Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 View Care Center during CMS and state inspections, most recent first.
Call lights were not kept within reach for two residents. One resident with glaucoma, myopathy, severely impaired cognition, and high fall risk was observed in bed unable to find the call light, and staff later found a call pad under the pillow. Another resident with hemiplegia, hemiparesis, dementia, and severe cognitive impairment had the call light placed on the side of the bed next to the pillow even though the resident could not move the left hand and staff stated it should have been placed by the right hand for access.
Incomplete and Non-Individualized Care Plans: The facility failed to create and carry out resident-centered CPs for three residents. One resident with blindness and severe cognitive impairment had an activity CP that still referenced family participation even though no family contacts existed. Another resident receiving IV ampicillin had CP interventions that did not match the resident’s actual IV status and lacked documented monitoring for nephrotoxicity and hearing changes. A third resident developed BLE scaling and stiffness after A&D ointment use, but no CP or SBAR/COC addressed the change in condition.
Catheter care was not provided as ordered for two residents with indwelling catheters. One resident with a suprapubic catheter and another resident with a Foley catheter were observed in bed with tubing not secured to the thigh or connected to the securement device, despite orders and care plans directing catheter stabilization. RN, LVN, TN, and the DON all confirmed the tubing should have been secured to prevent pulling, dislodgement, and injury.
GT site care and feeding precautions were not followed for two residents with GTs. One resident with dementia and severe cognitive impairment had a GT dressing left unchanged despite orders for daily cleansing and dressing changes, and drainage was observed at the site. Another resident was observed lying flat in a supine position while receiving continuous GT feeding, even though the CP and OSR required HOB elevation during tube feeding; RN and DON confirmed the ordered positioning was not being followed.
Outdated food items were found in multiple kitchen storage areas, including an open loaf of wheat bread, baking soda, tortillas, and a tray of grilled cheese sandwiches and pizzas. The DS stated each item should have been discarded because it was past its use-by date, and the IPN stated food beyond the use-by date was not acceptable for residents and could cause food-borne illness. Facility P&Ps required date marking and discarding outdated food products.
An RN failed to timely document a resident’s respiratory assessment after assessing lung sounds and breathing for chest congestion, and also failed to timely sign an IVAR for another resident’s scheduled IV ampicillin dose. The DON stated assessments and medication administration should be documented at the time of service, and staff said the delays occurred because the RN was helping another shift and was busy.
A resident with a midline catheter had an undated dressing after RN care, despite facility policy requiring the dressing to be labeled with the date of change. In a separate event, a resident on EBP for a GT and ESBL history received direct hygiene care from a CG without the required gown and gloves, even though the care plan, order, and staff interviews confirmed PPE was required for high-contact care activities.
A resident’s ampicillin IV bag was observed hanging at the bedside with the resident’s first and last name and room number uncovered, and on one occasion the bag was unattended and not connected to the resident. RN 1 stated the information was not covered and could be seen by unauthorized people, and the DON stated housekeeping and maintenance staff did not need access to residents’ health information. The resident had osteomyelitis and bacteremia, with the H&P noting capacity for medical decisions and the MDS showing moderately impaired cognition and need for staff assistance with multiple ADLs.
A resident with hyperlipidemia, anemia, and dementia had an elevated triglyceride level and an RD recommendation for omega three 1,200 mg daily. RN stated the recommendation was received but was not followed up with the primary physician, and the DON stated there was no specific timeframe for acting on RD recommendations even though they should be acted on as soon as possible. The care plan noted nutritional problems and included RD evaluation and diet change recommendations.
A resident receiving O2 therapy and nebulizer treatments had the nebulizer mask left hanging on the bedrail and the O2 tubing left on the bed when the resident was not in the room. The resident had diagnoses including ARF with hypoxia and HF, and the care plan and orders included O2 via NC and albuterol nebulizer treatments. The LVN and DON stated respiratory supplies should be stored in a clear bag when not in use for infection control, and the facility policy required respiratory equipment to be covered when not in use.
A resident with intact cognition, multiple fall‑related diagnoses, and a history of hoarding was care‑planned for assistance in keeping the room clean and clutter‑free, but surveyors observed the room heavily cluttered around and on the bed, with access blocked on one side and clothes and personal items piled on surfaces and the floor. Staff reported the room had been cluttered for years and that they avoided touching the resident’s belongings, despite facility policies requiring belongings to be kept neat and the environment safe and homelike. Surveyors also found multiple packs of cigarettes in an open bedside drawer and Benadryl capsules on the bed and in the resident’s jacket pocket, even though there was no IDT assessment or order for self‑administration and no locked bedside storage, resulting in unsecured medications and cigarettes at the bedside.
The facility failed to complete Advance Directive documentation for three residents, risking non-compliance with their treatment preferences. One resident's form was incomplete, another's AD was missing from the chart, and a third's form did not indicate if an AD was executed. The Social Services Director and Director of Nursing acknowledged these oversights, which could lead to inappropriate care.
The facility failed to create individualized care plans for two residents with PTSD, despite their diagnoses and observed behaviors. Both residents lacked care plans addressing PTSD, contrary to the facility's policy on Trauma Informed Care, which emphasizes minimizing triggers and re-traumatization.
The facility failed to follow infection control policies for three residents, leading to potential infection spread. A CNA did not wear the required PPE while changing a resident on EBP, and another resident lacked proper signage for contact isolation. Staff acknowledged the importance of PPE, and the DON emphasized reassessment and proper cohorting for residents on transmission-based precautions.
The facility failed to obtain informed consent for the use of a wander guard alarm on a resident with severe cognitive impairment and anxiety, violating their rights and potentially causing psychological distress. Despite the facility's policy requiring consent for such devices, there was no documented evidence of consent being obtained, as confirmed by interviews with an LVN and the DON.
A resident with dementia and fall risk had a call light out of reach, contrary to their care plan and facility policy. The resident was unaware of the call light's location, and staff confirmed it should be accessible. The facility's policy requires call lights to be within reach.
A facility failed to complete the required Level I PASRR for a resident readmitted with severe cognitive impairment and multiple diagnoses, including cancer and bipolar disorder. The resident was in the facility for over 30 days without the necessary PASRR I evaluation, which should have triggered a PASRR II. Staff interviews revealed a lapse in the process of coordinating PASRR evaluations, contrary to the facility's policy.
A facility failed to develop a care plan for a resident prescribed Zoloft for depression, despite the resident's diagnoses of major depressive disorder and hypertension. The absence of a care plan was confirmed by the RN Supervisor and DON, who acknowledged that a plan should guide staff in monitoring the medication's effectiveness. This oversight was contrary to the facility's policy requiring comprehensive care plans with measurable objectives and timeframes.
A resident with moderately impaired cognition and orthopedic aftercare was not provided with effective constipation management for five days. Despite complaints and the known side effect of Norco, the facility delayed administering Milk of Magnesia (MOM) and failed to document its effectiveness or follow up with additional treatment. The facility's policy on monitoring and reporting adverse reactions was not followed, leading to a delay in necessary care.
A facility failed to follow its catheter care policy for a resident with an indwelling catheter. The resident's catheter port was visibly soiled, and there was no securement device in place, contrary to the care plan and physician's orders. Staff interviews confirmed these oversights, which could increase the risk of infection and injury.
A resident receiving tube feeding through a gastrostomy tube was observed to have the feeding running while being changed in a supine position, contrary to the care plan requiring head elevation to prevent aspiration. The LVN and CNA involved acknowledged the oversight, and the DON confirmed the need to pause feeding during such procedures. The resident had a history of cerebral palsy, paraplegia, and aphasia, and was at high risk for complications.
A facility failed to ensure that pharmacy recommendations for a resident were signed and dated by the attending physician, as required for proper medical care. The SNPRs for September and December 2024 were not appropriately signed, and the last physician note was from December 28, 2024. The resident had severe cognitive impairment and used a wheelchair. The DON confirmed the importance of signed SNPRs for indicating physician evaluation.
The facility did not post nurse staffing information in a prominent place accessible to all residents and visitors. Observations showed the information was only available at the reception desk near Nursing Station A, leaving it inaccessible to those near Nursing Station B. The Director of Staff Development confirmed the limited posting and acknowledged the need for additional postings to comply with the facility's policy.
A facility failed to obtain informed consent for Trazodone 50 mg prescribed for insomnia in a resident with intact cognitive abilities. The resident did not sign the Physician Document of Informed Consent, indicating that the risks, benefits, and alternatives of the medication were not discussed, contrary to the facility's policy.
A resident with dementia and bipolar disorder was left alone with a family member during a visit, despite being on 1:1 monitoring for agitation. The family member hit the resident, causing physical harm, after the resident became verbally aggressive. The incident was reported after the resident called for a nurse, and the family member admitted to the abuse.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents. Resident 5 was admitted and later readmitted with diagnoses including unspecified glaucoma and myopathy. The resident’s records showed severely impaired cognition, dependence for toileting, showering, dressing, and footwear, and maximum assistance needed for oral and personal hygiene. The fall risk assessment identified the resident as high risk for falls due to disorientation, chairbound status, poor vision, and use of assistive devices. The care plan directed staff to place the call light within reach and encourage use of it for assistance as needed, with prompt response to requests for help. During observation on 4/21/2026, Resident 5 was awake and lying in bed but unable to find the call light. The resident stated the call light could not be found. A CNA also could not find the call light, and stated the resident could not ask for help if the call light was not within reach and accessible. An RN later found a call pad below the resident’s pillow and stated it should be within reach and next to the resident so the resident could call for assistance if needed. Resident 12 was admitted and readmitted with diagnoses including hemiplegia, hemiparesis, and dementia. The resident’s care plan identified an ADL self-care performance deficit related to hemiplegia, hemiparesis, and dementia, and included encouraging the resident to use the bell to call for assistance. The MDS showed severely impaired cognition and dependence or substantial/maximal assistance needs for multiple ADLs. During observation, Resident 12 was in bed with a splint on the left hand, and the call light was placed up on the left side of the bed next to the pillow. A CNA stated the resident could not move the left hand and that the call light should be placed next to the resident’s right hand where it could be reached.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans for three sampled residents. For one resident with blindness, bipolar disorder, generalized muscle weakness, and severely impaired cognition, the activity care plan still included an intervention to invite and encourage family members to attend activities even though the resident had no family or friend contacts. The resident required extensive assistance with eating, hygiene, dressing, bathing, toileting, and mobility, and the facility’s own records and staff interviews confirmed that the family-related activity intervention was not applicable to the resident. For another resident admitted with osteomyelitis and bacteremia, the care plan included interventions that did not match the resident’s actual condition and treatment needs. The resident was not receiving IV hydration, yet the IV therapy care plan included monitoring for signs and symptoms of fluid under or overload when on IV hydration. The same care plan also directed nursing staff to check for nephrotoxicity and hearing changes while the resident was receiving ampicillin IV every six hours, but nursing progress notes and the MAR did not show documentation of monitoring for nephrotoxicity or hearing changes during the period reviewed. For a third resident with peripheral vascular disease, osteoarthritis, and mental disorders, the resident reported scaling and stiffness of both lower extremities and toes after A&D ointment was applied to the bilateral lower extremities. Staff later observed flakiness and scaling, and the resident complained of tightness. The treatment nurse stated the condition was not reported to the physician, and the record review found no care plan addressing the complaint and no SBAR/change-of-condition documentation related to the skin changes and stiffness after the ointment application. Facility staff and the MDS coordinator stated that a specific care plan and SBAR/COC should have been developed for the resident’s condition.
Catheter tubing not secured for two residents
Penalty
Summary
Failure to provide appropriate catheter care was identified for two residents with indwelling catheters. Resident 6 was admitted with diagnoses including obstructive and reflux uropathy and benign prostatic hyperplasia, and the record showed an order for staff to apply a catheter stabilization device and check placement every shift. The care plan also identified a suprapubic catheter and directed staff to secure the catheter in place and check placement. During observation, Resident 6 was asleep in bed with the catheter tubing hanging on the left side of the bed. RN 1 stated the suprapubic catheter tubing did not have a catheter securement device and was not secured on the resident's thigh. Later, TN 1 stated the securement lock was on the resident's right thigh while the catheter tubing was hanging on the left side of the bed, and that the tubing should have been secured on the thigh to prevent pulling and injury. Resident 55 had diagnoses including CKD, HF, and dementia, and the care plan identified an indwelling catheter with high risk for catheter-related infection or trauma. The order summary showed an order to apply a catheter stabilization device to secure the Foley catheter in place. During observation, Resident 55 was lying in bed with a Foley catheter that was not connected to the securement device. LVN 1 stated the tubing should be secured to prevent it from being pulled out during movement and causing trauma or injury, and the DON stated the Foley catheter tubing should be secured on the resident's thigh to prevent pulling and dislodgement during bed mobility.
GT Site Care and Feeding Position Not Provided as Ordered
Penalty
Summary
Resident 3 had diagnoses including encounter for attention to a GT and dementia, with severely impaired cognition and dependence on staff for multiple activities of daily living. The physician’s order and care plan required GT site care with normal saline, pat dry, and a dry dressing every day shift, and the care plan also directed local GT site care as ordered and monitoring for signs and symptoms of infection. During observation, Resident 3 was found with a GT site dressing dated 4/19/2026 and light brown drainage at the site. RN 1 stated the dressing had not been changed the prior day, and the Treatment Nurse stated the dressing was forgotten and needed to be cleaned and changed daily as ordered to prevent infection. The DON stated licensed nurses were responsible for changing the GT site dressing daily as ordered. Resident 6 had diagnoses including encounter for attention to a GT, obstructive and reflux uropathy, and benign prostatic hyperplasia, and the care plan required head of bed elevation of at least 30 to 45 degrees during and after tube feeding. The order summary also directed staff to elevate the head of bed a minimum of 30 degrees at all times during administration of feedings or medications. During observation, Resident 6 was asleep, lying flat in bed in a supine position while connected to ongoing GT feeding at 50 ml/hr. RN 1 stated the resident should have had the head of bed elevated 30 to 45 degrees during feeding to prevent aspiration, and the DON stated the head of bed should have been elevated at least 30 degrees while on GT feeding.
Outdated Food Items Found in Kitchen Storage Areas
Penalty
Summary
Safe food storage practices were not maintained in the facility kitchen when surveyors found multiple food items past their use-by dates. During observation and interview with the Dietary Supervisor, an open loaf of wheat bread in the bread storage area was beyond its use-by date, an open plastic container of baking soda in dry storage was beyond its use-by date, an open pack of tortillas in the walk-in refrigerator was beyond its use-by date, and a tray of grilled cheese sandwiches and pizzas in the walk-in refrigerator was beyond its use-by date. In each instance, the Dietary Supervisor stated the items should have been discarded because they were past the use-by date. The Infection Preventionist Nurse stated that food beyond the use-by date should be thrown away because it could cause food-borne illnesses and that it was not acceptable to have food for residents beyond the use-by date. The Dietary Supervisor also stated that food beyond the use-by date could affect food quality, including bread losing moisture, and could cause nausea and vomiting. Facility policies titled Date Marking for Food Safety and Food storage both stated that food should be clearly marked with the date by which it must be consumed or discarded and that outdated food products should be discarded.
Delayed Documentation of Resident Assessment and IV Antibiotic Administration
Penalty
Summary
Licensed nursing staff failed to timely document required care in the medical record for two sampled residents. Resident 11 was admitted with diagnoses including COPD, asthma, and dementia, and the record showed moderately impaired cognition with dependence or assistance needed for several activities of daily living. During an observation on 4/21/2026, RN 1 assessed Resident 11’s lung sounds and breathing at the bedside for chest congestion, but the resident’s Nurses Progress Note did not contain documentation of that respiratory assessment when reviewed later. RN 1 stated the respiratory assessment should have been documented in the progress note and explained it was not documented because RN 1 was helping the 3 PM to 11 PM shift. The DON stated licensed nurses should document assessments after they are completed and that documentation is important for notifying the physician of any change in condition and for recording interventions for continuity of care. Resident 100 was admitted with osteomyelitis and bacteremia, and the record showed moderately impaired cognition with dependence or assistance needed for multiple activities of daily living. The resident had an active order for IV ampicillin 2 grams every six hours for bacteremia. The IV Administration Report showed RN 1 administered the 12 PM dose and signed it at 6:58 PM, and LVN 5 stated the dose was not documented timely. RN 1 stated the delay occurred because RN 1 was busy, and the DON stated it was not acceptable to document the medication administration at that time because the standard of practice was to document at the time of service.
Infection Prevention Failures With Midline Dressing Labeling and EBP PPE Use
Penalty
Summary
The facility failed to implement infection prevention procedures for Resident 100 by not ensuring a midline dressing was dated after it was changed. Resident 100 was admitted with diagnoses including osteomyelitis and bacteremia, had moderately impaired cognition, and required varying levels of staff assistance with hygiene, toileting, bathing, and mobility. The order summary required licensed staff to change the midline dressing on admission and as needed for site maintenance, and the IV administration record showed RN 3 changed the dressing on 4/20/2026 at 9 PM. However, observations on 4/21/2026 at 10:37 AM and again at 12:35 PM showed the midline dressing at the bedside and later in the dining room without a date. During interview, LVN 5 stated the dressing should be dated so it could be monitored daily, staff would know when it was changed, and when the next change was due, and said an undated dressing was not acceptable. LVN 5 also stated licensed nurses should check that the dressing was intact and dated, and that if a licensed nurse noted it was undated, the nurse should have informed the RN. The infection preventionist reviewed the photographs and stated the RN should have dated the midline site dressing during the dressing change, and RN 1 stated the RN should have changed and dated the dressing to prevent infection at the midline site. The facility policy required the nurse to label the dressing with the date the dressing change was performed. The facility also failed to follow Enhanced Barrier Precautions for Resident 101. Resident 101 was admitted with diagnoses including sepsis and attention to a gastrostomy tube, was placed on EBP because of the GT and a history of ESBL in urine, and had severely impaired cognition with dependence on staff for oral hygiene, toileting, dressing, footwear, and personal hygiene. The care plan and order summary required EBP for high-contact care activities, including hygiene and device care. During observation, CG 1 was cleaning the resident’s arms, face, and neck with a wet towel while not wearing a gown and gloves. LVN 6 stated visitors and CG 1 needed to wear the required PPE while providing care, and CG 1 acknowledged not wearing a gown and gloves despite knowing the purpose was to prevent spread of infection. The DON stated caregivers, visitors, and staff needed to wear gown, gloves, and masks before providing direct care to residents on EBP.
Uncovered Identifiable Information on IV Bag
Penalty
Summary
The facility failed to protect identifiable health information on an ampicillin IV bag for one sampled resident. Resident 100 was admitted with diagnoses including osteomyelitis and bacteremia, had capacity to make medical decisions per the H&P, and the MDS indicated moderately impaired cognition with needs for staff assistance with eating, oral hygiene, personal hygiene, toileting hygiene, showering/bathing, and mobility. The resident had an active order for ampicillin IV for bacteremia. During observations at the resident’s bedside, the ampicillin IV bag was hanging on the IV pole with the resident’s first and last name and room number uncovered. On one observation, the IV bag was unattended by facility staff and not connected to the resident. RN 1 stated the resident’s health information was not covered while the bag was hanging at the bedside and that it risked exposing the resident’s health information to unauthorized people. The DON stated housekeeping and maintenance personnel had access to residents’ rooms and did not need to know residents’ health information, and that everyone in the facility should protect residents’ health information in accordance with HIPAA. The facility policy stated personal and medical records should be kept confidential and should not be left unattended or viewable by unauthorized persons.
Failure to Act on RD Nutritional Recommendation
Penalty
Summary
The facility failed to ensure a dietary recommendation from the Registered Dietitian was acted upon for one sampled resident with hyperlipidemia, anemia, and dementia. The resident was admitted on 6/4/2024 and later readmitted, and the MDS dated 2/24/2026 indicated severely impaired cognition and dependence on staff for eating, toileting, bathing, dressing, and footwear. A triglyceride lab result dated 2/25/2026 showed a level of 226 mg/dl, above the normal level of below 150 mg/dl. A Nutritional Assessment dated 2/25/2026 documented the RD recommendation for omega three oral capsule 1,200 mg once daily for elevated triglycerides. The care plan revised 4/8/2026 identified nutritional problems related to hyperlipidemia, anemia, and dementia and included an intervention for the RD to evaluate and make diet change recommendations as needed. During interview and record review, RN 1 stated the RD recommendation was received on 2/25/2026, that it was RN 1's responsibility to carry it out, and that RN 1 did not follow up with the primary physician. The DON stated there was no specific timeframe to act on RD recommendations, but they should be acted upon as soon as possible; the facility policy stated supplements may be recommended by an RD and implemented post physician orders.
Respiratory Equipment Left Unstored
Penalty
Summary
The facility failed to provide necessary care and services for a resident receiving oxygen therapy and breathing treatments. The resident was admitted with diagnoses including acute respiratory failure with hypoxia, heart failure, and anxiety, and the care plan identified oxygen therapy related to shortness of breath with goals for the resident not to have signs and symptoms of poor oxygen absorption. The resident also had orders for oxygen via nasal cannula at 2 liters per minute and for albuterol nebulizer treatments every 6 hours as needed for shortness of breath or wheezing. During observation, the resident was not in the room and the nebulizer mask was left hanging on the bedrail while the oxygen tubing was left on the bed. The LVN stated that the nebulizer mask and oxygen tubing should be stored inside the transparent bag intended for respiratory supplies when not in use to prevent contamination and spread of infection. The DON also stated that all respiratory supplies should be placed inside the clear, transparent bag when not in use for infection control. The facility policy on oxygen administration stated that staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment, and that delivery services should be kept covered in a plastic bag when not in use.
Failure to Maintain Safe, Clutter‑Free Room and Control Bedside Medications and Cigarettes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and clutter‑free room environment for one resident, as well as failure to control access to medications and cigarettes in that resident’s room. The resident had a history of bilateral spinal stenosis, PTSD, repeated falls, lower back pain, tobacco use, and chronic pain syndrome, and was assessed as having intact cognition and capacity to make medical decisions. The resident required supervision or partial/moderate assistance with multiple ADLs, including toileting, bathing, and dressing. The care plan documented that the resident kept personal belongings on the floor, around the bed, and on top of the bed, refused to have staff clean and declutter the room, and was at risk for falls due to clutter. Interventions in the care plan included assisting the resident with keeping the area clean and clutter‑free, creating a regular cleaning schedule, encouraging the resident to participate in sorting/discarding items, and offering alternative measures to keep personal items in safe areas. Despite these identified risks and planned interventions, observations on the survey date showed the resident’s room remained full of clutter on and alongside the bed. Bags of clothes and other items were piled against the wall and bed on one side, blocking access to that side of the bed. On the other side and on top of the bed were various clothes and items including hats, napkins, a surgical mask, a comb, an apple, cookies, a clothes hanger, socks, gloves, and a stuffed animal, with the resident’s food tray sitting on or near the clothes. A three‑drawer dresser next to the bed had multiple items cluttered on top, the top drawer was open with several packs of cigarettes visible inside, and clothes were on the floor in front of the dresser. Staff interviews indicated that the resident’s room had been full of clutter for years, that the resident became angry if staff touched the resident’s belongings, and that staff generally did not touch the resident’s items, despite the facility’s policies requiring belongings to be kept in a neat and orderly fashion and the environment to be safe and homelike. In addition to the clutter and cigarettes, the resident had medications at the bedside without an order for self‑administration and without locked storage. The resident reported having a bottle of Benadryl capsules in the dresser for sinus problems and believed it had been stolen, then produced two pink and white Benadryl capsules from a jacket pocket and placed them on the bed. The DON confirmed seeing two Benadryl capsules on the resident’s bed and the ADM stated they were not aware the resident had Benadryl in the room or was self‑medicating. Both the ADM and DON acknowledged there had been no interdisciplinary team assessment authorizing the resident to self‑administer medications, despite facility policy stating that residents have the right to self‑administer medications only if the interdisciplinary team determines it is clinically appropriate. Social services documentation showed the resident had been educated about hoarding behaviors and the associated health, safety, and tripping hazards, and noted ongoing noncompliance with room cleanliness, but there were no further follow‑up notes for several weeks prior to the survey. These actions and inactions resulted in a cluttered, unsafe room environment with accessible cigarettes and unsecured medications at the bedside, contrary to the facility’s policies on resident personal belongings, safe and homelike environment, and resident rights to receive treatment and supports for daily living safely.
Failure to Complete Advance Directive Documentation
Penalty
Summary
The facility failed to adhere to its policy on Advance Directives (AD) for three residents, leading to potential issues in honoring their medical treatment preferences. For Resident 31, the Advance Directive Acknowledgement Form (ADA) was not filled out completely, leaving it unclear whether the resident had an AD. This oversight was acknowledged by the Social Services Director (SSD) and the Director of Nursing (DON), who both noted the risk of providing services not aligned with the resident's wishes. Resident 17's case involved the absence of a copy of the AD in the medical chart, despite the resident's expressed desire to have one in place. The SSD confirmed that there was no follow-up with the resident's family to establish an AD, and the DON emphasized the importance of having the AD in the chart to guide care decisions. The facility's policy requires that ADs be determined and documented upon admission, which was not followed in this instance. For Resident 28, the ADA form was incomplete, failing to indicate whether the resident had executed an AD. The SSD and DON both recognized that this omission could lead to the resident receiving inappropriate services. The facility's policy mandates that the ADA form be completed upon admission to ensure that residents' treatment preferences are known and respected, which was not done in this case.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility failed to develop specific and individualized person-centered care plans for two residents who were trauma survivors, leading to a deficiency in providing trauma-informed care. Resident 17, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and post-traumatic stress disorder (PTSD), did not have a care plan addressing PTSD. Despite having a positive trauma screen and a history of PTSD, the care plans did not include interventions to manage triggers or prevent re-traumatization. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of a care plan for PTSD, which was against the facility's policy. Similarly, Resident 54, who was readmitted with PTSD and spinal stenosis, also lacked a care plan addressing PTSD. The resident was cognitively intact and required assistance with daily activities. Interviews with a Licensed Vocational Nurse and the Director of Nursing revealed that Resident 54 exhibited behaviors such as non-compliance and hoarding, which could be related to PTSD. Despite these observations, there was no specific care plan to manage PTSD symptoms and triggers, which was acknowledged as necessary by the facility's staff. The facility's policy on Trauma Informed Care emphasized the need for care plans that recognize the interrelation between trauma and its symptoms, and the importance of minimizing triggers and re-traumatization. However, the facility did not adhere to this policy for Residents 17 and 54, resulting in a failure to provide the necessary care, treatment, and services for these trauma survivor residents.
Infection Control Deficiencies in PPE Usage and Signage
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies for three residents, leading to potential cross-contamination and infection spread. For Resident 74, who was on Enhanced Barrier Precautions (EBP) due to COVID-19, MRSA, and immunodeficiency, a Certified Nurse Assistant (CNA 5) was observed changing the resident's diaper without wearing the required gown, only wearing gloves. This was acknowledged by CNA 5, who admitted the importance of wearing a gown, mask, and gloves to protect both the resident and themselves. Interviews with other staff, including a Licensed Vocational Nurse (LVN 4) and the Infection Preventionist (IP), confirmed that proper PPE, including gowns and gloves, should be worn during high-contact activities for residents on EBP. Resident 59, diagnosed with ESBL in the urine, was on contact isolation, yet there was no appropriate signage outside the resident's room indicating the transmission-based precautions. The Treatment Nurse (TN) and Infection Prevention Nurse (IPN) confirmed the absence of documentation clearing the resident from contact isolation, emphasizing the need for proper signage to prevent infection spread. The Director of Nursing (DON) also stated that residents on transmission-based precautions should be reassessed and cohorted properly to ensure the safety of other residents. For Resident 10, who was on EBP due to a gastrostomy tube and risk for multidrug-resistant organism infection, a CNA (CNA 4) was observed changing the resident's linen while only wearing gloves, without the required gown. The CNA acknowledged the oversight and the importance of wearing the full PPE during high-contact activities. The Infection Prevention Nurse (IPN) and the Director of Nursing (DON) reiterated the necessity of wearing the required PPE to prevent the spread of infection, as outlined in the facility's policy.
Failure to Obtain Informed Consent for Wander Guard Alarm
Penalty
Summary
The facility failed to implement its policy and procedure regarding informed consent for the use of a wander guard alarm for Resident 59. Resident 59 was admitted with diagnoses including osteoporosis, unsteadiness on feet, and anxiety, and was identified as being at risk for elopement. The Minimum Data Sheet indicated that Resident 59 had severely impaired cognition and required varying levels of assistance with daily activities. During an observation, Resident 59 was seen wearing a wander guard alarm bracelet, but there was no documented evidence that consent was obtained prior to its application. Interviews with Licensed Vocational Nurse 4 and the Director of Nursing confirmed that consent should have been obtained to ensure the resident or their responsible party was informed about the use of the wander guard. The facility's policy on informed consent requires that consent be obtained for medical interventions, including the prolonged use of devices like the wander guard. The failure to obtain informed consent violated Resident 59's rights and placed them at risk for psychological distress due to the discomfort and sound of the alarm.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 89, which had the potential to prevent the resident from receiving necessary care and services. Resident 89 was admitted with diagnoses including dementia, depressive disorder, and unsteadiness on feet, and was assessed to have severely impaired cognition. The resident required supervision or assistance with various activities of daily living and was identified as being at risk for falls. The care plan for Resident 89 included interventions to place the call light within reach and encourage its use for assistance. During an observation, the call light was found hanging on the wall, out of reach, and the resident was unaware of its location. A Certified Nurse Assistant confirmed that the call light should be placed where the resident could see and use it. The Director of Nursing also stated that the call light should be within easy reach to address needs immediately. The facility's policy on call lights, revised in December 2022, indicated that staff should ensure call lights are within reach and secured as needed.
Failure to Complete PASRR for Resident
Penalty
Summary
The facility failed to complete the Level I Pre-Admission Screening and Resident Review (PASRR) for a resident who had been in the facility for more than 30 days. This oversight was identified during a review of the resident's admission record and clinical documentation. The resident, who was readmitted to the facility with diagnoses including malignant neoplasm of the esophagus and bipolar disorder, was found to be severely cognitively impaired and dependent on assistance for personal care. Despite these conditions, the necessary PASRR I evaluation was not conducted upon the resident's readmission, which should have triggered a PASRR II evaluation. Interviews with facility staff revealed a breakdown in the process of coordinating PASRR evaluations. The Admissions Coordinator typically requests PASRR I from the hospital and passes it to the Minimum Data Set Assistant (MDS A), who is responsible for PASRR II. However, in this case, the MDS A acknowledged that a new PASRR I screening should have been completed upon the resident's readmission to determine if a PASRR II was still needed. The facility's policy requires that residents not screened due to certain exceptions must undergo a Level I screening if they remain in the facility for more than 30 days, which was not adhered to in this instance.
Failure to Develop Care Plan for Zoloft Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed Zoloft, a medication used to treat depression. The resident, who had been admitted and readmitted to the facility with diagnoses including major depressive disorder and hypertension, had an active order for Zoloft 50 mg once a day. Despite this, there was no care plan in place to monitor the effectiveness of the medication or to guide staff in implementing specific interventions for the resident. This oversight was confirmed during a review of the resident's medical records and interviews with the Registered Nurse Supervisor and the Director of Nursing, both of whom acknowledged the absence of a care plan. The facility's policy and procedure on comprehensive care plans, revised in December 2022, requires that care plans include measurable objectives and timeframes to meet residents' needs as identified in comprehensive assessments. The lack of a care plan for the use of Zoloft for this resident had the potential to result in inconsistency of care and unnecessary use of psychotropic medication. The deficiency was identified during a survey, highlighting the need for a structured approach to monitor the resident's progress and document alternative interventions as needed.
Failure to Manage Resident's Constipation
Penalty
Summary
The facility failed to manage constipation for a resident over a period of five days, from February 15 to February 19, 2025. The resident, who had been admitted with orthopedic aftercare following surgical amputation and obesity, had moderately impaired cognition and required assistance with daily activities. Despite the resident's complaints of constipation and the known side effect of constipation from taking Norco, the facility did not administer Milk of Magnesia (MOM) until February 19, 2025, and failed to document its effectiveness or follow up with additional treatment when it proved ineffective. Licensed Vocational Nurse 2 (LVN 2) acknowledged the resident's complaints and administered MOM on February 19, 2025, but did not document the outcome or notify the physician when the medication was ineffective. The facility's Medication Administration Record (MAR) showed no bowel movement for the resident since February 14, 2025, and no administration of MOM on the preceding days. The facility's policy required monitoring and reporting adverse reactions to analgesic therapy, but this was not adhered to, resulting in a delay in necessary care and services for the resident.
Failure to Follow Catheter Care Policy
Penalty
Summary
The facility failed to adhere to its policy on foley catheter care for a resident, identified as Resident 50, who had an indwelling catheter. The resident was admitted with diagnoses including benign prostatic hyperplasia and sepsis and was noted to have severely impaired cognitive abilities. During an observation, the resident's catheter port was found to be visibly soiled with a brown substance resembling feces, and there was no securement device in place as required by the care plan and physician's orders. Interviews with facility staff, including the Infection Prevention Nurse, a Licensed Vocational Nurse, and the Director of Nursing, confirmed that the soiled catheter and lack of a securement device were not in compliance with the facility's policies. The staff acknowledged that these oversights could increase the risk of infection and injury to the resident. The facility's policy on catheter care, revised in December 2022, mandates appropriate care and maintenance of dignity and privacy for residents with indwelling catheters.
Improper Management of Tube Feeding for Resident
Penalty
Summary
The facility failed to ensure proper management of tube feeding for a resident, identified as Resident 16, who was receiving nutrition through a gastrostomy tube. During an observation, it was noted that the tube feeding was running while the resident was being changed in a supine position, which is against the care plan that requires the head of the bed to be elevated at least 30-45 degrees during and after feeding to prevent aspiration. The Licensed Vocational Nurse (LVN) acknowledged that the tube feeding should have been paused during the resident's change to prevent choking or aspiration. Resident 16 had a medical history that included cerebral palsy, paraplegia, and aphasia, and was assessed as completely immobile and unable to make decisions. The resident's care plan indicated a high risk for complications such as aspiration, and the facility's policy required the head of the bed to be elevated during feedings. Despite this, the tube feeding was not paused during the resident's care, as confirmed by both the LVN and a Certified Nurse Assistant (CNA), who stated that the feeding sometimes resumed before the resident's care was completed. The Director of Nursing also confirmed that the tube feeding should be turned off during such procedures to prevent serious complications.
Failure to Ensure Physician Signatures on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations for a resident were signed and dated by the attending physician, which is a requirement for maintaining proper medical care and continuity. Specifically, the Skilled Nursing Pharmacy Recommendations (SNPR) for September 2024 and December 2024 for Resident 22 were not appropriately signed and dated by the attending physician. The Medical Record Director (MRD) noted that the September 2024 SNPR was undated, and the December 2024 SNPR lacked both a signature and a date. The MRD also mentioned that the physician likely visited in January 2025, but there was no record of this visit, and the last physician note was from December 28, 2024. Resident 22, who was readmitted to the facility with diagnoses including gastrostomy and diabetes mellitus, was noted to have severely impaired cognition and used a wheelchair for mobility. The Director of Nursing (DON) confirmed that during physician visits, the physician should sign the pharmacy recommendations, emphasizing the importance of a signed SNPR for indicating the physician's evaluation and acknowledgment. The facility's policy requires that the medical care of each resident be under the supervision of a licensed physician, with orders and progress notes maintained according to OBRA regulations and facility policy.
Inadequate Posting of Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent place readily accessible to residents and visitors. Observations on multiple dates revealed that the Nurse Staffing Sheet, which contains the facility's current resident census and total number and actual hours worked by licensed and unlicensed nursing staff, was only posted at the reception desk near the entrance across from Nursing Station A. This made the information inaccessible to residents and visitors on the opposite side of the facility by Nursing Station B. Interviews with the Director of Staff Development confirmed that the staffing information was only posted in the reception area and acknowledged that it should also be posted at Nursing Station B to ensure accessibility. The facility's policy and procedure indicated that staffing information should be posted in a prominent place readily accessible to residents and visitors, which was not adhered to in this instance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure informed consent was obtained for the administration of Trazodone 50 mg every night for insomnia in one of the sampled residents. Resident 31, who was admitted with chronic pain syndrome and low back pain, had intact cognitive abilities and the capacity to understand and make decisions. Despite this, the Physician Document of Informed Consent (PDIC) form for Trazodone was not signed by the resident, indicating that the risks and benefits of the medication were not discussed with them. During interviews, both the Registered Nurse Supervisor and the Director of Nursing confirmed that the PDIC form was not signed, which meant that the resident was not informed about the medication's risks, benefits, or alternative treatments. The facility's policy requires that residents be educated on these aspects before administering psychotropic drugs, but this was not adhered to in the case of Resident 31.
Resident Abuse by Family Member During Visitation
Penalty
Summary
The facility failed to protect a resident from physical abuse during a visitation by a family member. The resident, who had diagnoses of dementia and bipolar disorder, was on 1:1 monitoring due to agitation and aggressiveness. However, the staff left the resident alone with the family member, who subsequently hit the resident, resulting in discoloration of the resident's right lower lip and left temporal area. The incident was reported after the resident yelled for a nurse, and the family member admitted to hitting the resident due to verbal aggression. The resident's progress notes indicated that the resident was given Tylenol for pain and was transferred to a general acute care hospital for further assessment. Interviews with staff and the resident's roommate confirmed the sequence of events leading to the abuse. The facility's policy on abuse, neglect, and exploitation defines abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish, which was not adhered to in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baldwin Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coast Care Convalescent Center | 0.2 mi | ★★★★★ | 18 | 0 |
| Victoria Care Center | 1.4 mi | ★★★★★ | 13 | 0 |
| West Covina Healthcare Center | 1.8 mi | ★★★★★ | 17 | 0 |
| Garden View Post Acute Rehabilitation | 1.8 mi | ★★★★★ | 20 | 0 |
| West Covina Medical Center D/p Snf | 2 mi | ★★★★★ | 15 | 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.