20 Reports
Inspection Report — Jan 26, 2026
Annual Inspection
Date: Jan 26, 2026
Visit Reason
Annual compliance inspection of the Nursing Care Institution at Sierra Winds conducted off-site on 26 January 2026.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Dec 29, 2025
Complaint Investigation
Date: Dec 29, 2025
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On-site complaint investigation of complaint 00152898 at a Nursing Care Institution, conducted 29 December 2025.
Complaint Details
The state compliance survey was conducted on December 29, 2025, in conjunction with the investigation of complaint 00152898. No deficiencies were cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Oct 9, 2025
Annual Inspection
Date: Oct 9, 2025
Visit Reason
On-site complaint and annual compliance inspection of Nursing Care Institution SIERRA WINDS conducted 8-9 October 2025.
Complaint Details
Off Site Revisit was conducted on 1/23/2026. No deficiencies were identified.
Findings
The inspection identified 12 deficiencies related to personnel qualifications, training, medication administration, and food safety standards.
Deficiencies (12)
R9-10-403 — The facility failed to ensure that one Dietary Aide’s (#28) record included certification required for the position.
R9-10-403 — The facility failed to ensure that a policy was established and implemented regarding CPR training requirements for staff.
R9-10-403 — The facility failed to ensure that a level 1 PASARR was conducted for one resident (#7).
R9-10-403 — The facility failed to ensure that medications were stored in accordance with professional standards to protect the health and safety of two residents (#12 and #25).
R9-10-403 — The facility failed to ensure the indwelling catheter tubing was not dragging and touching the floor for one resident (#31).
R9-10-406 — The facility failed to ensure that one staff member (#43) completed Dementia Care training and four staff members (#24, #43, #6, and #30) received Disaster training.
R9-10-406 — The facility failed to ensure that one Housekeeper’s (staff #6) personnel record included documentation of fingerprint clearance.
R9-10-406 — The facility failed to ensure that one staff member (#43) was educated on abuse and that two staff members (#43 and #6) received Elder Justice Act training.
R9-10-406 — The facility failed to ensure that two staff members (#43 and #6) are educated on the rights of the resident and the responsibilities of the facility to properly care for its residents.
R9-10-406 — The facility failed to ensure the recreational activities program was directed by a qualified professional.
R9-10-421 — The facility failed to ensure medications were administered following physician-ordered parameters for one resident (#31).
R9-10-423 — The facility failed to ensure that raw shelled eggs were stored in accordance with professional food safety standards.
Report Facts
Deficiencies cited: 12
Inspection Report — Apr 3, 2025
Complaint Investigation
Date: Apr 3, 2025
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On-site complaint investigation of intake numbers AZ00160227, AZ00161089, AZ00165496, AZ00166350, AZ00166956, AZ00167227, and AZ00169200 at a Nursing Care Institution, conducted 2-3 April 2025.
Complaint Details
The Risk-Based complaint survey was conducted on April 2, 2025 through April 3, 2025 for the investigation of intake #s: AZ00160227, AZ00161089, AZ00165496, AZ00166350, AZ00166956, AZ00167227, AZ00169200.
Findings
This inspection resulted in no citations or deficiency findings.
Report Facts
Complaints investigated: 7
Inspection Report — Feb 26, 2025
Complaint Investigation
Date: Feb 26, 2025
Visit Reason
On-site complaint investigation of complaint SF00115562 and federal complaints AZ00223520, AZ00223403, and AZ00223402 at a Nursing Care Institution, conducted 26 February 2025.
Complaint Details
An investigation of complaint SF00115562 was conducted from February 26, 2025 through February 27, 2025. An investigation of complaints AZ00223520, AZ00223403, and AZ00223402 was conducted from February 26, 2025 through February 27, 2025. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jan 14, 2025
Complaint Investigation
Date: Jan 14, 2025
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On-site complaint investigation of intakes AZ00221658, AZ00221767, AZ00221657, and AZ00221764 at a Nursing Care Institution, conducted 14 January 2025.
Complaint Details
A complaint survey was conducted on January 14, 2025 of intakes AZ00221658, AZ00221767, AZ00221657, and AZ00221764. The investigation included clinical record review, staff interviews, and facility documentation and policy review.
Findings
The inspection found one deficiency related to inadequate supervision of residents to prevent resident-to-resident altercations, resulting in injury and escalation of behaviors.
Deficiencies (1)
R9-10-414 — The facility failed to ensure adequate supervision was provided for two residents to prevent further resident-to-resident altercations, resulting in a skin tear and escalating aggressive behaviors requiring hospital transfer.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #43 | Licensed Practical Nurse | Witnessed two incidents involving residents #6 and #7 and described facility supervision practices and resident behaviors. |
Inspection Report — Dec 11, 2024
Complaint Investigation
Date: Dec 11, 2024
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On-site complaint investigation of multiple complaints including AZ00219666, AZ00215479, AZ002190436, AZ002190387, AZ002190241, AZ002190182, and AZ002190177 at a Nursing Care Institution, conducted 11 December 2024.
Complaint Details
The complaint survey was conducted on December 11, 2024, investigating intake numbers AZ00219666, AZ00215479, AZ002190436, AZ002190387, AZ002190241, AZ002190182, and AZ002190177. Federal comments referenced similar intake numbers including AZ00219662, AZ00215479, AZ002190435, AZ002190387, AZ002190240, AZ002190182, and AZ002190176.
Findings
The inspection found one deficiency related to the facility's failure to ensure a resident was free from preventable falls. The deficiency involved inadequate implementation of fall prevention interventions for a cognitively intact resident with a history of falls.
Deficiencies (1)
R9-10-414 — The facility failed to ensure that one resident was free from preventable falls despite care plans and interventions addressing fall risk. Clinical records and staff interviews revealed insufficient monitoring and inconsistent application of fall prevention measures.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 21, 2024
Complaint Investigation
Date: Oct 21, 2024
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On-site complaint investigation of intake numbers AZ00188590, AZ00189329, AZ00198659, AZ00188589, AZ00189328, AZ00198658 and AZ00217478 at a Nursing Care Institution, conducted 21 October 2024.
Complaint Details
The complaint survey was conducted on October 21, 2024, investigating intake numbers AZ00188590, AZ00189329, AZ00198659, AZ00188589, AZ00189328, AZ00198658 and AZ00217478. No deficiencies were cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 7
Inspection Report — Sep 30, 2024
Complaint Investigation
Date: Sep 30, 2024
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On-site complaint investigation of intake numbers AZ00216625, AZ00216624, and AZ00216457 at a Nursing Care Institution, conducted 30 September 2024.
Complaint Details
The complaint survey was conducted on September 30, 2024, investigating intake numbers AZ00216625, AZ00216624, and AZ00216457. No deficiencies were cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Aug 29, 2024
Complaint Investigation
Date: Aug 29, 2024
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On-site complaint investigation of intake numbers AZ00214657 and AZ00214654 at a Nursing Care Institution, conducted 29 August 2024.
Complaint Details
An onsite complaint survey was conducted from August 28, 2024 to August 29, 2024 for the investigation of intake # AZ00214657. An onsite complaint survey was conducted from August 28, 2024 to August 29, 2024 for the investigation of intake # AZ00214654. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Jun 21, 2024
Complaint Investigation
Date: Jun 21, 2024
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On-site complaint investigation of complaints AZ0020611, AZ00206421, AZ00212108, and AZ00212117 at a Nursing Care Institution, conducted 20-21 June 2024.
Complaint Details
The investigation of complaint #'s AZ0020611, AZ00206421, AZ00212108 and AZ00212117 was conducted June 20-21, 2024. The following deficiencies were cited.
Findings
The inspection found two deficiencies related to failure to implement and document adequate fall safety measures for a resident at risk of falls. The facility lacked timely fall risk assessment and did not ensure interventions were in place to prevent falls with injury.
Deficiencies (2)
§483.25(d) — The facility failed to ensure fall safety measures were implemented to prevent a fall with major injury for resident #19, including lack of timely fall risk assessment and absence of documented interventions to reduce fall risk.
R9-10-425 — The administrator failed to ensure the premises were free from conditions that could cause physical injury, as fall safety measures were not in place or documented for resident #19 who experienced multiple falls including one with rib fractures.
Report Facts
Deficiencies cited: 2
Complaints investigated: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Registered Nurse | Interviewed regarding fall interventions and monitoring |
| Staff #4 | Certified Nursing Assistant | Interviewed regarding fall precautions and resident monitoring |
| Staff #4 | Director of Nursing | Interviewed regarding fall risk management and documentation |
Inspection Report — May 23, 2024
Complaint Investigation
Date: May 23, 2024
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On-site complaint investigation of intake AZ00210352 at a Nursing Care Institution, conducted 23 May 2024.
Complaint Details
A complaint survey was conducted on May 23, 2024 for the investigation of intake # AZ00210352. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — Apr 10, 2024
Complaint Investigation
Date: Apr 10, 2024
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On-site complaint investigation of complaints AZ00208330 and AZ00208333 at a Nursing Care Institution, conducted 9 and 10 April 2024.
Complaint Details
The onsite complaint survey was conducted on 4/9/2024 and investigated complaints # AZ00208330/AZ00208333. The following deficiencies were cited.
Findings
The inspection found two deficiencies related to failure to administer medications and treatments as ordered for multiple residents, including incomplete documentation of medication administration and care interventions.
Deficiencies (2)
§483.21(b)(3) — The facility failed to ensure that residents' medications were administered as ordered by the provider based on standards of practice for three residents, with multiple instances of undocumented medication administration and care interventions.
R9-10-421 — The administrator failed to ensure medications were administered in compliance with orders, as evidenced by multiple undocumented medication administrations and treatments for three residents without documented refusals or reasons.
Report Facts
Deficiencies cited: 2
Inspection Report — Jan 30, 2024
Enforcement
Date: Jan 30, 2024
Visit Reason
Civil monetary penalty, action 00111822 (invoice INV-258482), assessed 30 January 2024.
Findings
A $1,500.00 penalty was assessed and paid in full on 6 October 2024.
Report Facts
Penalty amount: 1500
Amount paid: 1500
Amount remaining: 0
Inspection Report — Jan 12, 2024
Annual Inspection
Date: Jan 12, 2024
Visit Reason
On-site complaint investigation and annual compliance survey conducted 9 through 12 January 2024 at a Nursing Care Institution, including investigation of complaints AZ00188177, AZ00188225, AZ00204573, and AZ00204502.
Complaint Details
The state compliance survey was conducted 01/09/2024 though 01/12/2024 in conjunction with the investigation of AZ00188177, AZ00188225, AZ00204573, AZ00204502. The federal recertification survey was conducted concurrently, investigating complaints AZ00188177, AZ00188224, AZ00204573, AZ00204502.
Findings
The inspection found eight deficiencies including failure to provide written notice of the bed-hold policy to a resident, incomplete discharge/transfer paperwork, failure to notify a physician of low blood pressure readings, unsafe water temperatures causing a fall with injury, and inadequate fall prevention measures. A Condition of Immediate Jeopardy was identified and subsequently abated.
Deficiencies (8)
R9-10-403 — The facility failed to provide a written notice of the bed-hold policy and implications of returning to the facility to resident #423 upon admission and at transfer.
§483.15(c) — The facility failed to ensure discharge/transfer paperwork was completed for resident #423, risking unsafe transition of care.
§483.15(d) — The facility failed to provide resident #423 and/or representative with written notice of the bed-hold policy duration at transfer.
§483.21(b)(3) — The facility failed to meet professional standards by not notifying the physician of low blood pressure readings for resident #423.
§483.25(d) — The facility failed to prevent a fall resulting in a fracture for resident #73 and failed to maintain safe water temperatures, resulting in a Condition of Immediate Jeopardy that was later abated.
R9-10-411 — The facility failed to ensure transfer/discharge documentation was completed for resident #423, including absence of a physician transfer order.
R9-10-414 — The facility failed to maintain resident #423's highest practicable well-being by not notifying the physician of low blood pressure readings.
R9-10-425 — The facility failed to maintain premises free from conditions causing physical injury, as evidenced by a fall with injury to resident #73 and delayed hospital transfer.
Report Facts
Deficiencies cited: 8
Complaints investigated: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #16 | Licensed Practical Nurse | Interviewed regarding bed-hold policy and discharge orders for resident #423. |
| Staff #19 | Social Services Director | Interviewed regarding bed-hold policy and consent responsibilities. |
| Staff #62 | Director of Nursing | Interviewed regarding transfer orders and fall incident procedures. |
| Staff #271 | Administrator | Informed of water temperature issues and involved in Plan of Correction. |
| Staff #56 | Maintenance Director | Conducted water temperature testing and interviewed about boiler adjustments. |
| Staff #23 | Licensed Practical Nurse | Interviewed about safe water temperature knowledge. |
| Staff #259 | Registered Nurse | Interviewed about safe water temperature knowledge. |
| Staff #264 | Restorative Nursing Assistant | Interviewed about water temperature checks before resident bathing. |
| Staff #204 | Certified Nursing Assistant | Interviewed about reporting hot water issues. |
| Staff #284 | Certified Nursing Assistant | Interviewed about safe water temperature standards. |
| Staff #86 | Registered Nurse | Interviewed about water temperature concerns and reporting. |
| Staff #267 | Certified Nursing Assistant | Interviewed about water temperature for bathing and hand washing. |
| Staff #58 | Licensed Practical Nurse | Interviewed about knowledge of safe water temperature. |
| Staff #205 | Certified Nursing Assistant | Interviewed about fall response procedures. |
Inspection Report — Jan 12, 2024
Date: Jan 12, 2024
Visit Reason
On-site inspection of a Nursing Care Institution at Sierra Winds conducted 12 January 2024. The inspection type was Other and included a recertification survey for Medicare under Life Safety Code 2012.
Findings
The inspection found four deficiencies related to emergency preparedness planning, emergency communication planning, special locking exit doors, and improper use of power strips. The facility acknowledged the findings and provided plans of correction.
Deficiencies (4)
42 CFR 483.73 — The facility failed to develop Emergency Preparedness policy and procedures based on community risk assessments prior to developing the emergency plan, which may cause harm during an emergency.
42 CFR 483.73 — The facility failed to have documentation in the emergency preparedness communication plan that included methods for sharing patient information with other health providers and releasing patient information during evacuation.
NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.2.2.2.4 — The facility failed to maintain two special locking exit doors that required more than 15 pounds of force to release, potentially causing harm in an emergency.
NFPA 101, Life Safety Code, 2012, Chapter 2, Section 2.1 — The facility failed to ensure staff did not use daisy chained power strips, creating a potential electrical overload and fire hazard.
Report Facts
Deficiencies cited: 4
Inspection Report — Dec 21, 2023
Complaint Investigation
Date: Dec 21, 2023
Visit Reason
On-site complaint investigation of intakes AZ00204235, AZ00204371, AZ00204381 and AZ00204413 at a Nursing Care Institution, conducted 21 December 2023.
Complaint Details
A complaint survey was conducted on December 21, 2023 for the investigation of intake #s: AZ00204235, AZ00204371, AZ00204381 and AZ00204413. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Sep 27, 2023
Complaint Investigation
Date: Sep 27, 2023
Visit Reason
On-site complaint investigation of multiple complaints including AZ00200948, AZ00200207, AZ00200198, AZ00190848, AZ00195846, AZ00197151, AZ00194770, AZ00195015, AZ00195604, and AZ00188688 at a Nursing Care Institution, conducted 26-27 September 2023.
Complaint Details
An onsite survey was conducted 26-27 September 2023 for investigation of intake numbers AZ00200948, AZ00200207, AZ00200198, AZ00190848, AZ00195846, AZ00197151, AZ00194770, AZ00195015, AZ00195604, and AZ00188688. A complaint survey was also conducted for intake numbers AZ00200946, AZ00200204, AZ00200196, AZ00190848, AZ00195846, AZ00197150, AZ00194770, AZ00195013, AZ00195603, and AZ00188688.
Findings
The inspection found four deficiencies related to failure to report and prevent abuse involving resident #7 and resident #8. The facility did not immediately report an allegation of abuse to the State Agency as required and failed to ensure resident #7 was free from abuse.
Deficiencies (4)
R9-10-403.F — The facility failed to ensure an allegation of abuse for resident #7 was reported immediately to the State Agency as required, despite documentation and investigation of an incident involving resident #7 and resident #8.
§483.12 — The facility failed to ensure resident #7 was free from abuse by another resident, which could result in physical or emotional harm.
§483.12(c) — The facility failed to report an allegation of abuse for resident #7 immediately to the State Agency, risking lack of investigation and protection from further abuse.
R9-10-410.B — The facility failed to ensure resident #7 was not subjected to abuse, despite evidence of an incident involving resident #8 hitting resident #7's right leg.
Report Facts
Deficiencies cited: 4
Complaints investigated: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #2 | Certified Nursing Assistant | Interviewed regarding incident involving residents #7 and #8 on September 27, 2023. |
| Staff #4 | Director of Nursing | Interviewed regarding incident and reporting on September 27, 2023. |
| Staff #35 | Administrator | Interviewed regarding decision not to report incident to State Agency on September 27, 2023. |
Inspection Report — Apr 11, 2023
Enforcement
Date: Apr 11, 2023
Visit Reason
Civil monetary penalty, action 00113549 (invoice INV-259860), assessed 11 April 2023.
Findings
A $500.00 penalty was assessed and paid in full on 2 June 2023.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Report
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