Above average — CMS composite of the measures below.
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 Valley Rehab Center during CMS and state inspections, most recent first.
A resident with a chronic indwelling catheter and history of UTIs did not receive a physician-ordered urinalysis because an LVN failed to enter the order, resulting in a delay of care. Facility policy requires nurses to promptly and accurately enter new physician orders into the MAR/eMAR.
The facility failed to provide binding Arbitration Agreements in a form and manner that three Spanish-speaking residents could understand, leading them to sign without comprehending the implications. The agreements were presented in English, contrary to the facility's policy requiring translation for populations with limited English proficiency exceeding 5%.
The facility failed to follow infection control protocols, including not placing a symptomatic resident on Droplet Isolation Precautions, not dating or timing oxygen and nebulizer tubing, improperly managing a suction machine, and neglecting hand hygiene before meals.
The facility failed to provide adequate dining room accessibility and space for its 132 residents. Observations revealed that the dining room door was locked, limiting access, and the space could only accommodate a small number of residents at a time. Residents were observed waiting in the hallway for their turn to dine, as the dining room could not accommodate more than eight residents simultaneously. The Administrator acknowledged the issue, and no policy addressing dining room space was provided.
A facility failed to accurately complete the MDS for a resident by incorrectly coding Aspirin as an anticoagulant. The MDS consultant confirmed the error, and the MDS nurse acknowledged the mistake. This inaccuracy could potentially affect the resident's care, as the MDS is crucial for establishing person-centered care needs.
A facility failed to implement communication interventions for a Spanish-speaking resident, who was at risk for impaired communication. The resident's care plan lacked interventions despite goals for communication being set. The resident expressed difficulty in communicating with English-speaking staff and preferred communication in her language. A Registered Nurse Consultant confirmed the requirement for interventions in care plans, which was not met.
A resident was administered Potassium Chloride ER tablets inappropriately when an LVN crushed the tablets and mixed them with applesauce, contrary to guidelines that specify extended-release tablets should not be crushed. The DON confirmed the error, and a pharmacist reiterated that Potassium ER should not be crushed, aligning with the facility's policy against crushing such medications.
A facility failed to implement a physician's wound treatment orders for a resident's right heel blister. The physician ordered cleansing with normal saline and Betadine application twice daily, but the order was not recorded or carried out. The facility's policy requires immediate recording and implementation of such orders, which was not followed in this case.
A resident with documented hearing loss was not provided with hearing aids as recommended by an audiogram. Facility staff were unaware of the recommendation, and the facility's policy to ensure access to necessary adaptive equipment was not followed.
A facility failed to follow its policy for labeling IV tubing, as observed during an interview with an LVN. The IV tubing for a resident was not labeled with the date, time, and initials of the person who hung it, contrary to the facility's policy. This policy aims to prevent infections associated with contaminated IV therapy equipment, and it requires that any unlabeled tubing be changed and labeled.
The facility failed to complete the required annual competency for a CNA. The CNA was hired and completed their initial orientation and competency checklist shortly after hiring. However, the Director of Staff Development could not provide documentation of the CNA's 2024 annual competency, indicating it was not completed as required.
A cook in the facility failed to follow the standardized recipe for Zesty Spinach by adding unmeasured amounts of ingredients, contrary to the facility's food preparation policy. The cook admitted to not using the recipe and relying on taste, which was confirmed as incorrect by the Certified Dietary Manager.
A resident with hemiplegia did not receive necessary adaptive feeding devices as specified on their meal ticket, despite facility policies requiring such provisions. The oversight was confirmed by both the Registered Dietician and Certified Dietary Manager, highlighting a deficiency in care.
A facility failed to follow its smoking policy for a resident, as tobacco was found at the bedside without a completed smoking care plan or assessment. Staff confirmed that tobacco should be locked up, and the DON acknowledged the absence of necessary evaluations. The facility's policy requires smoking evaluations and care plans, which were not adhered to in this case.
The facility did not meet the required minimum square footage for resident rooms, affecting 20 out of 48 bedrooms. Rooms intended for multiple residents were below the 80 square feet per resident requirement, with measurements showing insufficient space. The Administrator acknowledged the deficiency but noted that residents had adequate privacy and storage. No previous room waiver was available.
A resident with severe cognitive impairment was verbally abused by his roommate, who had intact cognition, for over a year. The abuse included derogatory remarks and racial slurs, which were known to staff but not reported to the Administrator or DON as required by facility policy. The resident's condition improved after being moved to a different room.
A resident with severe cognitive impairment was subjected to persistent verbal abuse by a roommate with intact cognition. Despite staff awareness, the abuse was not reported to the Administrator as required by facility policy. The resident, who suffers from quadriplegia and dysphasia, showed signs of distress during the period of abuse but improved after being moved to a different room. Staff interviews confirmed the failure to report the abuse, which violated the facility's procedures.
The facility did not follow its policy for timely reporting a resident-to-resident abuse incident to the CDPH. An altercation occurred where a moderately cognitively impaired resident kicked a severely cognitively impaired resident. The incident was not reported within the required two-hour timeframe, leading to a 48-hour delay. The Administrator was unaware of the incident until two days later, and the Social Services Director confirmed the reporting lapse.
A facility failed to follow a resident's care plan by not using a mesh stop sign intended to prevent wandering residents from entering the room. This oversight was confirmed by a CNA and the SSD, despite the care plan's directive following an incident of inappropriate touching. The facility's policy emphasizes maintaining residents' well-being, which was not upheld in this case.
A facility failed to implement a physician's order to increase a resident's Xanax dosage to 1 mg three times a day. Instead, the resident continued to receive 1 mg twice daily due to a communication lapse by the Social Service Director, who did not relay the updated order to nursing staff. This oversight was contrary to the facility's medication administration policy.
A facility failed to complete competency evaluations for an LVN before allowing independent medication administration. The LVN's skills checklist was incomplete, yet they worked across all stations providing care. The facility's policy requires competency validation during onboarding, which was not adhered to, as confirmed by the DSD and Administrator.
A facility failed to document medication administration timely for a resident, leading to potential inaccuracies in medical records. A resident reported not receiving medications on time, and a review showed Levothyroxine Sodium was documented 10 days late by an ADON, contrary to policy requiring immediate documentation.
A resident with mobility issues and a care plan requiring a Hoyer lift for transfers experienced multiple falls and injuries due to staff not adhering to the care plan. Despite being assessed as dependent on assistance, staff used inappropriate transfer methods, leading to significant injuries, including broken bones and the need for surgery.
A facility failed to implement nutritional interventions for a resident as recommended in a Nutritional Risk Assessment. The assessment suggested adding a nutritional supplement, protein supplement, zinc, and vitamin C. During a review, the DON could not provide evidence of these recommendations being carried out, acknowledging they should have been addressed within 72 hours. The facility's policy required the FNS Director or Dietitian to complete dietary recommendations within three days.
A facility failed to implement a care plan for a resident at high risk for falls. The care plan required a bed alarm, but during an observation, the resident did not have one. Interviews with the ADON and MDSC confirmed the resident's fall risk and attempts to get out of bed. The resident's fall risk assessment showed a high score, and the ADON acknowledged the care plan was not followed.
A facility failed to ensure a resident's call light was within reach, as it was found hanging on the wall behind the bedside drawer. The resident, who had severe cognitive impairment and bilateral above-the-knee amputation, was unable to locate the call light. A CNA confirmed the call light was not accessible, contrary to the facility's policy requiring call lights to be within reach.
Failure to Enter and Implement Physician Order for Urinalysis
Penalty
Summary
A deficiency occurred when a physician ordered a urinalysis (UA) for a resident with a chronic indwelling catheter and a history of urinary tract infections (UTIs) due to the presence of spasms. The order was discussed with nursing staff on the date of service, but the Licensed Vocational Nurse (LVN) assigned to the resident did not enter the physician's order into the system. As a result, the urinalysis was not ordered or collected as required. Review of facility policy confirmed that nurses are responsible for promptly and accurately entering new physician orders into the Medication Administration Record (MAR/eMAR). This failure led to a delay in care for the resident.
Failure to Provide Arbitration Agreements in Residents' Preferred Language
Penalty
Summary
The facility failed to ensure that the binding Arbitration Agreement (AA) was presented in a form and manner that residents could understand, specifically for three residents who primarily spoke Spanish. The AAs were provided in English, which the residents could not read or understand. This led to the residents signing the agreements without comprehending their implications. Interviews with the residents revealed that they did not know what an arbitration agreement was and did not remember signing it. The facility's policy required that vital information be translated if the limited English proficiency population exceeded 5%, which was the case here. The Admission Coordinator acknowledged that the AAs were written in English, which hindered Spanish-speaking residents from reviewing the agreements to decide if they wanted to rescind them within the 30-day period allowed. The facility's policy on Binding Arbitration Agreements emphasized the importance of explaining the terms and conditions in a manner that residents understand, considering their language and literacy. Despite this, the facility did not provide the AAs in Spanish, failing to adhere to their own policy and procedures, and potentially compromising the residents' ability to make informed decisions.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control standards in several instances. One resident, who exhibited flu-like symptoms and was treated with influenza medication, was not placed under Droplet Isolation Precautions. Despite being symptomatic and receiving medications like Tamiflu and Xofluza, there was no documentation or evidence that isolation precautions were implemented to protect staff and visitors, as confirmed by the Director of Nursing and the Infection Preventionist. Additionally, two residents requiring oxygen therapy had issues with their equipment. The oxygen and nebulizer tubing for these residents were not dated or timed, and in one case, the oxygen tubing was found on the floor uncovered. The facility's policy required these items to be changed weekly and labeled, but this was not followed, as noted by the Licensed Vocational Nurse during observations. Another resident using a portable suction machine had the suction canister and tip improperly managed. The canister was not labeled or dated, and the suction tip was left uncovered on the bedside table. The facility's policy required the canister to be changed twice a week and the tip to be covered, but these procedures were not adhered to. Furthermore, a resident was not provided hand hygiene before being served lunch, contrary to the facility's hand hygiene policy.
Inadequate Dining Room Accessibility and Space
Penalty
Summary
The facility failed to ensure that the dining room was accessible and had adequate space to accommodate the 132 residents residing at the facility. During observations and interviews, it was noted that the dining room door was closed and had a coded lock, restricting resident access. The dining room contained seven round tables with a seating chart for 15 residents, but typically only accommodated around eight residents at a time. Residents were observed waiting in the hallway for their turn to enter the dining room, as the space could not accommodate more than eight residents at once. The Assistant Director of Nursing (ADON) confirmed that the facility lacked the space to accommodate more residents in the dining room simultaneously. Further observations revealed that the dining room door remained closed and locked, preventing residents from freely accessing the space. The Certified Dietary Manager (CDM) was unsure why the door was locked and confirmed that the dining room could not accommodate the additional residents waiting in the hallway. The Administrator acknowledged that the dining room should not have a closed, locked door and should be a common space allowing residents to come and go. A policy and procedure addressing dining room space was requested but not provided, indicating a lack of formal guidelines to ensure adequate dining accommodations for all residents.
Inaccurate MDS Coding for Resident's Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one of the residents, identified as Resident 47. During an interview and record review, it was discovered that the MDS-Section N-Medications for Resident 47, dated January 6, 2025, incorrectly coded Aspirin as an anticoagulant. The Medication Administration Record (MAR) for February 2025 did not provide documentation that Resident 47 was on anticoagulant medications. The MDS consultant confirmed that Aspirin, which was prescribed to Resident 47, should not have been coded as an anticoagulant on the MDS. The MDS nurse acknowledged the mistake in coding Aspirin as an anticoagulant. The CMS Resident Assessment Instructions Manual specifies that anticoagulant medications such as warfarin, heparin, or low-molecular weight heparin should be coded if taken by the resident during the 7-day look-back period. However, antiplatelet medications like Aspirin should not be coded as anticoagulants. The failure to accurately code the medication could potentially lead to Resident 47 not receiving care based on his specific needs, as the MDS is a tool used to collect data to establish person-centered care needs.
Failure to Implement Communication Interventions for Spanish-Speaking Resident
Penalty
Summary
The facility failed to develop and implement communication interventions for Resident 329, who is at risk for impaired communication due to her primary language being Spanish. The care plan report for Resident 329 indicated goals for communication, such as being able to make needs known and having no declines in communication, but did not list any interventions to achieve these goals. This omission was identified during a review of the care plan report. During an interview, Resident 329, who only speaks Spanish, expressed that English-speaking staff sometimes did not understand her, and she did not understand them. Although staff used an interpreter to communicate with her, Resident 329 preferred to have someone who could speak her language directly. The Registered Nurse Consultant confirmed that care plans are required to have interventions listed, which was not the case for Resident 329. The facility's policy and procedure for comprehensive person-centered care plans also emphasized the need for interventions to address the underlying sources of problem areas, which was not adhered to in this instance.
Improper Administration of Potassium Chloride ER Tablets
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for one resident. During an observation, an LVN was seen preparing to administer Potassium Chloride ER tablets to a resident by crushing them and mixing them with applesauce. This action was contrary to the medication's administration guidelines, which specify that extended-release tablets should not be crushed, as it can alter the medication's intended release and effectiveness. The LVN did not verify the medication's form against the resident's Medication Administration Record (MAR) and Order Listing Report (OLR), which did not specify the extended-release form. The Director of Nursing (DON) confirmed that the LVN should have clarified the discrepancy between the medication package and the MAR/OLR and should not have crushed the extended-release tablets. A pharmacist also confirmed that Potassium ER tablets should not be crushed. The facility's policy and procedure documents further supported that medications like extended-release tablets should not be crushed, and alternative forms should be sought if necessary. This failure had the potential to impact the resident's treatment for hypokalemia by not delivering the medication as intended.
Failure to Implement Physician's Wound Treatment Orders
Penalty
Summary
The facility failed to implement its policy and procedure for handling physician orders, specifically for a resident identified as Resident 126. The deficiency occurred when the wound treatment orders for Resident 126's right heel blister were not implemented. During an interview and record review, it was found that the physician had ordered a specific wound treatment on 2/19/25, which included cleansing the blister with normal saline, patting it dry, and applying Betadine twice a day. However, this order was not recorded in the resident's medical record, and the treatment was not carried out. The facility's policy requires that telephone and verbal orders be recorded and implemented immediately, with the nurse taking the order signing it with a full signature. The policy also mandates that all physician orders be complete and clearly defined to ensure accurate implementation. In this case, the registered nurse consultant confirmed that the physician's order for the wound treatment was not documented or implemented, leading to a failure in providing necessary wound care for Resident 126.
Failure to Provide Hearing Aids for Resident
Penalty
Summary
The facility failed to provide hearing aids for Resident 22, which was identified as a deficiency. The resident had an initial ENT consultation on June 11, 2024, where difficulty hearing and stuffy ears were noted, and an audiogram was recommended. The audiogram, conducted on July 10, 2024, confirmed that Resident 22 had a significant hearing loss that qualified them for hearing aids, particularly noting greater difficulty in the right ear. Despite these findings, Resident 22 reported not having hearing aids and not being seen by a hearing doctor recently. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's need for hearing aids. The Social Service Director Case Manager and Social Services staff both stated they were unaware of the audiogram's recommendation for hearing aids. The facility's policy on hearing and vision services mandates that residents receive necessary adaptive equipment, and the social worker is responsible for assisting residents in accessing these services. However, this policy was not followed, resulting in the deficiency.
Failure to Label IV Tubing as per Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the administration of intravenous (IV) fluids, specifically in the case of one resident. During an observation and interview with a Licensed Vocational Nurse (LVN), it was noted that the IV tubing for a resident was not labeled as required. The LVN acknowledged that the tubing should have been labeled with the date, time, and initials of the person who hung the IV tubing. A review of the facility's policy, dated February 2023, confirmed that the tubing should be labeled to prevent infections associated with contaminated IV therapy equipment. The policy also stated that any unlabeled tubing must be changed and labeled accordingly.
Failure to Complete Annual Competency for CNA
Penalty
Summary
The facility failed to ensure that annual competencies were completed for one of the five sampled Certified Nursing Assistants (CNA). During an interview and record review with the Director of Staff Development (DSD), it was found that CNA 1, who was hired on December 26, 2023, had completed their new employee orientation and competency checklist by December 27, 2023. However, the DSD was unable to provide documentation of a 2024 annual competency for CNA 1, indicating that it had not been completed as required. The facility was also unable to provide the requested policy related to this requirement.
Failure to Follow Recipe in Food Preparation
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Food Preparation' when a cook did not measure recipe ingredients as required. During an observation and interview, it was noted that the cook, while preparing spinach to be pureed, added unmeasured amounts of garlic powder, iodized salt, chili powder, and melted butter, instead of following the specified recipe for Zesty Spinach. The cook admitted to not using the recipe and relying on taste instead. The Certified Dietary Manager confirmed that the cook should have followed the recipe and measured the spices as indicated. The facility's policy requires food to be prepared using approved recipes that are standardized to meet the resident census, with specific instructions on portion yield, preparation methods, ingredient quantities, and time and temperature guidelines.
Failure to Provide Assistive Feeding Devices
Penalty
Summary
The facility failed to provide necessary assistive feeding devices for a resident, identified as Resident 72, who required them due to hemiplegia following a stroke. During an observation, it was noted that Resident 72's lunch tray lacked the adaptive equipment specified on the meal ticket, such as a two-handle sip cup and special spoons. The resident confirmed not having received these items for some time. The Registered Dietician and Certified Dietary Manager acknowledged that the adaptive devices listed on the meal ticket were not provided, despite being responsible for ensuring the correct equipment was included with meals. Further review of Resident 72's records revealed that occupational therapy had recommended specific adaptive equipment to aid in self-feeding, including a universal cuff, built-up utensils, and a plate guard. These recommendations were documented in the resident's treatment notes and order listing report. The facility's policy on assistive devices emphasized the provision of specialized eating utensils to support resident independence, yet this policy was not followed in Resident 72's case, leading to a deficiency in care.
Failure to Implement Smoking Policy for Resident
Penalty
Summary
The facility failed to implement its Policy and Procedure (P&P) titled 'Smoking' for one of the residents, identified as Resident 4. During an observation, it was noted that Resident 4 had a can of tobacco at the bedside, which was against the facility's policy that requires tobacco to be locked up. Licensed Vocational Nurse (LVN) 4 confirmed that the tobacco should not have been left at the bedside. Additionally, the facility did not complete a smoking care plan or smoking assessment for Resident 4, which are necessary to ensure safe smoking practices. Interviews with staff and family members further highlighted the oversight. The Activities Assistant mentioned that Resident 4 should not have full access to his chewing tobacco as it could lead to excessive use. The Director of Nursing (DON) confirmed that there was no tobacco use care plan or safe smoking evaluation for Resident 4, which should have been in place. A family member also noted that Resident 4's tobacco pouches were usually at the bedside, indicating a lack of adherence to the facility's smoking policy. The facility's P&P requires a smoking evaluation upon admission and regular reevaluations, with any smoking-related privileges or restrictions noted in the care plan, none of which were completed for Resident 4.
Facility Fails to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum square footage required by regulation in 20 out of 48 facility bedrooms. During an observation and interview with the Environmental Services Director (ESD), it was noted that multiple occupancy rooms did not meet the required 80 square feet per resident. Measurements of these rooms revealed that they were significantly below the required space, with rooms housing three residents each but only providing between 208 and 219 square feet in total. The Administrator confirmed that there had been no changes to the room sizes or the facility floor plan since the previous survey. Despite the deficiency in room size, the Administrator stated that residents had a reasonable amount of privacy, adequate storage, and sufficient space for ambulation or wheelchair use. However, the facility was unable to provide a copy of a previous room waiver, indicating a lack of documentation to justify the current room sizes.
Failure to Protect Resident from Verbal Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident from verbal abuse inflicted by his roommate. The resident, who had severe cognitive impairment and was unable to speak, was subjected to verbal aggression and derogatory remarks by his roommate, who had intact cognition. The abuse included being called a pedophile, racial slurs, and other derogatory terms. This situation persisted for approximately one year and seven months while the two residents shared a room. Interviews with staff members, including CNAs, LVNs, and the Director of Staff Development, revealed that the abusive behavior was known among the staff. Despite this, the verbal abuse was not reported to the Administrator or the Director of Nursing as required by the facility's policy. Staff members noted that the resident's condition improved after being moved to a different room, indicating the negative impact of the abuse on his well-being. The facility's policies on abuse reporting and behavioral assessment were not followed, as the staff failed to report the abuse immediately. The facility's policy required that any suspicion of abuse be reported to the Administrator and other officials according to state law. The failure to report and address the verbal abuse in a timely manner resulted in the resident experiencing agitation, restlessness, and difficulty sleeping, with the potential for psychosocial harm.
Failure to Report Verbal Abuse in LTC Facility
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting of verbal abuse, resulting in a deficiency. Resident 1, who has severe cognitive impairment and is unable to speak, was subjected to persistent verbal abuse by his roommate, Resident 2, who has intact cognition. Despite multiple staff members being aware of the verbal abuse, it was not reported to the Administrator as required by the facility's policy. Resident 1, who suffers from quadriplegia and dysphasia following a cerebral infarction, shared a room with Resident 2 for approximately one year and seven months. During this time, Resident 2 frequently directed verbal abuse towards Resident 1, including calling him derogatory names and using racial slurs. Staff members, including CNAs and LVNs, observed these interactions and noted that Resident 1 appeared more comfortable and rested after being moved to a different room. Interviews with various staff members, including CNAs, LVNs, the Social Service Director, and the Director of Staff Development, revealed that the verbal abuse was known but not reported to the Administrator or the Director of Nursing. The facility's policy requires that any suspicion of abuse be reported immediately to the Administrator, but this protocol was not followed. The failure to report the abuse allowed the situation to persist, impacting Resident 1's well-being.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely reporting of a resident-to-resident abuse allegation to the California Department of Public Health (CDPH). An incident occurred involving two residents, where one resident, who was moderately cognitively impaired, kicked another resident with severe cognitive impairment during an argument. This incident was not reported to the CDPH within the required timeframe as outlined in the facility's policy, which mandates immediate reporting within two hours for allegations involving abuse or resulting in serious bodily injury. The deficiency was identified during interviews and record reviews. The Administrator was unaware of the incident until two days after it occurred, indicating a lapse in communication and reporting procedures. The Social Services Director confirmed that the staff should have notified the abuse coordinator immediately, and the incident should have been reported to the CDPH as per the facility's policy. This oversight resulted in a delay of approximately 48 hours before the incident was reported to the appropriate authorities.
Failure to Implement Care Plan for Resident Safety
Penalty
Summary
The facility failed to ensure that the care plan for a resident was followed, specifically regarding the use of a mesh stop sign intended to deter wandering residents from entering the resident's room. The care plan, which was undated, included an intervention to place a bright-colored stop sign at the entrance of the resident's room due to an incident on 12/3/24 where the resident was allegedly inappropriately touched by another resident. During an observation and interview on 12/30/24, it was noted that the mesh stop sign was not in use, which was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that the sign should have been in place. The Social Service Director (SSD) also confirmed that the stop sign should always be used to prevent wandering residents from entering the room. The facility's policy on comprehensive, person-centered care plans emphasizes the importance of services that maintain the resident's highest practicable well-being, which was not adhered to in this instance.
Failure to Implement Physician Orders for Medication Dosage
Penalty
Summary
The facility failed to ensure that physician orders were implemented correctly for a resident, resulting in the resident not receiving the prescribed medication dosage. The physician's order, dated December 11, 2024, indicated that the resident's Xanax dosage should be increased to 1 mg three times a day. However, the Order Summary Report from December 30, 2024, showed that the resident was still receiving Xanax 1 mg twice a day, as per an earlier order from October 24, 2024. The Medication Administration Record for December 2024 confirmed that the resident was administered Xanax 1 mg twice daily. During an interview, the Social Service Director admitted to receiving the updated physician order but failing to communicate it to the nursing staff, which led to the resident not receiving the correct dosage as per the updated order. The facility's policy on administering medications requires that medications be administered according to prescriber orders, which was not followed in this case.
Incomplete Competency Evaluation for LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) had completed the necessary competency evaluations before independently providing care to residents. The LVN Competency Skills Checklist for LVN 1 was found to be incomplete, lacking validation in several critical areas such as effective communication, nursing process utilization, emergency procedures, medication administration, and pain management. Despite these incomplete competencies, LVN 1 was assigned to work across all three stations in the facility, administering medications to residents without direct supervision. Interviews with the Director of Staff Development and the facility Administrator confirmed that LVN 1's competencies were not completed as required by the facility's policy. The policy, dated December 31, 2015, mandates that all competencies must be validated during the onboarding period, which is the first 90 days of employment, before a nurse can perform skills independently. The Administrator acknowledged that LVN 1 should not have been passing medications independently without completed competencies, indicating a lapse in adherence to the facility's procedures for ensuring staff competency.
Failure to Document Medication Administration Timely
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for one resident, leading to potential inaccuracies in the resident's medical record. During an interview, a resident reported not receiving her scheduled 6 a.m. medications on time. A review of the Administration History (AH) for another resident revealed that Levothyroxine Sodium, a thyroid medication, scheduled for administration on December 9th, was not documented until December 19th by the Assistant Director of Nursing (ADON). The ADON admitted to administering the medication on the scheduled date but failed to document it immediately, as required by the facility's policy and procedure for administering medications. The policy mandates that the individual administering the medication must initial the resident's Medication Administration Record (MAR) immediately after giving each medication and before administering the next ones. This lapse in documentation could lead to inaccuracies in the resident's medical records, as the medication was documented 10 days after it was administered.
Failure to Implement Care Plan Leads to Resident Injuries
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident requiring assistance with activities of daily living (ADL), specifically in the use of a Hoyer lift for transfers. Despite the care plan indicating the necessity of a Hoyer lift, the resident was transferred using alternative methods, such as a sliding board and standing pivot, which were not appropriate for their condition. This led to multiple falls, resulting in significant injuries, including two broken bones in each lower leg, necessitating surgical intervention. The resident, who was readmitted with diagnoses including difficulty in walking, muscle wasting, and generalized muscle weakness, was assessed as being dependent on assistance for transfers. The care plan specified the use of a Hoyer lift, yet staff members, including a CNA, reported using a gait belt and other methods for transfers. The resident experienced falls during these transfers, with one incident involving the resident being asked to stand and use a walker, leading to a fall when the resident expressed feeling tired and weak. Interviews with staff revealed a lack of adherence to the care plan, with conflicting instructions from therapy and nursing staff regarding transfer methods. The resident, who was cognitively intact, reported that the Hoyer lift was never used, and staff continued to use inappropriate transfer techniques, resulting in further falls and injuries. The facility's failure to follow the established care plan and ensure the use of the Hoyer lift as required contributed directly to the resident's injuries.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to implement nutritional interventions for a resident, as identified in a Nutritional Risk Assessment (NRA) dated September 6, 2024. The NRA recommended the addition of a nutritional supplement (Boost) 4oz daily, a protein supplement (Prostat) 30ml, zinc, and vitamin C. During an interview and record review on October 1, 2024, the Director of Nursing (DON) was unable to provide evidence that these nutritional recommendations were implemented. The DON acknowledged that the recommendations should have been addressed within 72 hours. The facility's policy and procedure for Nutritional Screening/Assessments/Resident Care Plan, dated 2023, stated that the Food and Nutrition Services (FNS) Director and/or Facility Registered Dietitian should complete dietary recommendations within three days.
Failure to Implement Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to implement the care plan for one of the residents, identified as Resident 1, who was at high risk for falls. The care plan, dated May 16, 2017, specified the use of a bed alarm to alert staff when the resident attempted to get out of bed. However, during an observation on July 19, 2024, it was noted that Resident 1 did not have a bed alarm on his bed. Interviews with the Assistant Director of Nursing (ADON) and the Minimum Data Set Coordinator (MDSC) confirmed that Resident 1 was at risk for falls and occasionally attempted to get out of bed. The Fall Risk Observation/Assessment conducted on July 5, 2024, indicated that Resident 1 had a high fall risk score of 24. The ADON acknowledged that the care plan was not followed, as Resident 1 was expected to have a bed alarm in place. The facility's policy and procedure on comprehensive person-centered care plans, dated December 2016, required the development and implementation of care plans with measurable objectives and timetables to meet residents' needs. The failure to provide a bed alarm as per the care plan had the potential to place Resident 1 at risk for falls resulting in injuries.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, identified as Resident 5. During an observation and interview, it was noted that Resident 5 was lying in bed and unable to locate his call light, which was hanging on the wall behind his bedside drawer. Resident 5 expressed his inability to find the call light, and a Certified Nursing Assistant (CNA) confirmed that the call light was not within reach, acknowledging that it should have been accessible to the resident. Resident 5's Minimum Data Set (MDS) assessment indicated a severe cognitive impairment with a BIMS score of 7 and limitations in both lower extremities that interfered with daily functions. The resident's care plan highlighted a self-care performance deficit related to general weakness, impaired balance, and bilateral above-the-knee amputation, necessitating assistance for personal care activities. The facility's policy on call light usage, dated 2018, required that call lights be placed within reach of each resident, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 205 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Porterville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sierra View Medical Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Sequoia Transitional Care | 0.6 mi | ★★★★★ | 12 | 0 |
| River Walk Care Center | 1.1 mi | ★★★★★ | 18 | 0 |
| Gateway Post Acute | 1.4 mi | ★★★★★ | 0 | 0 |
| Lindsay Gardens Nursing & Rehabilitation | 11 mi | ★★★★★ | 22 | 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.