the thermometer reached 32 degrees Fahrenheit ( F - a unit of measurement). CK 2 stated he needed to calibrate thermometer at 40 F.

During an interview on February 25, 2026, at 7:22 AM, with the Registered Dietician (RD).

The RD stated the cooks should calibrate the thermometer at 32 F.

The RD stated failure to calibrate thermometers may result in inaccurate reading thermometers.During a review of the facility provided in service education document titled, TIME AND TEMPERATURE CONTROL AND RECORDING, undated, the document indicated, PURPOSE: To educate all new hires and current employees on the importance of and guidelines for time and temperature control and recording procedures.Thermometers The first step in avoiding temperature abuse is to maintain a properly calibrated thermometer.Calibrate and testing Using Ice-Point Method: .if the temperature is at 32 F, .It is now ready for use.6.

Potentially Hazardous Foods (PHFs) are those capable of supporting bacterial growth associated with foodborne illness PHFs. PHFs shall be cooled within four hours to 41 F or less if prepared from ingredients at ambient temperature, such as reconstituted FOODs and canned tuna. (Food Code, 2025).

During an interview on February 23, 2026, at 12:30 PM, with [NAME] 2 (CK 2) in cook area, CK 2 was asked to demonstrate cooling process for making Tuna Salad. CK 2 unable demonstrated despite the Certified Dietary Manager (CDM) providing him with a copy of the cooling log.

During an interview on February 25, 2026, at 7:22 AM, with the Registered Dietician (RD).

The RD stated CK 2 should know the cooling process for making Tuna Salad.

The RD stated the potential risk for CK 2 did not know the cooling process making Tuna Salad was foodborne illness outbreak.

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Sierra Vista 3455 East Highland Ave Highland, CA 92346

During an observation on February 23, 2026, at 11:04 AM in the kitchen, Dietary Aide 3 (DA 3) was observed preparing dessert for the lunch service for the residents. DA 3 used a spatula to slice two of two sheet pans of cake into even portions. DA 3 then applied frosting to all slices of cake on both sheet pans and used a spatula to separate each cake slice portion and distribute them onto dessert plates. No additional or differing size chocolate cakes were prepared for lunch.

During an observation on February 23, 2026, at 12:01 PM in the dining room, all residents, including residents who were on CC Diet were observed being served the same size chocolate cake with frosting as regular diet residents.

During a concurrent interview and record review on February 23, 2026, at 12:30 PM with the Certified Dietary Manager (CDM), the therapeutic spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diet) on February 23, 2026 was reviewed.

The therapeutic spreadsheet indicated, Residents on CC diet were to receive a 1/2 portion of chocolate cake, plain (without frosting) for lunch.

The CDM admitted DA 3 did not prepare CC dessert and CC diet Residents being served regular dessert.

During an interview on February 25, 2026, at 7:23 AM with the RD, and the CDM, both of them stated food service employees should follow the spreadsheet when preparing and serving food.

The RD stated in response to risks of giving CC residents regular dessert portion, Blood sugar can spike, because they get more carbohydrates.

During a review of facility's Policy and Procedure (P&P) titled, Menus, dated September 2017, the P&P indicated, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines.

During a review of facility provided diet definition titled, Controlled-Carbohydrate Diet, dated February 2025, the definition indicated, The controlled-carbohydrate diet incorporates the (menu company) regular menu with consistent amounts of carbohydrate meals and snacks. In this diet, priority is given to the total amount of carbohydrate consumed at each meal and snack rather than to the specific source of carbohydrate.

Portion sizes on this menu must be followed.

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Sierra Vista 3455 East Highland Ave Highland, CA 92346

During a review of the

staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. 8.

During an observation on February 23, 2026, at 10:21 AM, in the kitchen, a white napkin was used to wipe inside of the ice storage bin of the ice machine, and the napkin was pulled out with a black substance on it.

During an interview on February 25, 2026, at 7:23 AM, with the Registered Dietician (RD) and the Certified Dietary Manager (CDM), the CDM stated potential risks to be cross contamination of the ice stored in the ice storage bin.

During a review of the facility's Policy and Procedure (P&P) titled, Equipment, dated September 2017, the P&P indicated, All foodservice equipment will be clean, sanitary. 9.

During an interview on February 24, 2026, at 2:13 PM, with Primary Counselor 1 (COUN 1), COUN 1 stated the microwave in the vending machine room is used to heat residents' outside food.

During an observation on February 24, 2026, at 2:18 PM, in the vending machine room, the microwave was observed to have a brown substance splattered on the ceiling of the microwave.

During an interview on February 25, 2026, at 7:23 AM, with the Registered Dietician (RD) and the Certified Dietary Manager (CDM), the CDM stated potential risks to be cross contamination.

During a review of the facility's Policy and Procedure (P&P) titled, Equipment, dated September 2017, the P&P indicated, All foodservice equipment will be clean, sanitary, and in proper working order.

During a review of the facility's P&P titled, Food: Preparation, dated September 2017, the P&P indicated, Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination.

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Sierra Vista 3455 East Highland Ave Highland, CA 92346

During a concurrent observation and interview on February 23, 2026, at 8:38 AM with Certified Dietary Manager (CDM) outside by the dumpsters, CDM advised the state of the dumpsters is Horrible. CDM advised the lids are supposed to be able to close (and if they don't) they bring rodents and flies.

During a review of the facility's policy and procedure (P&P) titled, Dispose of Garbage and Refuse, dated August 2017, the P&P indicated, All garbage and refuse will be collected and disposed of in a safe and efficient manner.

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Sierra Vista 3455 East Highland Ave Highland, CA 92346

intended for internal use are stored in a medication cart or other designated area. H.

Potentially

deteriorated medications and those in containers that are cracked, soiled, or without secure closures

N.

Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures. O.

Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified.A review of the facility's P&P titled, Infection Prevention and Control Program, dated September 18, 2024, indicated, Purpose: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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Sierra Vista 3455 East Highland Ave Highland, CA 92346

During a review of FDA (Food and Drug Administration) Food Code 2025, Section 5-202.12., the FDA Food Code indicated, A handwashing sink shall be equipped to provide water at a temperature of at least 85 degrees Fahrenheit ( F - a unit of measurement) through a mixing valve or combination faucet. An inadequate flow or temperature of water may lead to poor handwashing practices by food employees. A mixing valve or combination faucet is needed to provide properly tempered water for handwashing.

The International Plumbing Code (IPC) states that tempered water is having a temperature range between 85 F and 110 F.

During an observation on February 23, 2026, at 8:50 AM, in the kitchen at the handwashing sink near dietary office, the surveyor turned on hot water to wash her hands.

The water in the handwashing sink was cold.

Surveyor let the water ran for approximate1 minute and checked the water with thermometer which indicated 63 F. An additional follow up observation on February 23, 2026 at 8:55 AM, revealed the water was too hot.

Surveyor checked the water with thermometer which indicated 114 F. In a concurrent interview with the Certified Dietary Manager (CDM), the CDM stated handwashing water temperature supposed to be at least 85 degrees F. to 110 degrees F.

During an interview on February 25, 2026, at 7:22 AM, with the Registered Dietitian (RD) and CDM.

The CDM stated according to standard of practice and Food Code, handwashing temperature should be at least 85 F to 110 F.

The RD explained if handwashing temperature too hot, it would be scalding food service employees.

And if too cold, lower than 85 F, it may result in ineffective handwashing. 2.

During a concurrent observation and interview on February 23, 2026, at 9:20 AM, with the Certified Dietary Manager (CDM), in the kitchen. inside the Veggie reach-in freezer had ice condensation buildup on the ceiling.

The CDM stated the reach-in freezer not supposed to have ice condensation buildup on the ceiling.

During an interview on February 25, 2026, at 7:22 AM, with the Registered Dietician (RD) and CDM.

The RD stated it was an early sign of malfunction freezer with the ice condensation buildup.

The RD stated malfunction freezer could affect the quality of foods stored in the freezer.

During a review of the facility's policy and procedure (P&P) titled, Equipment, revised dated 9/2017, the P&P indicated, All foodservice equipment will be .in proper working order.

Procedures: 1.

All equipment will be routinely . maintained .

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Sierra Vista 3455 East Highland Ave Highland, CA 92346

During a concurrent interview and record review on February 25, at 11:20 AM, with Administrator, the facility's Policy and Procedure (P&P) titled, Maintenance Service undated, was reviewed.

The P&P indicated, 1.

The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2b. maintaining the building in good repair and free from hazard.

The Administrator stated the facility did not follow the P&P.

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Sierra Vista 3455 East Highland Ave Highland, CA 92346