Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Homes during CMS and state inspections, most recent first.
The facility failed to have a qualified, full-time CDM overseeing food and nutrition services. A Dietary Supervisor and another supervisor were covering the role, handling kitchen staff in-services and competency oversight, while the RD was onsite about 8 hours a week and available by phone. Record review showed no CDM certificate for either supervisor, and the job description required a current CDM certificate for the Food & Nutritional Manager role.
A facility failed to ensure dietary and maintenance staff were trained to perform food service tasks safely and effectively. Two DAs did not demonstrate or verbalize the correct use and timing of a QUAT test strip for the sanitizing bucket, while a maintenance staff member did not follow the manufacturer’s instructions for cleaning the ice machine and described using methods taught by a former employee. Leadership and the RD stated the staff were not competent in these tasks.
Expired produce, unlabeled cooked chicken, and outdated freezer items were found stored with resident food, while an ice machine had visible contamination and a staff member stored a lunch bag in a resident refrigerator. In addition, a resident food refrigerator was found at freezing temperatures with incomplete temperature logs, and staff and the RD acknowledged the items and conditions were not stored or maintained properly.
Water pitchers were left on dressers and out of reach for several residents, including residents with severe cognitive impairment and multiple chronic conditions. Observations showed a resident in bed, a resident unable to respond appropriately, a resident in a wheelchair, a resident not in the room, and another resident sitting in bed, all with pitchers placed where they could not access them. CNA and nursing leadership acknowledged the pitchers should have been placed within reach near the bedside.
An RN, DSD, and DON confirmed an incomplete O2 order for a resident on oxygen therapy, and staff observed the resident’s O2 tank empty while still set for delivery. In separate events, unopened meds for two residents were found in the cart, and the IP, DSD, and DON confirmed doses were not given as scheduled despite MARs showing them as administered. The RD also faxed significant weight-loss recommendations for two residents, but staff did not receive timely physician responses.
Incomplete POLST Documentation: Multiple residents had incomplete POLST forms, with missing patient identifiers, physician and preparer information, signatures, dates, and required treatment sections. Staff stated the POLST is used to communicate end-of-life wishes, including CPR/DNR status and artificial nutrition preferences, but the forms reviewed were not fully completed for several residents with significant medical conditions and cognitive impairment.
Staff failed to follow infection control practices in multiple resident rooms. A resident on Droplet Precautions was entered by staff wearing only a surgical mask and no goggles, despite the posted PPE requirements. In another room, a urinal was left on a dresser near a water pitcher, and in a third room, a resident’s nasal cannula tubing was found on the floor instead of being stored properly. Interviews with CNA, RN, IP, DSD, and DON staff confirmed these were not the expected infection control practices.
A facility failed to ensure psychotropic and antipsychotic medication orders for two residents included resident-specific target symptoms or behaviors, and it also failed to document specific non-pharmacological interventions before use. One resident with schizophrenia and dementia had an olanzapine order without clear manifestations, and another resident with depression and severe cognitive impairment had aripiprazole, mirtazapine, and sertraline orders without specific target behaviors. The MAR listed non-drug interventions, but only check marks were documented, not which interventions were actually used.
PASRR screening was not completed correctly for a resident with schizophrenia. The resident’s record showed diagnoses including schizophrenia, Alzheimer’s disease, anxiety, and depression, and the resident was receiving olanzapine for schizophrenia. However, the PASRR Level I screening incorrectly indicated no diagnosed mental disorder and no psychotropic meds for mental illness, so a Level II PASRR was not triggered. The DSD confirmed the schizophrenia diagnosis should have been marked yes, and the DON stated PASRR should have been verified before admission.
Missing Care Plan for Oxygen Therapy: A resident with Alzheimer's disease, hypothyroidism, osteoporosis, and pulmonary edema had an oxygen order for 2 LPM PRN, but staff did not develop a care plan for the oxygen therapy. An IP stated the resident's O2 saturation was in the 80s and the care plan should have been created when the order began and revised after the change in condition. The DON stated care plans should be completed with all orders, and the facility policy required individualized care plans to be reviewed and updated with changes in condition or orders.
A resident with multiple chronic conditions and moderate cognitive impairment was observed using O2 at 4 L/min, but the care plan still reflected an older 2 L/min PRN order. Record review showed the physician changed the O2 order to 4 L/min via NC, yet the care plan was not revised to match the current order. The IP and DON both confirmed the care plan was not updated to reflect the new O2 therapy order.
Failure to Initiate Bowel and Bladder Training: A resident with a BIMS score of 13, always incontinent of bowel and bladder, and identified on the B&B screener as a candidate for scheduled toileting was not placed on a bowel and bladder training program. Staff interviews confirmed the resident was not on a toileting program, despite the resident stating she wore a brief and had no bowel or bladder training. Facility policy described retraining and scheduled toileting for residents who could benefit.
A resident with severe cognitive impairment had a lorazepam order on the MAR, but the medication record sheet lacked complete administration instructions and the label was incomplete. Another resident with moderate cognitive impairment received lorazepam, but the CDR was not signed by the LN. The medication refrigerator was found below the required range with incomplete temperature logs, the MDL lacked required witness signatures for destroyed medications, and loose meds were found in the med cart.
Call Lights Not Within Reach for Three Residents: A facility failed to keep call lights within reach for three residents who were observed in bed. One resident’s call light was on the floor, and two others had call lights placed on dressers instead of within reach. The affected residents had severe cognitive impairment and required varying levels of assistance with ADLs, transfers, toileting, and personal care. CNA and RN interviews confirmed the call lights were not properly positioned, and the facility policy required call lights to be within resident reach at all times when in bed.
Two residents with new diagnoses of serious mental illness were not referred for a required Level II PASRR evaluation. Facility records showed that after being diagnosed with conditions such as bipolar disorder, anxiety disorder, and psychosis, the necessary referral to the state-designated authority was not made. Staff interviews revealed a lack of awareness and follow-through regarding the PASRR process.
The facility failed to accurately code the MDS for two residents, resulting in one being incorrectly documented as rarely/never understood and another missing active diagnoses of anxiety and depression. The errors were identified during a survey, and facility leadership confirmed that the MDS did not accurately reflect the residents' conditions at the time of assessment.
A resident receiving hospice care did not have hospice services addressed in their care plan, despite documentation and staff acknowledgment that such services were being provided. Facility staff, including the MDS Coordinator and DON, confirmed the omission and stated that the care plan should have included details about hospice involvement and services.
No Qualified Full-Time CDM Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to have a qualified, full-time certified dietary manager (CDM) overseeing Food and Nutrition Services. During interviews, the Dietary Supervisor stated the CDM was on leave and that the Dietary Supervisors were covering the role. One Dietary Supervisor stated he was responsible for in-services for kitchen staff and for making sure dietary staff were trained and competent in their jobs. The Registered Dietitian stated she came to the facility about eight hours a week and was available by phone, and that the Dietary Supervisor was covering for the CDM and providing kitchen staff in-services. Record review showed the CDM leave documents indicated the CDM should have returned from leave earlier than the date later given by the Administrator, and no CDM certificate was provided for either Dietary Supervisor. The job description for Food & Nutritional Manager required a certified dietary manager with a current CDM certificate. The Administrator stated the facility had a full-time CDM who was out on leave, that the Dietary Supervisor was filling the CDM role until the return date, and that the RD was in the facility eight hours a week and was supposed to supervise kitchen staff.
Inadequate Training for Sanitizing Procedures and Ice Machine Cleaning
Penalty
Summary
The facility failed to ensure dietary and maintenance support personnel were trained to carry out food and nutrition service functions safely and effectively for all residents. During a concurrent observation and interview in the kitchen, a Dietary Aide placed a test strip into a red sanitizing bucket and then compared the strip to the bottle, stating the solution was at 200 ppm and that 200 ppm was good. The Dietary Aide stated she was responsible for preparing the sanitizing bucket and said she put the test strip in the bucket until it changed color, leaving it in for 1 to 2 seconds. She also stated she had an in-service the prior week on sanitizing and that the solution was used to clean germs on kitchen surfaces. During a later interview, another Dietary Aide stated he was responsible for testing the sanitizing solution and described rinsing the bucket, obtaining the sanitation solution, and checking it with the test strip. He stated he usually put the strip in and it turned right away, and that he would compare it to the bottle. He stated the range should have been 200 ppm and that inaccurate testing could cause pathogens to grow and could lead to cross-contamination when surfaces were not cleaned properly. The Dietary Supervisor stated he was unsure how long the strip should be in the sanitizing solution until he checked the policy binder, then stated the strip should have been left in the solution for 10 seconds. He stated the two Dietary Aides were not competent in their training and needed more training. The Registered Dietician also stated the Dietary Aides should have followed the manufacturer or policy guidelines and were not competent in the sanitization process when they could not demonstrate and verbalize the correct timing. The facility also failed to ensure Maintenance staff properly cleaned the ice machine according to the manufacturer’s instructions. During observation, the ice machine contained black and pink substance inside and a white substance outside, and the Maintenance Supervisor stated those conditions were unacceptable. The Maintenance staff member responsible for monthly cleaning stated he cleaned the ice machine by using descaler in the tray, taking components apart, spraying the front and probe with a descaling solution, soaking components for one minute, and washing them with a sanitizing solution mixed with water. He stated he had been trained by an employee who no longer worked at the facility. The Registered Dietician stated the person servicing the ice machine should be competent and that it should be cleaned according to the manufacturer’s guideline. The Maintenance Supervisor later stated the staff member was not competent and needed to be retrained, and the Administrator stated maintenance staff should have cleaned and sanitized the ice machine and that the staff member needed more training on cleaning the ice machine and following the manufacturer’s guidelines.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
Safe and sanitary food preparation and storage practices were not followed for all residents when expired and improperly labeled food items were found in multiple kitchen and resident food storage areas. In the walk-in produce refrigerator, two bags of cabbage with a used-by date of 2/2/26, a bag of celery with a used-by date of 1/30/26, and a bag of daikon with a used-by date of 2/2/26 were stored with other produce. The Dietary Supervisor stated these items should have been discarded by their used-by dates, and the Registered Dietician stated they should have been discarded and checked daily by kitchen staff. The facility policy required food brought into the facility for resident consumption to be labeled and dated, and food past the manufacture expiration date to be discarded immediately by designated staff. In the freezer, two cartons of apple cobbler pie with a received date of 7/22/25 and no used-by date were found on the top shelf. The Dietary Supervisor stated the pies were past the expiration date and should have been thrown away. In refrigerator 3, two packs of cooked chicken were found unlabeled, with no pulled-out date and no used-by date, stored on a tray next to deli ham. The Dietary Supervisor stated the chicken should have been labeled with a pulled-out date and used-by date, and the facility policy required meat placed in the refrigerator for thawing to be labeled with pull-by and used-by dates. Additional food safety concerns were identified in other resident food storage areas. The ice machine contained black and pink substances inside and white substances outside, and the Maintenance Supervisor stated it should not have been in that condition. A staff member’s lunch bag was also stored in the resident refrigerator in the east dining room; the CNA acknowledged it was her lunch bag and stated it should have been kept in the break room. In the west wing nursing station, the resident food refrigerator was observed at 32 degrees F and later at 24 degrees F, while temperature logs for November 2025 through January 2026 showed multiple missed entries and repeated temperatures at or below 32 degrees F. Facility staff stated the refrigerator was used for residents’ food and snacks, that temperatures should be checked daily, and that the refrigerator should have been maintained at the appropriate temperature range.
Water pitchers left out of residents’ reach
Penalty
Summary
The facility failed to ensure water pitchers were within reach for five sampled residents: Resident 9, Resident 11, Resident 13, Resident 39, and Resident 55. During observations on 2/4/2026, Resident 9 was lying in bed with eyes closed and his water pitcher was on the dresser and not within reach. Resident 11 was observed dressed and lying in bed and unable to respond appropriately to questions, with the water pitcher also placed on the dresser and out of reach. Resident 13 was sitting in her wheelchair in her room, and her water pitcher was on the dresser and not within reach. Resident 39 was not in her room, and her water pitcher was observed on her dresser and not within reach. Resident 55 was dressed and sitting in bed, and his water pitcher was on the dresser and not within reach. Resident 9’s record showed diagnoses including acute and chronic respiratory failure with hypoxia, dementia, epileptic seizures, bipolar disorder, and heart failure, and his MDS showed a BIMS score of 03, indicating severe cognitive impairment. Resident 11’s record showed diagnoses including essential hypertension, GERD, varicose veins with ulcer, alcoholic cirrhosis with ascites, venous insufficiency, and anxiety disorder, and his MDS showed a BIMS score of 07, indicating severe cognitive impairment. Resident 13’s record showed diagnoses including pneumonia, anemia, Alzheimer’s disease, hyperlipidemia, heart failure, essential hypertension, presence of cardiac pacemaker, depression, and hypokalemia, and her MDS showed a BIMS score of 06, indicating severe cognitive impairment. Resident 39’s record showed diagnoses including hyperlipidemia, essential hypertension, neuromuscular scoliosis, multiple sclerosis, and edema, and her MDS showed a BIMS score of 09, indicating moderate impairment. Resident 55’s record showed diagnoses including type 2 diabetes mellitus, major depressive disorder, anxiety disorder, essential hypertension, and acute respiratory failure with hypoxia, and his MDS showed a BIMS score of 00, indicating severe cognitive impairment. During interviews, CNA 4 stated the pitchers should not have been placed on the dressers and should be on the bedside table or nightstand within reach, while RN 1 stated it was the CNA’s responsibility to place the pitchers and that they should be near the bedside. The DON and DSD both stated the pitchers should not have been on the dressers and should have been placed where residents could reach them.
Incomplete oxygen order, empty O2 tank, missed medications, and delayed response to weight loss
Penalty
Summary
Resident 39 had an incomplete oxygen order dated 9/23/25. The order directed oxygen at 4 L/min via nasal cannula every shift to help maintain normal oxygen levels, but it did not state whether the oxygen was continuous or PRN. During interviews, RN 1, the DSD, and the DON all confirmed that the order was incomplete because it did not specify the frequency of administration or the oxygen saturation target. The DON stated the missing information was important so licensed nurses could follow the physician’s direction and provide care in accordance with the ordered treatment. Resident 39 was observed sitting in a wheelchair with a nasal cannula in place and an oxygen tank attached to the wheelchair. The tank was found empty while still set at 4 L/min. CNA 3 and the IP both observed the empty tank and stated it should be addressed immediately. RN 1, the DSD, and the DON later confirmed that the tank was empty despite being set for oxygen delivery, and that the expectation was for licensed nurses to routinely check tank levels to ensure an adequate oxygen supply. Resident 39’s record showed diagnoses including hyperlipidemia, hypertension, neuromuscular scoliosis, multiple sclerosis, and edema, and the MDS indicated oxygen therapy was in use. Resident 13 and Resident 47 also had medication administration issues. On observation, unopened prepacked medications for Resident 13 were found in the medication cart, including potassium chloride ER, lisinopril, metoprolol succinate ER, sertraline HCl, and memantine. Unopened prepacked sertraline HCl for Resident 47 was also found in the cart with package dates from earlier in the week. The IP, DSD, and DON confirmed that Resident 13’s medications were not administered as scheduled on 2/5/26 and that Resident 47 did not receive sertraline on 2/1/26 and 2/2/26, despite the MAR showing the doses as administered. Resident 13’s diagnoses included heart failure, hypertension, depression, hypokalemia, anemia, and Alzheimer’s disease, and Resident 47’s diagnoses included hypokalemia, pneumonia, hypertension, and depression. Resident 8 and Resident 29 had significant weight loss recommendations faxed to the physician that were not responded to within 24 hours. For Resident 8, the RD recommended increasing whole milk and adding weekly weights after noting significant weight loss over one month. For Resident 29, the RD recommended removing diet restrictions, continuing weekly weights, and upgrading textures to regular after noting poor intake and significant weight loss. Staff interviews confirmed the recommendations were faxed but not followed up in a timely manner, and the RD and DON stated the physician response should have been received within a day. Resident 29 was observed in a wheelchair with a family member who expressed concern about poor intake and weight loss, and the record noted the resident was blind and had difficulty eating the minced and moist diet.
Incomplete POLST Documentation
Penalty
Summary
Medical records were incomplete and not accurately documented for eight sampled residents because their POLST forms were not fully completed. The affected residents were Resident 9, Resident 11, Resident 36, Resident 39, Resident 55, Resident 6, Resident 7, and Resident 38. The report states that the incomplete POLSTs involved missing resident-identifying information, physician information, preparer information, signatures, dates, and other required sections depending on the resident's form. Resident 36, Resident 9, Resident 11, Resident 55, and Resident 39 were observed in their rooms or common areas and had diagnoses including chronic kidney disease, dementia, respiratory failure, heart failure, cirrhosis, venous insufficiency, anxiety, major depressive disorder, multiple sclerosis, and other chronic conditions. Their MDS assessments showed cognitive impairment ranging from moderate to severe for several of these residents. During record review with RN 1 and the MR, the second page of each of these residents' POLST forms was found incomplete, including missing patient information, supervising physician name, and preparer name/title and phone number. RN 1 stated the POLST was important because it informed medical professionals of the residents' wishes and allowed the legal decision-maker to determine whether they wished to be resuscitated. The MR stated she typically only reviewed the front of the POLST form and was unaware that the back portion was required to be completed. Resident 6, Resident 7, and Resident 38 also had incomplete POLST forms. Resident 6's POLST lacked a date, patient date of birth, and section D information identifying who the form was discussed with. Resident 7's POLST lacked the patient date of birth and the back side information identifying who completed the POLST and additional contact information. Resident 38's POLST was missing completion of section C for artificially administered nutrition. Staff interviewed about these forms stated that all sections should have been completed and that the POLST communicated the resident's end-of-life wishes, including CPR status, DNR status, and whether tube feeding would be used. The DON stated the POLST was communication between facilities to honor residents' wishes, and the professional reference in the report stated that both the physician and patient must sign the POLST, or the legally recognized decision-maker may participate if the patient lacks capacity.
Infection Control Failures With PPE Use and Improper Storage of Resident Equipment
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program when staff entered a resident’s room under Droplet Precautions without the appropriate PPE. Resident 9 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, dementia, epileptic seizures, bipolar disorder, and heart failure. The resident’s MDS showed a BIMS score of 03 out of 15, indicating severe cognitive impairment. During observation, the room had Droplet Precaution signage posted, but CNA 1, CNA 4, RN 1, the Social Services Director, and the Maintenance Supervisor entered the room wearing a surgical mask but no goggles. Staff interviews confirmed that goggles were expected under Droplet Precautions and that the staff members did not follow the precaution requirements. The facility also failed to maintain proper infection control practices in Resident 11’s room when a urinal was observed on the dresser near the resident’s water pitcher. Resident 11 was admitted with diagnoses including essential hypertension, GERD, varicose veins with ulcer, alcoholic cirrhosis with ascites, venous insufficiency, and anxiety disorder. The resident’s MDS showed a BIMS score of 07, indicating severe cognitive impairment, and the resident required substantial to maximal assistance with multiple activities of daily living. During observation, the urinal was seen on the dresser close to the water pitcher. CNA 4, RN 1, the IP, the DSD, and the DON all confirmed the urinal was in an inappropriate location and stated it should not have been placed on the dresser near the resident’s water. The facility further failed to maintain infection control for Resident 49 when the resident’s nasal cannula tubing was found on the floor. Resident 49 was admitted with diagnoses including Alzheimer’s disease, hypothyroidism, osteoporosis, and pulmonary edema. The resident’s MDS showed a BIMS score of 00, indicating cognitive impairment, and the resident had an order for oxygen at 2 liters per nasal cannula as needed for shortness of breath. During observation, CNA 5 confirmed the nasal cannula was on the floor and stated it should have been stored on the oxygen concentrator handle or in a bag when not in use. The IP and DON stated the tubing should be stored in a bag when not in use and should not be on the floor.
Psychotropic Orders Lacked Resident-Specific Target Symptoms and Documented Non-Drug Interventions
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for unnecessary psychotropic medication use for two sampled residents. For one resident with diagnoses including schizophrenia, Alzheimer’s disease, COPD, diabetes mellitus, anxiety disorder, and depression, the physician order for olanzapine did not include resident-specific symptoms or behaviors that would indicate why the antipsychotic was being used. The consultant pharmacist recommended changing the order to include specific manifestations such as hallucinations, combativeness, delusions, or irritability with aggression, but the recommendation had no documented physician response or order change. The DON stated the nurses were responsible for verifying that orders were complete and that unclear orders could result in unnecessary medications being given. For another resident with diagnoses including COPD, pneumonia, anxiety disorder, major depressive disorder, depression, and rheumatoid arthritis, the orders for aripiprazole, mirtazapine, and sertraline did not include resident-specific manifestations or target symptoms. The consultant pharmacist recommended adding observable behaviors such as lack of motivation, crying, self-isolation, feelings of helplessness, and poor appetite, but there was no documentation of physician response or change to the orders. The resident’s care plan addressed antidepressant use and monitoring for side effects and effectiveness, but it did not list target behaviors. The DON stated there were no manifestations listed for the antidepressant orders and that nurses were responsible for verifying the orders were complete. The facility also failed to document specific non-pharmacological interventions before use of psychotropic medications. For the resident with severe cognitive impairment and a BIMS score of 6, the MAR listed interventions for agitation, depression, lack of motivation, and sadness/crying, including orientation/redirection, quiet calm environment, music, one-on-one attention, daily activities, and RNA/exercise routine, but the documentation only showed check marks and initials without identifying which intervention was actually attempted. The IP and DON stated that a check mark did not specify which intervention was implemented. Facility policy stated psychotropic medications should not be given unless a comprehensive assessment identified clear indications and parameters for use, and that targeted behavior should be clearly and specifically identified and monitored every shift.
PASRR Screening Not Completed for Resident With Schizophrenia
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed correctly for one resident with a documented diagnosis of schizophrenia. During a concurrent observation and interview, the resident was seen dressed and lying in bed with his lower legs elevated and stated he had been at the facility for nine years because it was a retirement home and he was a retired man. The resident’s admission record listed diagnoses including schizophrenia, Alzheimer’s disease, COPD, diabetes mellitus, anxiety disorder, and depression. Record review showed the resident’s MDS dated 4/15/24 documented a BIMS score of 15, partial to moderate assistance with ADLs, and diagnoses of Alzheimer’s disease, depression, and schizophrenia. The MDS also indicated the resident was receiving antipsychotic and antianxiety medications. A physician medication review report dated 2/11/26 listed olanzapine 5 mg, 0.5 tablet by mouth in the evening, for schizophrenia related to paranoid schizophrenia. The resident’s PASRR Level I screening dated 12/09/21 indicated the resident did not have a diagnosed mental disorder such as schizophrenia and did not take psychotropic medications for mental illness, resulting in a negative Level I finding for SMI. During interview, the DSD stated the resident did have schizophrenia and that question 10 should have been marked yes, which would have triggered a Level II PASRR screening. The DON stated staff should have verified a completed PASRR before admission and that if a Level II screening was needed, it should have been completed.
Missing Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed and implemented for a resident who had an oxygen order that began on 4/18/25. During an observation on 2/4/26 at 3:47 p.m., an oxygen concentrator was seen next to the bed, with the oxygen tubing wrapped on the side rail and the nasal cannula on the floor. During a concurrent interview and record review, the Infection Preventionist stated the resident was admitted on [DATE] and had oxygen at 2 LPM as needed. The IP also stated the resident's nursing note showed oxygen saturation in the 80s on 1/31/26, and that the resident did not have a care plan. The IP stated an initial care plan should have been completed when the oxygen order was started and revised every three months, and that the care plan should have been revised after the change in condition and low oxygen saturation. The resident's admission record showed diagnoses of Alzheimer's Disease, hypothyroidism, osteoporosis, and pulmonary edema. The MDS dated 2/12/26 indicated a BIMS score of 00, showing severe cognitive impairment. The DON stated the care plan should have been done with all orders, created immediately or by the end of the day, and that nurses were responsible for the care plan. The facility policy stated individualized care plans should reflect unique diagnoses and needs, support continuity of care and communication, be expanded as needs are identified, and be reviewed weekly and upon condition or order changes.
Care Plan Not Updated After Oxygen Order Change
Penalty
Summary
The facility failed to ensure that Resident 39’s care plan was reviewed and revised after a change in the physician’s oxygen order. Resident 39 was admitted from an acute care hospital with diagnoses including hyperlipidemia, essential hypertension, neuromuscular scoliosis, multiple sclerosis, and edema. The resident’s MDS dated 11/24/25 showed a BIMS score of 09 out of 15, indicating moderate cognitive impairment, and also indicated that the resident was receiving oxygen therapy. On 2/5/26, Resident 39 was observed in the hallway sitting in a wheelchair with a nasal cannula in place and an oxygen tank attached to the wheelchair set at 4 L/min. Record review showed the resident initially had an oxygen order for 2 L/min via nasal cannula dated 8/28/25, and that order was discontinued on 9/23/25. A new physician order dated 9/23/25 directed oxygen at 4 L/min via nasal cannula every shift to help maintain normal oxygen levels. However, the care plan dated 9/5/25 still listed oxygen as ordered PRN at 2 L/min via nasal cannula and checking oxygen saturation. During interview and record review, the IP stated the care plan was not updated to reflect the new 4 L/min oxygen order and that there was no revised care plan in place for that order. The IP stated that when a new order was received, it was the responsibility of licensed nurses to initiate and update the care plan immediately. The DON also stated the care plan reflected an oxygen order of 2 L/min that was no longer consistent with the current physician order and should have been updated to reflect the new order. Facility policy stated care plans are to be updated upon any condition changes or order changes, and the job descriptions reviewed stated licensed nurses are responsible for recognizing changes in condition and taking necessary action.
Failure to Initiate Bowel and Bladder Training
Penalty
Summary
The facility failed to ensure services were provided to restore or improve normal bladder and bowel function to the extent possible for one resident. During a concurrent observation and interview, the resident was seen dressed and sitting in a wheelchair next to the bed and stated she had been at the facility for a couple of months, wore a brief, had no bowel or bladder training, and had recently had irritation to her buttocks area. Record review showed the resident was admitted with multiple diagnoses including metabolic encephalopathy, pneumonia, type 2 diabetes mellitus, sepsis, acute kidney failure, atrial fibrillation, UTI, weakness, and anxiety disorder. The MDS indicated the resident had a BIMS score of 13, suggesting cognitive intactness, and required supervision or touching assistance for toileting hygiene and toilet transfer. The MDS also indicated the resident was always incontinent of urine and bowel and that no trial of a toileting program had been attempted on admission, entry, or reentry, or since urinary incontinence was noted. The facility's Bowel and Bladder Screener identified the resident as a candidate for scheduled toileting, with a score of 13 and recommendations for a scheduling toilet program. Staff interviews confirmed the resident was not on a bowel and bladder training program. The IP and DSD both stated the resident should have had a bowel and bladder training program initiated, and the LVN stated the resident was not on a toileting program. Facility policy described bowel and bladder retraining, including assessing residents who could benefit, evaluating the schedule, and training staff to use the resident's schedule every two hours.
Medication labeling, storage, and controlled drug accountability failures
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles. For Resident 11, who had diagnoses including essential hypertension, GERD, varicose veins with ulcer, alcoholic cirrhosis with ascites, venous insufficiency, and anxiety disorder, the admission record and MDS showed severe cognitive impairment with a BIMS score of 07. The resident had an order for lorazepam 0.5 mg by mouth at bedtime for anxiety and/or sleep, but the medication record sheet did not include the administration instructions. During review of the medication packet and record sheet, staff stated the labeling was incomplete and lacked the pharmacy-generated sticker, and the DON stated the handwriting was sloppy and illegible and did not constitute a complete order. For Resident 47, whose record showed diagnoses including hypokalemia, pneumonia, essential hypertension, and depression, the MDS showed moderate cognitive impairment with a BIMS score of 11. The resident had an order for lorazepam 0.5 mg, 0.5 tablet by mouth at bedtime for anxiety/phobias. The MAR showed the medication was administered on 1/3/26, but the CDR was not signed by the LN for that administration. During review, staff confirmed there was a blank space requiring a LN signature and stated the controlled drug accountability process required the LN to sign when the medication was given. The medication refrigerator in the medication room was also not maintained and monitored as required. During observation, the refrigerator temperature was 34 F, and later it was observed at 26 F while containing residents’ medications including insulin glargine, influenza vaccine, lorazepam oral concentrate, and tuberculin. Review of the temperature logs for November 2025 through January 2026 showed multiple missed entries on AM, PM, and NOC shifts, and many recorded temperatures were at 36 F and below. The facility’s MDL also showed repeated missing second-witness signatures and, in one instance, missing signatures by both witnesses for destroyed medications. In addition, three loose medications were found in the west wing medication cart, and staff stated they were not disposed of properly according to the facility’s discard process.
Call Lights Not Within Reach for Three Residents
Penalty
Summary
The facility failed to ensure that resident call lights were within reach for three sampled residents. During an observation in one resident’s room, the resident was lying in bed with eyes closed, and the call light was found on the floor at the head of the bed. In two other rooms, the call lights were observed on dressers and not within the residents’ reach while the residents were in bed. Resident 9 had diagnoses including acute and chronic respiratory failure with hypoxia, dementia, epileptic seizures, bipolar disorder, and heart failure. The resident’s MDS showed a BIMS score of 03, indicating severe cognitive impairment, and substantial/maximal assistance was coded for multiple areas of care, including toileting, bathing, dressing, hygiene, transfers, and mobility. Resident 11 had diagnoses including essential hypertension, GERD, varicose veins with ulcer, alcoholic cirrhosis with ascites, venous insufficiency, and anxiety disorder. The resident’s MDS showed a BIMS score of 07, indicating severe cognitive impairment, and the resident required substantial/maximal assistance in multiple functional areas, with dependence for shower/bath self and incontinence noted for bladder and bowel function. Resident 55 had diagnoses including senile degeneration of brain, hypothyroidism, type 2 diabetes mellitus, major depressive disorder, anxiety disorder, essential hypertension, and acute respiratory failure with hypoxia. The resident’s MDS showed a BIMS score of 00, indicating severe cognitive impairment, and the resident required partial/moderate to substantial/maximal assistance in several functional areas. During a concurrent observation and interview, CNA 4 found Resident 9’s call light on the floor, and found Resident 11 and Resident 55’s call lights on their dressers. CNA 4 stated Resident 11’s call light should be positioned next to the resident at all times so it could be used when needed, and stated the call light for Resident 9 was behind the bed on the floor for an unknown reason. CNA 4 also stated Resident 55’s call light was on the dresser rather than within reach for an unknown reason. RN 1 later reviewed pictures and validated that the call lights for all three residents were not within reach, and stated call lights should always be kept at the bedside within residents’ reach. The DON and DSD also reviewed the pictures and stated call lights should be within reach while residents are in bed, consistent with the facility’s policy requiring call lights at every bedside, restroom, and shower area, with remotes within resident reach at all times when in bed.
Failure to Refer Residents for Level II PASRR After New Mental Illness Diagnoses
Penalty
Summary
The facility failed to refer two residents for a Level II Preadmission Screening and Resident Review (PASRR) after they were diagnosed with new serious mental illnesses. According to facility policy, a resident review (RR) must be initiated and a Level I screening submitted in the PASRR system when there is a significant change in a resident's physical or mental condition, including new diagnoses of serious mental illness. For both residents, medical records showed new diagnoses of conditions such as bipolar disorder, anxiety disorder, psychosis, and dementia with agitation, but there was no evidence that the facility referred them to the appropriate state-designated authority for a Level II PASRR evaluation. Interviews with facility staff revealed a lack of awareness and follow-through regarding the PASRR process. The Admissions Coordinator stated that the MDS Coordinator was responsible for updating the PASRR when a new mental illness diagnosis occurred, but acknowledged that the process had not been completed. The MDS Coordinator confirmed she was unaware that a Level II PASRR was required for the affected residents. The Executive Director stated that staff were expected to revise and resubmit the PASRR to the state agency, but this had not occurred for either resident.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, resulting in inaccurate assessments. For one resident with a history of chronic obstructive pulmonary disease, a significant change in status MDS was coded to indicate the resident was rarely or never understood. Upon review, the MDS Coordinator acknowledged this was an error and that the resident's cognitive ability had been incorrectly documented. The inaccuracy was not identified until it was brought to the attention of the MDS Coordinator during the survey. For another resident with a history of anxiety disorder and major depressive disorder, the quarterly MDS did not reflect active diagnoses of anxiety or depression, despite these being present in the resident's medical history. The MDS Coordinator confirmed that these diagnoses were omitted from the MDS and subsequently amended the record. Both the DON and Executive Director stated their expectation that the MDS should accurately reflect residents' cognitive status and active diagnoses, but these were not captured at the time of the assessments.
Failure to Include Hospice Services in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing hospice care for a resident who was admitted with a history of anxiety disorder and major depressive disorder and was receiving hospice services. Documentation review showed that although the resident's admission orders included hospice care and restrictions on hospitalization and routine tests, there was no evidence in the care plan to indicate hospice services were addressed. The quarterly Minimum Data Set (MDS) confirmed the resident was on hospice, but the care plan did not reflect this, nor did it specify the services to be provided by the hospice agency. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed that hospice care was not included in the resident's care plan. The MDS Coordinator acknowledged the omission and stated that hospice should be included so staff are aware of the services and the involvement of the hospice team. The DON also stated that the care plan should include the reason for hospice admission and any specific requests from the resident or family. The Executive Director confirmed the expectation that hospice care be identified in the care plan.
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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 Reedley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vineyard Care Center | 0.5 mi | ★★★★★ | 2 | 0 |
| Palm Village Retirement Comm. | 1.2 mi | ★★★★★ | 1 | 0 |
| Dinuba Healthcare | 5.3 mi | ★★★★★ | 17 | 0 |
| Kingsburg Center | 8.3 mi | ★★★★★ | 3 | 0 |
| Bethel Lutheran Home | 9.1 mi | ★★★★★ | 19 | 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.