Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 La Sierra Care Center during CMS and state inspections, most recent first.
The facility failed to ensure the RD provided comprehensive oversight of dietary operations when the RD worked remotely and only completed one onsite kitchen audit. The RD stated her duties were mainly record reviews and resident nutrition follow-up by phone or email, while the CDM had no direct physical oversight of kitchen operations. The DON stated direct oversight of kitchen operations could not be provided remotely, and the RD’s job duties included weekly inspections, sanitation, safety, infection control, and food storage oversight. Surveyors also identified issues with menu recipes, alternate food options, and safe, sanitary food handling.
Incorrect Portion Size Served for Pureed Diet Meal: A cook used a #8 scoop instead of the required #6 scoop when serving pureed stir fried chicken on the tray line, and the CDM confirmed all pureed portions were plated with the wrong scoop size. The RD stated menu recipes were expected to be followed to ensure standardized portions and nutritional needs were met, and the DON stated residents were at risk of not having their nutritional needs met when the incorrect scoop size was used.
Failure to post or provide an alternative meal menu left most residents without clear access to appealing meal substitutes. A resident stated he only knew about PB&J, grilled cheese, and ham and cheese sandwiches, which he did not view as a real meal replacement, while another resident said he was unaware any alternative menu existed and would simply skip meals. The CDM, RD, and DON all confirmed there was no designated alternative menu posted or provided, and that sandwiches were not an appealing or nutritional substitute.
Unlabeled Food Items, Missing Dry Storage Log, and No Air Gap A CDM and RD identified multiple food safety issues in the kitchen, including four prune juice bottles without received-on date labels, no temperature log for the dry food storage room, and a food prep sink without an air gap. The CDM stated food and beverage items were expected to be labeled and rotated using FIFO, the dry storage area was supposed to stay between 50 and 70 degrees Fahrenheit, and the sink was used to wash produce, thaw frozen foods, and prep ingredients residents consumed. The RD and DON stated these conditions did not meet facility policy or food safety standards.
Incomplete POLST Documentation for Three Residents: The facility failed to keep complete and accurate medical records when the POLST forms for three residents had incomplete Section D, Information and Signatures. One resident had dementia and severe cognitive impairment, while two others were cognitively intact; all three had significant medical conditions including ESRD, CHF, COPD, stroke history, dysphagia, diabetes, and kidney disease. RN and MR staff stated the missing signature information should have identified who the POLST was discussed with and who made the end-of-life decision.
Insufficient Square Footage in Multiple Resident Rooms: A facility failed to provide at least 80 square feet per resident in 19 of 23 multiple-occupancy rooms. Surveyors found that the rooms contained three beds each and measured between 210 and 234 square feet, although the report noted residents had privacy, adequate room for nursing care and ambulation, accessible wheelchairs and toilet facilities, and adequate closet/storage space.
A resident with legal blindness, moderate cognitive deficit, and extensive ADL dependence was found in bed with the call light behind her instead of within reach. The resident stated she could not see, did not know where staff put the call light, and had not been given a bell. Staff interviews confirmed the resident needed the call light placed in her hand or otherwise made accessible, and the care plan already directed staff to keep it within reach and encourage use for assistance.
Failure to individualize care plan for a resident with severe vision impairment: A resident with legal blindness, moderate cognitive deficit, and multiple medical diagnoses had a care plan that only stated the call light should be within reach and did not include resident-specific interventions for blindness. During observation, the call light was found behind the resident, and the resident stated staff did not check on her, did not place the call light in her hand, and did not help with meals unless they were not busy. RN staff, the MDSC, and the DON stated the plan was not resident-specific and was not being implemented as written.
An opioid pain med was given outside the ordered pain range for one resident, tramadol was repeatedly administered outside the ordered parameters for another resident, and a resident with COPD and hospice care was found receiving O2 at a higher flow rate than ordered. RNs, the pharmacy consultant, and the DON confirmed the orders were not followed as written.
An unlabeled prescription eye drop bottle was found on a medication cart without the resident’s name, directions for use, or expiration date. RN and DON both stated the bottle should have been labeled so staff could identify the resident and verify the medication before administration; facility policy required medication labels to include the resident’s name, expiration date, route, and instructions.
Infection control failed during resident care and medication handling when a nurse used a tray in a resident’s room on EBP, then returned it to the med cart without sanitizing it. Staff also provided direct care to residents on EBP without the required gown use, including care for a resident with a g-tube and another resident with a stage 3 pressure ulcer. Interviews and policy review confirmed that reusable equipment should be disinfected between residents and that gowns and gloves were required for EBP high-contact care activities.
Failure to Develop and Implement Elopement Care Plan: A resident with dementia, severe intellectual disabilities, and moderate cognitive impairment was identified on admission as an elopement risk and was known to wander, especially in the evenings. Staff stated they were only watching and redirecting the resident and were not following an elopement care plan. The care plan was not initiated until after the resident had already eloped, despite facility policy requiring care plan strategies and interventions for residents at risk for wandering or elopement.
Nursing staff did not complete required documentation or head-to-toe assessments for a resident repeatedly found on the floor, contrary to facility policy, and failed to notify the physician or update care plans. Additionally, two CNAs were observed working without visible ID badges, in violation of facility procedures for staff identification.
The facility did not assess dietary preferences for several residents within 48 hours of admission, leading to meals being served without considering their preferences. This delay was acknowledged by the RD and DM, who noted potential negative effects on residents' recovery and nutritional status.
The facility failed to provide palatable meals, with residents reporting cold, tasteless food. Observations showed food served at inadequate temperatures, and residents expressed dissatisfaction with meal quality. The Dietary Manager acknowledged temperature complaints, attributing them to slow tray distribution.
The facility failed to ensure proper food safety and hand hygiene practices. Meal service temperatures were documented before food was placed on the steam table, contrary to protocol. Additionally, a dietary staff member did not change gloves after touching clothing during food preparation, violating hygiene standards.
The facility did not comply with room size requirements, as 19 out of 23 rooms failed to meet the minimum square footage per resident. Despite this, staff and administration reported no complaints or concerns about room sizes, and waivers were mentioned for some rooms.
A long-term care facility failed to maintain a medication error rate below 5%, with errors affecting two residents. One resident received atenolol without a required blood pressure check, while another was given lisinopril and amlodipine without a pulse check. The errors were attributed to incomplete adherence to physician orders and MAR prompts.
The facility failed to ensure that three residents were free from significant medication errors. For two residents, the facility did not obtain all required vital signs before administering antihypertensive medications, as the electronic MAR did not prompt for all necessary checks. Another resident received medications despite vital signs being outside physician-ordered parameters. The DON emphasized the importance of following physician orders to ensure resident safety.
The facility failed to ensure accurate MDS assessments for two residents. One resident was documented as using hearing aids, which they did not have, and another resident's discharge disposition was incorrectly recorded. Staff interviews revealed a lack of awareness and verification, leading to these inaccuracies.
A facility failed to submit an accurate PASRR for a resident with bipolar disorder, major depressive disorder, and anxiety disorder. The resident's PASRR Level I Screening inaccurately indicated negative results for serious mental illness, omitting key diagnoses and medication use. Staff interviews revealed a lack of formal PASRR policy and reliance on hospital-provided screenings, with the MDS Coordinator missing the inaccuracies. The DON acknowledged frequent issues with hospital PASRRs, requiring resubmission, which was not done in this case.
A resident with a history of hemiplegia and a contracted left hand had an outdated care plan that was not revised to reflect their current needs. Despite the resident's ability to communicate, the care plan included interventions that were no longer relevant, such as range-of-motion exercises and the use of a brace, which were not being performed or provided. Staff interviews confirmed the lack of updates to the care plan, and facility leadership acknowledged the need for revisions.
A resident with protein-calorie malnutrition did not receive fortified food as recommended by the RD due to a failure in entering the diet order. The SLP omitted the fortified portion from the order, and the DM was unaware of the need for fortified foods. Interviews revealed that staff did not ensure the correct diet orders were entered, leading to the resident not receiving the necessary nutritional supplementation.
A resident with COPD did not receive proper monitoring during nebulizer treatments, as required by facility policy. Observations showed the resident was left unattended, and medication was not fully administered. Interviews confirmed that staff should have stayed with the resident to ensure effective treatment and monitor for side effects.
Two residents in the facility did not receive their prescribed medications due to unavailability and lack of timely follow-up by staff. One resident, with a history of heart disease and depression, missed doses of escitalopram and prazosin, while another resident with major depressive disorder did not receive clonazepam, alpha-lipoic acid, and FiberChoice. The facility's protocol for obtaining medications was not adequately followed, leading to this deficiency.
The facility failed to transcribe physician orders for vital signs to the MAR for two residents, leading to incomplete monitoring before administering antihypertensive medications. One resident's atenolol order required blood pressure and pulse checks, but only pulse was documented. Another resident's orders for lisinopril and amlodipine required both blood pressure and pulse checks, but only blood pressure was recorded. This resulted from incomplete transcription and misunderstanding of the orders by LVNs.
The facility failed to maintain copies of daily staffing numbers, potentially affecting all residents. The Staffing Coordinator did not have records for a specific period due to a system glitch and did not keep handwritten forms. The Administrator confirmed that these records should be kept for at least a year for the facility's annual PPD review.
RD Oversight of Dietary Operations Not Fully Performed
Penalty
Summary
The facility failed to ensure a Registered Dietitian (RD) comprehensively and frequently evaluated the effectiveness of food service operations when lapses occurred in meal accuracy, nutritional value of menus, and food safety. The RD stated she had been a remote full-time RD since 6/2025 and had visited the facility in 6/2025, 8/2025, and 11/2025, with only one documented onsite kitchen audit on 11/11/25. She stated her primary duties were record reviews, nutritional assessments, diet recommendations, and resident weight reviews completed by email or phone, and that she did not review the Certified Dietary Manager’s kitchen audits. The CDM stated she provided no direct physical oversight of kitchen operations, while the RD stated the kitchen required direct physical oversight. The Administrator stated the RD was hired as an employee in 6/2025 and had been remote since then, and the DON stated direct oversight of kitchen operations could not be provided if the RD was remote. The DON also stated the facility was responsible for ensuring the RD’s required job duties were fulfilled while remote and that the RD job duty had not been fulfilled when she had been remote since 6/2025 and had only performed one onsite kitchen audit. During review of the 11/11/25 sanitation review, the RD identified general sanitation and maintenance issues in the kitchen, but there was no documented RD follow-up of those issues. The facility’s job duty document for the RD stated responsibilities included organizing, planning, and supervising dietary operations, performing weekly inspections, and ensuring sanitation, safety, infection control, and food storage oversight. During the survey, multiple issues were identified involving menu recipes, appealing alternate food options, and safe and sanitary food storage, preparation, and service.
Incorrect Portion Size Served for Pureed Diet Meal
Penalty
Summary
The facility failed to ensure that five residents on pureed diets received the correct serving scoop size for lunch when stir fried chicken was served on the tray line. The facility’s diet type report showed five residents were receiving pureed diet textures. The recipe for Stir Fried Chicken and the Stir-Fried Chicken Method both indicated that the pureed portion should be served with a #6 scoop, but during observation the cook used a #8 scoop to serve the item at the start and end of lunch tray line. The Certified Dietary Manager observed the incorrect scoop being used, and later confirmed that all pureed stir fried chicken had been plated using the wrong scoop size. During interview, the cook stated she used a #8 scoop to serve the pureed stir fried chicken and that cooks were responsible for ensuring the required menu scoop size was used during tray line. The CDM stated the wrong scoop size was used for all pureed stir fried chicken served that meal and that residents on pureed diets received less protein than the menu recipe called for. The RD stated menu recipes were expected to always be followed to ensure nutritional needs and standardized portion sizes were met, and that a #8 scoop was equivalent to 1/2 cup while a #6 scoop was equivalent to 2/3 cup. The DON stated residents were at risk of not having their nutritional needs met when served the incorrect scoop size and that facility policy and nutritional standards of practice were not followed.
Failure to Post or Provide Alternative Meal Menu
Penalty
Summary
The facility failed to provide appealing and nutritional alternative menu items for 62 of 65 residents eating at the facility because there was no posted or designated alternative meal menu. During observations, no alternative meal menu was posted outside the kitchen, inside the kitchen, or in either dining room. The kitchen staff identified only peanut butter and jelly, grilled cheese, and ham and cheese sandwiches as alternative meal options, with the Certified Dietary Manager also stating that sometimes extra chicken fingers and hamburgers could be offered if available. During interview, a resident stated he had a copy of the current weekly menu but no copy of an alternative menu, and said alternative meal items were never the same and he never knew what options he had. He stated the only options he was told about were peanut butter and jelly, grilled cheese, and ham and cheese sandwiches, which he did not consider an actual meal replacement. Another resident stated he was not aware there was an alternative menu and would refuse meals and wait for the next meal instead. Staff interviews confirmed that residents were not provided a posted or copied alternative menu and that residents might not be available during kitchen rounds to hear verbal menu options. The CDM stated there was no designated alternative meal menu and that residents would not know their options if the menu was not posted or provided. The RD stated there was no alternative menu when she started in 6/2025, was not aware of a current alternative meal menu, and stated all menus needed to be posted and provided to residents for review. The RD also stated sandwiches were not an appealing or nutritional substitute to scheduled meal menus. The DON stated residents had a right to know their meal and alternative options, that sandwiches were not an appealing or nutritional substitute, and that facility policy was not followed when the alternative meal menu was not posted or provided to residents.
Unlabeled Food Items, Missing Dry Storage Temperature Log, and No Air Gap at Food Prep Sink
Penalty
Summary
Food and beverage items were not consistently stored and labeled in accordance with professional food safety standards. During observation in the dry food storage room, four 48 fl oz prune juice bottles were found without received-on date labels. The Certified Dietary Manager stated the bottles did not have received-on dates and explained that all food and beverage items were expected to have received-on, opened, and expiration date labels and be used in a first in, first out method. The dry food storage room also lacked a temperature record log. A wall-mounted thermometer in the room read 60 degrees Fahrenheit, and the CDM stated the room was required to remain between 50 and 70 degrees Fahrenheit. The CDM stated she checked the temperature twice daily on weekdays and cooks checked it on weekends, but there was no documentation of those checks. The Registered Dietician later stated that recording dry food storage temperatures was necessary to ensure temperatures were maintained and to monitor fluctuations, and that it could not be guaranteed temperatures were being monitored when no log existed. In the kitchen, the food preparation sink was observed without an air gap. The CDM stated the sink was used to wash fruit and vegetables, thaw frozen food items, and prep ingredients residents consumed, and that without an air gap substances could backflow into the sink and contaminate food items. The RD stated all food preparation sinks required an air gap to prevent backflow and cross contamination, and noted that the sink had never had one. The DON stated she expected the kitchen to adhere to facility policies and food safety standards, and that this had not occurred when the prune juice bottles were unlabeled, no dry storage temperature log was kept, and there was no air gap on the food preparation sink.
Incomplete POLST Documentation for Three Residents
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards for three sampled residents when their copies of the Physician Orders for Life-Sustaining Treatment (POLST) forms were incomplete. Resident 31 was observed in bed and stated he did not remember how long he had been at the facility or why he was there. His admission record listed diagnoses including dementia, hydronephrosis, chronic kidney disease, depression, dysphagia, and displacement of a nephrostomy catheter. His MDS showed a BIMS score of 3, indicating severe cognitive impairment. Review of his POLST showed Section D, Information and Signatures, was not complete. Resident 4 was observed in bed and stated he had been at the facility for rehabilitation after surgery and that he went to dialysis, where nurses at the dialysis facility changed his catheter dressing. His admission record listed diagnoses including COPD, pleural effusion, respiratory failure, CHF, end stage renal disease, dysphagia, and depression. His MDS showed a BIMS score of 13, indicating he was cognitively intact. Review of his POLST also showed Section D, Information and Signatures, was not complete. Resident 9 was observed in bed with a feeding pump paused next to his bed and stated he had been at the facility for two years due to a stroke. His admission record listed diagnoses including acquired absence of the left great toe, type 2 diabetes mellitus, gastrostomy, gastrointestinal hemorrhage, ulcer of the esophagus, dysphagia, and acute kidney failure. His MDS showed a BIMS score of 15, indicating he was cognitively intact. Review of his POLST showed Section D, Information and Signature, was not complete. RN 1 stated all sections of the POLST should have been completed, and the MR stated Section D should have identified who the form was discussed with and whether the resident had an advance directive. The DON stated Section D should have been completed for each resident's POLST and that the signature section was important to show who the decision maker was for end-of-life care and what the resident's wishes were.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 19 of 23 multiple resident rooms, specifically rooms 1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 23. During the survey period of 1/20/26 through 1/23/26, surveyors observed and reviewed records showing that these rooms did not meet the required square footage standards, with room sizes listed between 210 and 234 square feet and three beds in each room. The report states that the variations were in accordance with the particular needs of the residents, that residents had privacy, there was sufficient room for nursing care and resident ambulation, wheelchairs and toilet facilities were accessible, closets and storage space were adequate, and bedside stands were available.
Call Light Not Kept Within Reach for Blind Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident with severe visual impairment and dependence on staff for activities of daily living when the resident’s call light was not kept within reach. Resident 28 had diagnoses including legal blindness, muscle weakness, cerebral infarction, seizures, difficulty walking, anxiety disorder, asthma, insomnia, and convulsions. The resident’s MDS showed a BIMS score of 7, indicating moderate cognitive deficit, and vision was coded as severely impaired, with no vision or only light, colors, or shapes. The resident also required substantial to maximal assistance with multiple self-care and transfer tasks and was dependent for several ADLs. During observation, the resident was found lying in bed facing the wall with the call light behind her on the bed. The resident stated she was blind, that staff did not check on her, and that she did not have the call light. She stated it should be in her hand, that she did not know where staff put it, and that this created safety issues because she could not see. The care plan included an intervention to keep the call light within reach and encourage use for assistance, but staff interviews showed the resident’s call light had been clipped to the side of the bed or otherwise not placed where she could access it. Staff interviews confirmed awareness that the resident could not see and needed the call light placed in her hand or otherwise made accessible. CNAs stated the call light should have been in the resident’s hand because she could not see it, and that she needed frequent checks. RN staff stated blind residents should be given a bell or the call light and educated on its location. The MDSC stated the care plan should have been resident-specific for a legally blind resident and that the facility was not implementing the care plan as written. The DON also stated the call light should be given to the resident because she could not see and needed it to call for help.
Failure to Individualize Care Plan for Resident With Severe Vision Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with severely impaired vision. The resident was admitted with diagnoses including legal blindness, muscle weakness, cerebral infarction, other seizures, difficulty walking, anxiety disorder, asthma, insomnia, and convulsions. The resident’s MDS assessment showed a BIMS score of 7, indicating moderate cognitive deficit, and the vision section indicated severe impairment with no vision or only light, colors, or shapes perceived. During observation, the resident was found lying in bed facing the wall, with the call light behind her on the bed. The resident stated that she was blind, that staff did not check on her, and that she did not have the call light in her hand. She stated it should not be behind her, that she did not know where staff put it, and that this created safety issues because she could not see. The care plan reviewed for the resident included an intervention that the call light be within reach and that the resident be encouraged to use it, but it did not contain resident-specific interventions related to her severe vision impairment. The resident also stated that she could not eat by herself and that staff did not help with food unless they were not busy. She stated staff did not cue or prompt her during meals, that she had to wait until staff were available, and that her food sometimes got cold. She also stated she had never been given a bell and that staff did not discuss her plan of care with her. RN staff and the MDSC stated that blind residents should have individualized interventions such as placing the call light in the resident’s hand or on her chest, educating the resident each time staff left the room, and providing meal assistance by telling her where items were on the plate and orienting her to the dining room. The MDSC and DON both stated the care plan was not resident-specific and that the facility was not implementing the existing care plan interventions.
Medication and Oxygen Orders Not Followed
Penalty
Summary
Resident 13 had an active order for hydrocodone-acetaminophen 5-325 mg every 6 hours for severe pain rated 6-10, and an active order for acetaminophen 325 mg every 6 hours as needed for mild pain rated 1-5. Review of the MAR showed hydrocodone-acetaminophen was administered 12 times outside the ordered parameters between 1/15/26 and 1/22/26 for reported pain scores of 0-5. During observation, Resident 13 stated he was recently admitted, was recovering after a left below-knee amputation, could make his needs known, and did not have frequent pain. RN 3 stated the medication should have been given only as written and that if pain was outside the ordered range, the provider should have been contacted for clarification. Resident 19 had an order for tramadol HCL 50 mg twice daily for pain rated 4-10, with instructions to hold for signs and symptoms of sedation/overdose and if respirations were less than 12. The MAR showed tramadol was administered 48 times outside the ordered parameters between 11/1/25 and 1/22/26 for reported pain scores of 0-3. The record also showed an active order for acetaminophen 325 mg as needed every 6 hours for mild pain, with no pain scale included. During observation, Resident 19 was lying in bed and stated he frequently received pain medication. RN 3 and the pharmacy consultant stated the opioid orders were not followed as written when the medications were given outside the ordered pain ranges. Resident 35, who had COPD, dementia, anxiety disorder, and hospice services, had an order for oxygen at 2 L/min via nasal cannula continuously for shortness of breath. During observation, Resident 35 was found in bed with a nasal cannula connected to an oxygen concentrator set at 2.5 LPM. RN 2 and RN 1 both confirmed the concentrator was set above the ordered flow rate and stated the physician's order was not followed. The DON also confirmed the oxygen was not administered according to the physician's order.
Unlabeled Prescription Eye Drop Bottle on Medication Cart
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional standards when one of eight prescription eye drop bottles on the medication cart at Station 2 was found without the resident’s name, directions for use, or expiration date. During a concurrent observation and interview, RN 2 confirmed the bottle should have been labeled so staff would know which resident it belonged to if it came out of its container box and to prevent it from being given to the wrong resident. During interview, the DON stated the eye drop bottle should have been labeled with the resident’s name and administration instructions, and that nurses should check for a label before administering the medication. The DON also stated the bottle needed to be labeled in case it came out of the package so staff would know which resident it belonged to and what the directions were. Facility records reviewed included the Charge Nurse job description, which stated prescribed medication for one resident is not to be administered to another, and policies on Medication Labeling and Storage and Administering Medications, which required medication labels to include the resident’s name, expiration date, route, and instructions, and required staff to check the label three times before administration.
Infection Control Lapses During Resident Care and Medication Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during resident care and medication administration. During observation of care for a resident on Enhanced Barrier Precautions (EBP), an RN/LVN prepared a tray with blood glucose testing and medication supplies, donned a gown and gloves, placed the tray on the resident’s bedside table, completed the resident’s feeding and blood glucose check, and then returned the tray to the medication cart without sanitizing it. The nurse stated the tray should have been cleaned before being placed back in the cart because it had been used in the resident’s room and could spread contamination to another resident. The resident involved in this event had a g-tube and was on EBP, with the facility’s records showing EBP was ordered for the resident’s g-tube. The Infection Preventionist stated that trays used for patient care and medication administration should have been cleaned and sanitized before being returned to the medication cart. The DON also stated the tray should have been disinfected after use in the resident’s room and before being placed back in the cart because it came from an infected room. Facility policies reviewed stated reusable resident-care equipment must be cleaned and disinfected between residents, and non-critical items such as bedside tables are included in the cleaning and disinfection process. The facility also failed to ensure PPE was worn during care for two residents on EBP. One resident had a g-tube and was observed with EBP signage and a blue dot indicating EBP status; CNA care was provided while gloves were worn but no gown was used, even though the resident had a soiled brief and required direct care. Another resident had a stage 3 pressure ulcer and was also identified as being on EBP, yet the resident stated staff do not put on PPE when performing wound care and only wear gloves. Staff interviews confirmed that residents with wounds or g-tubes required gowns and gloves for EBP, and the IP, DON, RN, and CNA staff all stated the policy was not being followed during resident care.
Failure to Develop and Implement Elopement Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for one of three sampled residents who was identified as an elopement risk on admission. The resident had diagnoses including dementia and severe intellectual disabilities, and the MDS showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The admission/readmission data tool completed on 10/21/25 documented that the resident was independently mobile, was at risk for elopement, and that a care plan for elopement had been initiated. Interviews with the DON, LVN 1, RN 1, the MDS nurse, and the Administrator showed that staff knew the resident wandered the facility, especially in the evenings, and that she needed to be kept near the nurse's station for monitoring. Staff stated they were redirecting and watching her, but were not following a care plan for elopement. The MDS nurse reviewed the care plan report and stated the elopement care plan was not initiated when the resident was identified as at risk on admission, and instead was initiated after the resident had already eloped from the facility on the evening of 11/16/25. Facility policy required that residents identified as at risk for wandering or elopement have care plan strategies and interventions to maintain safety, and that comprehensive person-centered care plans be developed and implemented based on assessment data. The DON and Administrator both stated that a care plan for elopement should have been initiated when the resident was identified as an elopement risk on admission, and that nursing staff were expected to implement such care plans.
Failure to Document Falls and Ensure Staff Identification
Penalty
Summary
The facility failed to follow its own policies and procedures that meet professional standards of quality in two key areas. First, nursing staff did not complete required nursing documentation or head-to-toe assessments for a resident who was found on the floor 346 times within a month. Although the resident had diagnoses including Parkinsonism, persistent mood disorder, muscle spasms, difficulty walking, and lack of coordination, and was cognitively intact, only eight of the 354 episodes of being found on the floor were documented in the progress notes. Interviews with staff revealed that these incidents were not considered falls by the Director of Nursing, but rather resident behaviors, and thus were not assessed or documented according to facility policy. Both the facility's policies and staff interviews confirmed that each incident should have been documented, assessed, and communicated to the physician, but this did not occur. Further review of the facility's policies, including those on assessing falls and their causes, and behavior assessment, confirmed that staff are required to document all falls or incidents of residents being found on the floor, conduct head-to-toe assessments, notify the physician, and update care plans as needed. However, interviews with licensed nursing staff indicated that these protocols were not followed for the resident in question. Staff admitted that full assessments, documentation, and notifications were not completed, and that the resident was not placed under observation or had care plans updated as required by policy. Additionally, the facility failed to ensure that all Certified Nursing Assistants (CNAs) wore identification badges while on duty, as required by facility policy. During observations, two CNAs were found not wearing their ID badges and admitted to not having them at work, despite understanding the importance of proper identification for residents and families. The Director of Nursing confirmed that this was a violation of facility policy and could potentially cause confusion or delay in care if staff could not be properly identified.
Failure to Assess Dietary Preferences Timely
Penalty
Summary
The facility failed to assess dietary preferences for seven out of ten sampled residents within 48 hours of their admission, as required by their policy. This oversight resulted in the dietary preferences of these residents not being considered when meals were provided. For instance, one resident repeatedly informed staff that she does not drink milk, yet milk continued to be served to her. The Registered Dietitian (RD) and Dietary Manager (DM) acknowledged that the dietary profiles for several residents were either incomplete or delayed beyond the 48-hour window post-admission. The RD and DM both stated that the delay in completing dietary preferences could lead to negative side effects such as delayed wound healing, slower recovery, increased length of stay, and weight loss. The Director of Nursing (DON) confirmed the expectation for dietary preferences to be completed within 48 hours of admission, emphasizing the potential impact on residents' recovery and nutritional status. The facility's policy and procedure document also highlighted the importance of considering residents' food preferences to provide a well-balanced diet that meets their nutritional needs.
Deficiency in Meal Palatability and Temperature
Penalty
Summary
The facility failed to provide palatable meals to its residents, as evidenced by multiple observations and resident complaints. The facility's policy on Food and Nutrition Services, revised in 2017, mandates that each resident is provided with a nourishing, palatable, well-balanced diet that meets their nutritional and dietary needs. However, during a lunch meal service, the food was observed to be served at inadequate temperatures, with the rosemary roast pork at 90 degrees, mashed potatoes at 100 degrees, and zucchini/tomatoes at 100 degrees by the time the last resident tray was served. Residents reported the food as cold, tasteless, and unappetizing, with some stating they could not identify the vegetables served. The Dietary Manager acknowledged awareness of complaints about food temperatures but attributed the issue to slow meal tray distribution by staff. Several residents, including those with intact cognitive status, expressed dissatisfaction with the meals, citing issues such as cold temperatures, lack of seasoning, and unappetizing presentation. During a Resident Council Meeting, attendees reported the need for more seasoning and less spice in meals, and specific complaints were made about the lunch meal's lack of flavor and warmth. The Director of Nursing and the Administrator both expressed expectations for food to be served at appropriate temperatures and to be visually and tastefully appealing, indicating a disconnect between expectations and the actual service provided.
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper documentation and adherence to food safety protocols during meal service. During an initial tour of the facility's kitchen, it was observed that the meal service temperature logs for lunch were documented before the food was placed on the steam table. The Dietary Manager and staff confirmed that this practice was unacceptable and acknowledged that meal service temperatures should only be recorded when the food is placed on the steam table. Dietary Staff #15 admitted to pre-filling the temperature logs based on assumptions rather than actual measurements, despite knowing the importance of accurate temperature documentation to ensure food safety. Additionally, the facility failed to maintain proper hand hygiene during meal preparation. Dietary Staff #14 was observed wearing gloves while handling various surfaces and then preparing food without changing gloves. The staff member touched her clothing and continued food preparation without changing gloves or washing hands, which was against the facility's policy. Both the Dietary Manager and the Director of Nursing expressed that they expected staff to change gloves when necessary, especially after touching clothing or other surfaces, to prevent contamination.
Deficiency in Resident Room Size Compliance
Penalty
Summary
The facility failed to ensure that resident rooms met the required square footage per resident, as outlined in their policy and federal and state requirements. Specifically, 19 out of 23 resident rooms did not provide the minimum 80 square feet per resident in multiple occupancy rooms. The Client Accommodations Analysis, signed by the Maintenance Supervisor, documented that several rooms provided less than the required space, with measurements ranging from 70 to 78 square feet per resident. Interviews with facility staff, including the Maintenance Supervisor, Director of Nursing, and Administrator, revealed a lack of awareness or concern regarding the room sizes. The Maintenance Supervisor mentioned that waivers were in place for some rooms, and no complaints had been received from staff or residents. Similarly, the Director of Nursing and Administrator reported no complaints about room sizes, and the Administrator stated that as long as residents were comfortable and staff could provide care, he did not see an issue with the room sizes.
Medication Administration Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by observations during medication administration. Out of 28 opportunities, there were 3 medication errors, resulting in a 10.71% error rate. This affected two residents, one of whom was administered atenolol without the required blood pressure check, and another who received lisinopril and amlodipine without a pulse check. Resident #9, admitted in 2017 with a history of hypertension, had an order for atenolol with specific instructions to hold the medication if the systolic blood pressure was below 110 mmHg or the pulse was below 60 BPM. On a specific date, an LVN administered atenolol after checking only the resident's pulse, which was 84 BPM, but failed to check the blood pressure as required by the order. The LVN later acknowledged the oversight, realizing the need to read the full order and obtain all necessary vital signs. Resident #32, admitted in 2020 with chronic ischemic heart disease and hypertension, had orders for lisinopril and amlodipine with instructions to hold the medications if the pulse was below 60 BPM, SBP below 110 mmHg, or DBP below 60 mmHg. An LVN administered these medications after checking only the blood pressure, which was 122/78 mmHg, without obtaining the pulse. The LVN admitted to not checking the pulse, as the MAR only prompted for a blood pressure reading. Both the DON and the Administrator emphasized the importance of following physician orders and obtaining all necessary vital signs before medication administration.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors during medication administration. For Resident #9, the facility did not obtain the required vital signs before administering atenolol, an antihypertensive medication. The order specified that the medication should be held if the resident's pulse was less than 60 BPM or if the systolic blood pressure was less than 110 mmHg. However, the Licensed Vocational Nurse (LVN) administering the medication did not check the resident's blood pressure, as the electronic Medication Administration Record (MAR) only prompted for the pulse. This oversight was acknowledged by the LVN and the Director of Nursing (DON), who stated that all necessary vital signs should be obtained prior to medication administration. Resident #32 also experienced a similar issue where the facility did not obtain all required vital signs before administering lisinopril and amlodipine, both antihypertensive medications. The orders required that the medications be held if the resident's pulse was less than 60 BPM, systolic blood pressure was less than 110 mmHg, or diastolic blood pressure was less than 60 mmHg. During an observation, the LVN only obtained the resident's blood pressure and not the pulse, as the MAR only prompted for the blood pressure. The DON reiterated the importance of obtaining all necessary vital signs and following physician orders. For Resident #19, the facility failed to hold medications when the resident's vital signs were outside the physician-ordered parameters. The resident's MAR indicated that medications such as diltiazem, metoprolol tartrate, and hydrochlorothiazide should be held if the systolic blood pressure was less than 110 mmHg, diastolic blood pressure was less than 65 mmHg, or the pulse was less than 60 BPM. Despite this, the medications were administered on multiple occasions when the vital signs did not meet these parameters. Interviews with the LVNs involved revealed that they were aware of the parameters but did not hold the medications as required. The DON emphasized the importance of adhering to physician orders to ensure resident safety.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. Resident #46 was reported to have intact cognition and the use of a hearing aid in both annual and quarterly MDS assessments. However, interviews with the resident and staff revealed that the resident did not have hearing aids, contrary to what was documented. The MDS Coordinator and the Director of Nursing (DON) were unaware of this discrepancy, indicating a lack of communication and verification in the assessment process. Resident #69 was documented in the MDS assessment as having been discharged to a short-term general hospital. However, progress notes and a signed statement indicated that the resident left the facility against medical advice (AMA). The MDS Coordinator admitted to selecting the wrong discharge disposition, and the DON acknowledged the error, highlighting a failure in ensuring the accuracy of discharge information. Both cases demonstrate a deficiency in maintaining accurate resident assessments as per the facility's policy.
Inaccurate PASRR Submission for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a history of serious mental illness. The resident, admitted on 07/25/2024, had a medical history that included bipolar disorder, major depressive disorder, and anxiety disorder. Despite these diagnoses and the use of psychotropic medications, the PASRR Level I Screening dated 07/25/2024 indicated negative results for serious mental illness, failing to include the resident's actual diagnoses and medication use. Interviews with facility staff revealed a lack of a formal policy for PASRR, with reliance on a letter from the State Department of Health Care Services for guidance. The admissions department received the PASRR from the hospital, which was then reviewed by the Assistant Director of Nursing and Director of Nursing. However, the MDS Coordinator, responsible for ensuring the accuracy of the PASRR, admitted to missing the inaccuracies in the resident's Level I PASRR. The Director of Business Development and Marketing stated her role was limited to obtaining the Level I PASRR prior to admission, while the MDS Coordinator was tasked with reviewing it for accuracy. The Director of Nursing acknowledged issues with hospitals related to PASRRs, often requiring resubmission due to inaccuracies. The facility's Administrator confirmed that the interdisciplinary team should have reviewed the PASRR for accuracy upon receipt and resubmitted it if found inaccurate, which did not occur in this case.
Failure to Revise Resident's Care Plan
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #15, who was admitted with a medical history of hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, affecting the left nondominant side, and a contracted left hand. The care plan, which was supposed to be comprehensive and person-centered, included interventions for lymphedema and limited mobility that were outdated and no longer relevant to the resident's current condition. Despite the resident's intact cognition and ability to communicate, the care plan had not been updated to reflect the resident's current needs, such as the absence of a brace for the left wrist and fingers and the lack of range-of-motion exercises. Interviews with staff revealed that CNAs were not performing range-of-motion exercises on the resident's left hand due to contractures, and there was no documentation of such exercises in the resident's electronic medical record. The MDS Coordinator and the Director of Nursing acknowledged that the care plan should have been revised to reflect the resident's current status, including the removal of interventions related to a brace, assistive device, ROM, and compression stockings. The Administrator also confirmed that care plans should be updated when a resident's status changes, indicating a lapse in the facility's adherence to its policy on maintaining current and relevant care plans.
Failure to Provide Fortified Food for Nutritional Supplementation
Penalty
Summary
The facility failed to provide fortified food intended for nutritional supplementation to a resident diagnosed with protein-calorie malnutrition. The resident, who had a medical history including hyperlipidemia, peripheral vascular disease, hypertension, and other conditions, was admitted with a nutritional risk. The Registered Dietician recommended fortifying the resident's diet to prevent further weight loss. However, the Speech Language Pathologist did not include the high protein/fortified portion in the diet order, and the Dietary Manager was unaware of the need for fortified foods. The deficiency was identified during interviews and record reviews, which revealed that the diet order for high protein/fortified foods was not entered into the system. The Director of Nursing and the Administrator both expressed expectations that staff should ensure diet orders are correctly entered and residents receive the appropriate diet. Despite these expectations, the oversight resulted in the resident not receiving the necessary fortified foods as part of their nutritional care plan.
Failure to Monitor Nebulizer Treatment
Penalty
Summary
The facility failed to provide proper monitoring during the administration of a nebulizer treatment for a resident with chronic obstructive pulmonary disease (COPD) and other respiratory conditions. The facility's policy required staff to remain with the resident during the treatment, monitor for side effects, and ensure the medication was fully administered. However, observations revealed that the resident was left unattended during nebulizer treatments, with the nurse leaving the room before the medication was completely nebulized. The resident, who had a medical history of COPD, pneumonia, and shortness of breath, was observed on multiple occasions with a nebulizer machine on the nightstand and a medication cannister that was not fully utilized. On one occasion, the resident reported not receiving a nebulizer treatment that day, despite the medication cannister being partially full. This indicated a lack of adherence to the prescribed treatment schedule and monitoring requirements. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy required nurses to stay with the resident during nebulizer treatments to ensure the medication was administered effectively and to monitor the resident's response. The failure to adhere to these procedures resulted in a deficiency in providing safe and appropriate respiratory care for the resident.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure prescribed medications were available for two residents, leading to a deficiency in pharmaceutical services. Resident #2, who was admitted with a history of hypertensive heart disease and depression, did not receive their prescribed medications, escitalopram and prazosin, on multiple occasions. The Medication Administration Record (MAR) indicated that these medications were coded as 'Other,' meaning they were not administered due to pending pharmacy delivery. Despite the resident's statement that they had not refused any medications, the medications were not available on the medication cart, and the staff failed to follow the facility's policy for obtaining medications from the pharmacy or using the emergency medication kit. Resident #29, who had a history of major depressive disorder, also experienced a lack of medication availability. The resident's prescribed medications, including clonazepam, alpha-lipoic acid, and FiberChoice, were not administered as they were pending delivery from the pharmacy. The MAR and progress notes documented that these medications were on hold or coded as 'Other' due to unavailability. The central supply person informed the nurse that FiberChoice was not on the formulary list, and the nurse was expected to contact the physician for an alternative or order the medication from the pharmacy, which was not done in a timely manner. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility's protocol required nurses to contact the pharmacy, physician, and DON if medications were not available. They were also expected to follow up until the medications were received. However, this protocol was not adequately followed, resulting in the residents not receiving their prescribed medications on time. The deficiency highlights a failure in the facility's medication management and communication processes.
Failure to Transcribe Physician Orders for Vital Signs
Penalty
Summary
The facility failed to ensure that physician orders for vital signs were accurately transcribed to the medication administration records (MAR) for two residents during medication administration. Resident #9, who was admitted with a diagnosis of primary hypertension and had moderate cognitive impairment, had an order for atenolol with specific instructions to monitor blood pressure and pulse before administration. However, the MAR only prompted staff to document the resident's pulse, leading to a lack of blood pressure monitoring prior to administering the medication. This oversight was identified when a Licensed Vocational Nurse (LVN) realized the full order required blood pressure monitoring as well. Similarly, Resident #32, with a history of primary hypertension and chronic ischemic heart disease, had orders for lisinopril and amlodipine that required monitoring of both blood pressure and pulse. The MAR, however, only prompted for blood pressure documentation, resulting in the omission of pulse monitoring. LVN #13 administered the medications without obtaining the resident's pulse, as she was unaware of the complete order requirements. Both instances highlight a failure in the transcription process and understanding of the complete physician orders, leading to potential medication administration errors.
Failure to Maintain Daily Staffing Records
Penalty
Summary
The facility failed to maintain copies of the posted direct care daily staffing numbers, which had the potential to affect all residents residing in the facility. According to the facility's policy, revised in August 2022, the facility was required to post daily nursing staff data for each shift and maintain these records for a minimum of eighteen months or as required by state law. However, during an interview, the Staffing Coordinator admitted that she did not have the daily staffing postings for the period from July 23, 2024, through July 30, 2024, due to a glitch in their system. Although she handwrote the staffing numbers, she did not keep the forms. The Administrator confirmed that the daily staffing postings should be kept for at least a year for the facility's annual PPD review from the State and should be accurate, maintained together, and organized.
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What surveyors actually found near you
We read the 70 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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 Merced
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Merced Nursing & Rehabilitation Ctr | 0.1 mi | ★★★★★ | 1 | 0 |
| Golden Merced Care Center | 0.3 mi | ★★★★★ | 4 | 0 |
| Franciscan Post-acute Care Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Merced Behavioral Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Anberry Post Acute | 3 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.