Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sierra Winds during CMS and state inspections, most recent first.
Two residents with cognitive impairments were involved in multiple altercations due to inadequate supervision. One resident, experiencing delusions and agitation, prevented the other from moving her wheelchair, resulting in a skin tear. The agitated resident later escalated her behavior, throwing plates and ramming a cart into objects. Staff expressed concerns about insufficient staffing to provide necessary supervision, and the resident was eventually transferred to the hospital for evaluation.
A resident with severe dementia and a history of falls suffered a major injury due to the facility's failure to implement and document fall safety measures. Despite known risks, the resident's care plan lacked timely interventions, and staff interviews revealed inconsistencies in monitoring and documentation. The facility's policies on fall prevention were not followed, contributing to the resident's injury.
The report identifies instances where medications were not properly documented on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for three residents. For one resident, numerous medications were left blank or undocumented without reasons for non-administration, despite the resident's complaints. Another resident's essential medications for diabetes, hypertension, and pain management were also left blank or undocumented, with the use of registry staff contributing to delays. Similarly, a third resident's medications for hypertension, diabetes, and depression were left blank or undocumented, with staff interviews highlighting challenges related to registry staff usage.
A resident with intact cognition and undergoing antibiotic therapy was transferred to the ER without proper discharge/transfer paperwork. Staff interviews revealed that the standard procedure for documenting a discharge order was not followed, and no transfer order was found in the clinical record.
The facility failed to provide a written notice of the bed-hold policy to a resident upon admission and within 24 hours of transfer to a hospital. Despite the resident's intact cognition and ability to understand, there was no evidence of the notice being given. Staff interviews revealed confusion and lack of responsibility regarding the bed-hold policy, with the social services director stating that the facility does not have such a policy.
A resident with chronic kidney disease and heart failure had low blood pressure readings that were not promptly reported to the physician, and antihypertensive medications were administered despite orders to hold them for low BP. Staff interviews and record reviews revealed inconsistencies in monitoring and reporting protocols, leading to a failure to meet professional standards of care.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision for two residents, leading to multiple altercations between them. Resident #6, who has severe cognitive impairment and dementia, was involved in incidents with Resident #7, who has moderate cognitive impairment and behavioral issues. On December 20, 2024, Resident #6 was prevented from moving her wheelchair by Resident #7, requiring staff intervention. No injuries were reported at that time. On December 30, 2024, two separate incidents occurred involving the same residents. Resident #7, who was experiencing increasing delusions and agitation, again held onto Resident #6's wheelchair, resulting in a skin tear for Resident #7. Later that evening, Resident #7's behavior escalated further, leading to aggressive actions such as throwing dinner plates and ramming a dinner cart into objects and people in the hallway. Staff intervention was necessary, and Resident #7 was eventually transferred to the hospital for evaluation and treatment. Interviews with staff revealed that Resident #7 required constant supervision due to her behaviors, but the facility did not provide the necessary 1:1 care. Staff expressed concerns about the lack of adequate staffing to monitor residents with behavioral issues, which placed residents at risk. The Director of Nursing acknowledged the risks associated with insufficient supervision, including potential injury to residents.
Failure to Implement Fall Safety Measures
Penalty
Summary
The facility failed to implement fall safety measures for a resident, leading to a fall with major injury. The resident, who was admitted with diagnoses including metabolic encephalopathy and severe dementia, was assessed to require a two-person physical assist for mobility and had a moderate cognitive impairment. Despite being legally blind, disoriented, and incontinent, the resident's clinical record showed no documentation of a fall risk assessment or fall safety measures until after a fall occurred in February 2024. The resident had a history of multiple falls, some resulting in injuries, yet there was no evidence of a fall care plan prior to February 2024. The care plan eventually documented included interventions such as keeping the bed in the lowest position, clearing obstructions, and supervising ambulation. However, these interventions were not documented as being implemented or monitored, and the resident continued to experience falls, including a significant fall resulting in rib fractures. Interviews with staff revealed that while interventions like fall mats and low beds were known strategies, there was a lack of consistent documentation and monitoring of these interventions. The Director of Nursing acknowledged the absence of documentation and the inability to access previous care plan records due to a change in the electronic health record system. The facility's policies on fall risk assessment and management emphasized the need for a resident-centered fall prevention plan and documentation of interventions, which were not adhered to in this case.
Medication Administration Documentation Deficiencies
Penalty
Summary
The report details multiple instances where the nursing facility failed to ensure that residents' medications were administered as ordered by the provider, potentially resulting in residents not receiving prescribed doses of medications. Specifically, the report highlights deficiencies in medication administration for three residents: #525, #575, and #550. For Resident #525, the review of medication administration records revealed numerous instances where medications were left blank or undocumented on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) without any corresponding documentation of refusal or reasons for non-administration. Despite the resident's complaints and concerns about the timeliness and accuracy of medication administration, there was a lack of proper documentation to explain the discrepancies. Similarly, for Resident #575, the report identified multiple medications that were left blank or undocumented on the MAR and TAR, including essential medications for conditions such as diabetes, hypertension, and pain management. The report highlighted the impact of utilizing registry staff who may not be familiar with residents' routines, leading to delays in medication administration and potential adverse effects on residents' health. The lack of documentation regarding medication administration raised concerns about the facility's adherence to established protocols and standards for medication management. In the case of Resident #550, the report outlined instances where medications were left blank or undocumented on the MAR and TAR, including medications for conditions such as hypertension, diabetes, and depression. Interviews with staff members revealed challenges related to the use of registry staff, which contributed to delays in medication administration and potential risks to residents' health.
Failure to Complete Discharge/Transfer Paperwork
Penalty
Summary
The facility failed to ensure discharge/transfer paperwork was completed for a resident who was transferred to the hospital. The resident, who had intact cognition and was undergoing antibiotic therapy for a left hip infection, experienced a change of condition and was sent to the ER. Despite the transfer, there was no evidence of a physician order for the transfer or any completed discharge/transfer information in the clinical records. Interviews with staff revealed that the standard procedure for documenting a discharge order in the electronic record was not followed. The LPN could not locate a physician order for the transfer, and the DON confirmed that no transfer order was found in the clinical record. This oversight could result in the resident not receiving a safe and effective transition of care.
Failure to Provide Written Notice of Bed-Hold Policy
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy and the implications of returning to the facility to a resident upon admission and within 24 hours of transfer to a hospital. Resident #423, who had intact cognition as indicated by a BIMS score of 15, was admitted with diagnoses including aftercare following joint replacement surgery, unilateral primary osteoarthritis left hip, chronic kidney disease, and acute post hemorrhagic anemia. Despite the resident's ability to understand and be understood, there was no evidence in the clinical record that the resident was provided with a written notice of the bed-hold policy upon admission or at the time of transfer to the hospital on January 9, 2024. Interviews with staff revealed a lack of clarity and responsibility regarding the bed-hold policy. An LPN stated that a discharge order is entered into the electronic record when a resident is transferred or discharged, but there was no mention of providing a bed-hold notice. The social services director indicated that the registered nurse was responsible for obtaining consent for bed-hold, but later stated that the facility does not have a bed-hhold policy. This deficiency may result in residents and their representatives not being aware of the bed-hold policy and their right to return to the facility immediately to the first available bed.
Failure to Notify Physician of Low Blood Pressure Readings
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that the physician was promptly notified of low blood pressure readings for a resident with chronic kidney disease, hypertensive heart disease with heart failure, and acute post hemorrhagic anemia. The resident had specific physician orders to hold antihypertensive medications if systolic blood pressure was less than 110. Despite this, the resident's blood pressure readings on January 7, 2024, were significantly below this threshold, and the physician was not notified in a timely manner. Additionally, the antihypertensive medications were administered despite the low blood pressure readings, contrary to the physician's orders. The clinical record revealed that the resident's blood pressure was 88/47 at 9:48 a.m., 89/57 at 4:45 p.m., and 89/57 at 5:18 p.m. on January 7, 2024. The physician was only notified of the 9:48 a.m. reading at 1:45 p.m., approximately four hours later, and there was no evidence that the physician was notified of the subsequent low blood pressure readings. Furthermore, the medications metoprolol and losartan were administered on the same day despite the low blood pressure readings, and there was no documentation explaining why the medications were not held as per the physician's orders. Interviews with staff, including a CNA, an LPN, and the DON, revealed inconsistencies in the understanding and execution of protocols for monitoring and reporting vital signs, particularly in cases of hypotension. The facility's policies on blood pressure monitoring, resident examination and assessment, and administering medications were not adhered to, leading to the failure to provide care in accordance with professional standards. The deficiency was identified through clinical record reviews, staff interviews, and policy reviews, highlighting a significant lapse in the facility's adherence to established care protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Peoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Center At Arrowhead, Llc | 1.7 mi | ★★★★★ | 0 | 0 |
| Sun City Post Acute | 1.9 mi | ★★★★★ | 1 | 0 |
| Freedom Plaza Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Peoria Post Acute And Rehabilitation | 2.5 mi | ★★★★★ | 5 | 0 |
| Lake Pleasant Post Acute Rehabilitation Center | 2.7 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.