Above average — CMS composite of the measures below.
A standard survey is most likely before around July 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sierra View Medical Center during CMS and state inspections, most recent first.
A resident with a persistent vegetative state, chronic respiratory failure, and ventilator dependence had head lice first observed by a family member, who reported it to staff, but no timely action was taken to follow the facility’s head lice infection control policy. A CNA acknowledged being informed and shown a picture of the lice but could not recall reporting it to a nurse, and the LVN caring for the resident that day stated he was unaware of any lice. The Infection Control Nurse was not notified, the resident was not placed on contact isolation, and the physician was not notified for treatment until a later date when an RN assessed the resident after another family complaint and then initiated isolation, contrary to the facility’s written lice management protocol.
Surveyors found that empty and full oxygen cylinders were intermingled in the designated storage area, with three empty tanks stored alongside four full tanks. The Administrator confirmed the improper storage and was unsure of the cause. This deficiency was observed in one smoke compartment and affected 11 residents.
Surveyors identified that the facility's memorandum of understanding with partner facilities and providers, required for emergency preparedness, was expired at the time of review. The Administrator confirmed the agreement was not current and renewal was pending, resulting in noncompliance with emergency preparedness regulations.
Several residents receiving G-tube feedings were observed with their head of bed (HOB) elevated below the required 35 degrees, despite physician orders, care plans, and facility policy specifying this standard. Nursing staff acknowledged the HOB should have been higher during feedings, but did not maintain the required elevation, resulting in noncompliance with established protocols.
The facility did not consistently follow its policy requiring two licensed nurses to verify and sign narcotic count check sheets at each shift change, resulting in multiple instances of missing or incomplete documentation over several months. Interviews with the RN Supervisor and DON confirmed that this process was not properly followed, as required for controlled medication accountability.
Surveyors found that pre-made and opened food items, including sliced strawberries, strawberry puree, mixed fruit, brown rice, and breadcrumbs, were not labeled with use-by or opened dates and some were not covered as required. Staff confirmed these items should have been labeled and covered according to facility policy.
The facility did not perform required quarterly legionella testing of its water system, as confirmed by the absence of testing on several occasions and staff interviews. Additionally, an LVN failed to wear an isolation gown while providing suctioning care to a resident on contact and enhanced barrier precautions, contrary to facility policy.
The facility failed to ensure the Crash Cart was inspected daily, as required by policy. An RN confirmed that the Crash Cart Integrity Check List was not completed on multiple dates, potentially resulting in necessary supplies and medications being unavailable during an emergency.
The facility failed to ensure that two residents in a persistent vegetative state had appropriate surrogate decision-makers, relying instead on the Interdisciplinary Team (IDT) for advocacy. Despite attempts to contact a public conservatorship agency, no conservatorship was obtained, and the residents' rights to have a surrogate decision-maker were not honored.
The facility failed to ensure that two Respiratory Care Practitioners were competent in managing respiratory care equipment, leading to potential contamination and risk of respiratory infections for three residents. Observations revealed improper handling of tubing, and interviews confirmed that infection control policies were not followed.
The facility failed to follow infection control practices, including not changing suction canisters and Yaunker catheters per policy, not discarding contaminated T-pieces, improper storage of aerosol tubing, and inadequate hand hygiene by staff, leading to potential respiratory infection risks among residents.
The facility failed to re-evaluate the need for a left-hand mitten restraint for a resident after 90 days as per the physician's order. The restraint was found in the resident's room, and there was no current physician's order for its use, as the charge nurse did not re-evaluate the need for it.
The facility failed to ensure the head of bed was raised at least 35 degrees while a resident was receiving g-tube feedings. An LVN confirmed the head of bed was at 25 degrees, contrary to the physician's order and facility policy, increasing the risk of aspiration.
A facility failed to ensure a physician-ordered medication, Pantoprazole, was available for a resident requiring it to reduce stomach acid. Despite being ordered from the pharmacy, the medication was not received in time for administration, contrary to the facility's policy on timely drug administration.
The facility failed to include required language in arbitration agreements for two residents, potentially affecting their awareness of their rights to communicate with officials. Despite the Admin/DON stating that the facility does not offer arbitration agreements, signed agreements were found for two residents, lacking the necessary language. The facility could not provide a policy for arbitration agreements when requested.
Failure to Implement Head Lice Infection Control Policy and Timely Isolation
Penalty
Summary
The facility failed to implement its infection control guideline for head lice for one resident. On 11/6/25, the resident’s family member observed lice on the resident’s pillow at approximately 8:13 p.m. and reported this to staff, though the family member could not later identify which staff were notified. The resident, who had been admitted on 10/30/25 with a persistent vegetative state, chronic respiratory failure, and ventilator dependence, was under the care of CNA 1 and LVN 1 on that date. CNA 1 stated the complainant told her about the lice and showed her a picture on 11/6/25, but she could not remember if she reported this to a nurse or who the nurse was. LVN 1, who also worked with the resident on 11/6/25, stated he was not made aware of any lice by family or staff. The Infection Control Nurse (ICN) confirmed that she was not notified of the lice infestation on 11/6/25 and that the resident was not placed on isolation until 11/16/25, ten days after lice were initially observed. The ICN stated that facility interventions for lice include immediately placing the resident on contact isolation and notifying the physician, and there was no physician notification documented on 11/6/25. On 11/16/25, RN 1, who was working with the resident, received a complaint from the family about lice, assessed the resident, and noted lice, at which point the resident was placed on isolation. RN 1 reported he had not received any prior report indicating the resident had lice, although the complainant told him she had reported the issue to other staff previously. Review of the facility’s undated policy "INFECTION CONTROL GUIDELINE FOR PEOPLE WITH HEAD LICE" showed that patients with lice are to be placed in contact isolation, with gown and glove use, bagging of linens, and physician notification for treatment, measures that were not implemented when lice were first reported on 11/6/25.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to properly maintain the storage of medical gas cylinders, specifically oxygen tanks, as required by NFPA 101 and NFPA 99 standards. During a tour of the facility, surveyors observed that empty and full oxygen cylinders were intermingled within the designated storage area. Specifically, three empty oxygen tanks were found stored in the section intended for full tanks, alongside four full tanks. This observation was made in one of three smoke compartments and affected 11 of 33 residents. Upon interview, the Administrator confirmed the finding and indicated uncertainty regarding why the tanks were misplaced. The report notes that the storage closet did not comply with the requirement to segregate empty cylinders from full ones, as outlined in the relevant fire and safety codes. No additional information about the medical history or condition of the affected residents was provided in the report.
Plan Of Correction
Potential Patients affected The organization was unable to find in a retrospective review that any patients had been adversely affected and were not placed in an immediate jeopardy situation. Immediate Organizational Action During the building tour it was discovered that 3 empty oxygen tanks were being stored in the full section. The facility had Engineering remove the tanks. Organizational System Improvements: Persons responsible: Environment of Care/Safety & Security Manager The Environment of Care/ Safety & Security Manager had an additional 6 tank holder ordered so that there is available storage capacity for empty tanks, this will reduce the risk of comingling tanks. (see attachment C) PI Monitoring: The Facility will utilize its Environment of Care (EOC) rounds to ensure that proper tank storage is being adhered to.
Expired Emergency Operations Agreement
Penalty
Summary
The facility failed to maintain an up-to-date Emergency Operations Plan (EOP) as required by federal regulations. During a record review and interview with the Administrator, surveyors found that the memorandum of understanding with partner facilities and providers, which is necessary to ensure the continuity of services to residents in the event of limitations or cessation of operations, was expired. The agreement provided by the facility had an expiration date in February 2025, and at the time of the survey, it was no longer valid. The Administrator confirmed during the interview that the agreement was expired and stated that renewal was in process. This lapse in maintaining a current arrangement with other facilities could affect the facility's ability to properly respond during an emergency, as required by the emergency preparedness regulations. No specific residents or medical histories were mentioned in relation to this deficiency.
Plan Of Correction
Sierra View Medical Center Distinct Part Skilled Nursing Unit submits this plan of correction as part of the requirement under the State and Federal regulations. The plan of correction is submitted and shall not be construed as admission to the alleged deficiency cited or any liability. The plan of correction shall constitute a credible allegation of compliance. Potential Patients affected The organization was unable to find in a retrospective review that any patients had been adversely affected and were not placed in an immediate jeopardy situation. Immediate Organizational Action During document review, it was noted that the Hospital's Memorandum of Understanding (MOU) with its regional partners had expired on February 26, 2025. The MOU is normally updated by the EMS Coordinator-Disaster Services Fresno County MHOAC and sent out for all parties to agree upon. The Environment of Care/Safety & Security Manager from Sierra View notified the coalition of the need for an updated MOU. The EMS Coordinator from Fresno County then submitted an addendum to the coalition for an extension of the MOU until December 31, 2025. All parties agreed and the amendment to the MOU was officially updated. (Please see attachments A & B highlighted areas) Organizational System Improvements: Persons responsible: Environment of Care/Safety & Security Manager The Environment of Care/Safety & Security Manager will attend regular meetings with the coalition to ensure the MOU does not lapse. PI Monitoring: The MOU will be presented no less than annually to the organization’s Safety Committee for tracking purposes.
Failure to Maintain Required Head of Bed Elevation During G-Tube Feedings
Penalty
Summary
The facility failed to ensure that the head of bed (HOB) was properly elevated for five residents receiving gastrostomy tube (G-tube) feedings. During multiple observations, residents were found lying in bed with the HOB elevated to levels ranging from 18 to 27 degrees, which was below the required 35 degrees as specified in their physician orders and care plans. Nursing staff, including registered nurses, a licensed vocational nurse, and the director of nursing, acknowledged during interviews that the HOB should have been elevated to at least 30 or 35 degrees during tube feedings, in accordance with both physician orders and facility policy. Record reviews for each resident confirmed active orders and care plans specifying the required HOB elevation during tube feedings. The facility's policy also directed staff to elevate the HOB to 35-45 degrees during and for at least one hour after feedings. Despite these clear instructions, staff did not maintain the required HOB elevation during observations, resulting in noncompliance with physician orders, care plans, and facility policy for the care of residents with feeding tubes.
Failure to Consistently Complete Narcotic Count Documentation
Penalty
Summary
The facility failed to ensure that its policy and procedure for medication storage, specifically regarding the completion of Narcotic Count Check Sheets (NCCS), was consistently followed. Record review revealed that, across several months, there were multiple instances where either one or no licensed nurses signed the NCCS at required times, despite the policy mandating that two licensed nurses verify and sign the count at each shift change. Specific dates were identified where signatures were missing or incomplete, indicating that the required physical inventory of controlled medications was not properly documented. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that two nurses are responsible for counting narcotics and signing the NCCS at the beginning and end of each shift. The facility's policy also requires this process to be documented for all controlled substances in accordance with federal and state regulations. The observed lapses in documentation and missing signatures on the NCCS represent a failure to adhere to these established procedures.
Failure to Label and Store Food Items According to Standards
Penalty
Summary
Surveyors observed multiple instances in which food items in the facility's kitchen were not properly labeled or stored according to professional standards and facility policy. Specifically, twelve individual containers of sliced strawberries were found in the refrigerator without labels or dates, and the Nutritional Lead confirmed that these should have been labeled with the prepared and use-by dates. Additionally, two containers of strawberry puree and one container of mixed fruit were found uncovered and undated in the tray line refrigerator, and the Nutritional Lead acknowledged that these items should have been covered and dated. Further observations revealed that a 25-pound bag of brown rice and a 25-pound bag of Panko dry breadcrumbs, both stored in plastic bins, were open but not labeled with the date they were opened. Staff confirmed that these items should have been dated upon opening. Review of the facility's policy indicated that all foods in process must be covered, labeled, and dated with the expiration or opened date, but these procedures were not followed for the items observed.
Failure to Conduct Legionella Testing and Adhere to Contact Precaution Protocols
Penalty
Summary
The facility failed to follow standard infection prevention and control practices in two key areas. First, the facility did not conduct required quarterly testing of its water system for legionella bacteria, as indicated by the absence of testing on several documented dates. The Safety and Security Manager confirmed that the facility's water was not tested for legionella on multiple occasions, despite a previous request to begin such testing and a water management program recommending quarterly sampling. The Director of Nursing was unaware that the testing had not occurred, and the facility's water management plan outlined the need for routine monitoring and sampling. Second, a Licensed Vocational Nurse did not adhere to contact precaution protocols while providing respiratory care to a resident on contact and enhanced barrier precautions. During a suctioning procedure for a resident who was coughing, the nurse failed to wear an isolation gown as required by the facility's policy for contact precautions. The nurse acknowledged the omission and stated an attempt was made to avoid close contact, despite the policy specifying the use of gloves and gowns when entering the room of a resident on contact precautions, especially when substantial contact with the resident or their environment is anticipated.
Failure to Inspect Crash Cart Daily
Penalty
Summary
The facility failed to ensure that the Crash Cart, used for 30 sampled residents, was inspected daily. During an interview and record review with a Registered Nurse (RN), it was found that the Crash Cart Integrity Check List (CCICL) was not completed on multiple dates. The RN confirmed that the crash cart is supposed to be checked every night shift and acknowledged that if the checklist is blank, it means the cart was not checked. The RN also stated that the cart needed to be checked to ensure that the supplies and medications were functioning and available in case of an emergency. A review of the facility's policy and procedure for Crash Carts indicated that daily inspections should include checking the defibrillator, the contents on top of the crash cart, the oxygen cylinder, and verifying tamper-evident seals. The policy also required the staff nurse to sign the CCICL to document the completion of these checks. The failure to complete these daily inspections had the potential to result in necessary supplies and medications being unavailable during an emergency.
Failure to Ensure Surrogate Decision-Makers for Residents
Penalty
Summary
The facility failed to ensure that two residents, who were in a persistent vegetative state and lacked family or conservators, had appropriate surrogate decision-makers. Instead, the facility's Interdisciplinary Team (IDT) was used as the sole source of advocacy for these residents. The facility's policy required the appointment of a surrogate decision-maker when a resident lacked decision-making capacity and had no written advance directive or court-appointed conservator. However, the facility did not follow this policy, resulting in the residents' rights to have a surrogate decision-maker not being honored. Interviews and record reviews revealed that the Next of Kin sections for both residents were blank, and the Person to Notify was listed as the facility's medical director. The Ombudsman, who previously attended care planning sessions, no longer participated due to a recommendation from the state ombudsman. Social Services attempted to reach out to a public conservatorship agency for guidance but did not obtain conservatorship, leaving the IDT to continue representing the residents. This failure was documented in the facility's policy and procedure and an All Facilities Letter from the state health care agency, which indicated the need for public patient representatives in such cases.
Failure to Ensure Competency in Respiratory Care Practices
Penalty
Summary
The facility failed to ensure that two Respiratory Care Practitioners (RCP 1 and RCP 2) were competent in setting up and managing respiratory care equipment according to facility policy. This was observed in the cases of three residents (Resident 8, Resident 6, and Resident 10). During observations, corrugated tubing with oxygen was found laying on the floor, on empty beds, and touching the headboard, which is against the facility's infection control policy. Interviews with the RCPs and the Infection Preventionist (IP) confirmed that the tubing should have been placed in a clear plastic bag when disconnected from the resident to prevent contamination. Additionally, the tubing and water traps were not changed as required when contamination was identified, and PRN tubing changes were not documented, only weekly changes were recorded. Further review revealed that the annual competency assessments for RCP 1 and RCP 2 did not include evaluation of their ability to maintain infection control practices during the setup and changing of the tubing. The Manager of Respiratory Care Services (MRCS) acknowledged that these practices should have been part of the competency assessment and need to be incorporated. The failure to follow proper infection control procedures and the lack of comprehensive competency assessments had the potential to result in contaminated respiratory equipment being used, posing a risk of respiratory infections to residents with compromised respiratory systems.
Infection Control Deficiencies in Respiratory Care and Hand Hygiene
Penalty
Summary
The facility failed to follow standard infection control practices in several instances, leading to potential risks of respiratory infections among residents. In one case, a suction canister liner containing respiratory secretions was not changed when it was over three-quarters full for a resident with a tracheostomy. The resident was observed coughing with sputum filling his tracheostomy tubing, and the Registered Nurse acknowledged that the canister should have been changed at 750 ml. The Administrator/Director of Nursing confirmed that the canister should have been changed at that level. In another instance, a Yaunker suction catheter was not replaced per policy for a resident. The catheter was found open and dated as opened five days prior, but it should have been replaced three days after opening. Additionally, a T-piece used in oxygen delivery was found unlabeled, undated, and contaminated with dried mucus in another resident's room. The Respiratory Care Practitioner confirmed that the T-piece should have been discarded and replaced due to the lack of labeling and dating. Further observations revealed that aerosol tubing was not stored and secured properly, leading to potential contamination. Tubing was found laying on the floor, on empty beds, and touching the headboard in multiple residents' rooms. The Infection Preventionist and Respiratory Care Practitioner both stated that the tubing should have been placed in a clear plastic bag when disconnected to prevent contamination. Additionally, hand hygiene was not performed by a Licensed Vocational Nurse before and after glove use while providing care to two residents, which included administering medications and suctioning airways through tracheostomies. The facility's policy on hand hygiene was not followed, as confirmed by the Administrator/Director of Nursing.
Failure to Re-evaluate Restraint Use
Penalty
Summary
The facility failed to re-evaluate the need for a left-hand mitten restraint for Resident 14 after 90 days as per the physician's order. During an observation, a hand mitten restraint was found on the over bed table in Resident 14's room. A review of the physician's order dated 12/12/23 indicated that the restraint was to be re-evaluated after 90 days, which should have been done by 3/12/24. However, the Regulatory Registered Nurse confirmed that the order was out of compliance. Further review with the Administrator/Director of Nursing revealed that there was no current physician's order for the restraint, as the charge nurse did not re-evaluate the need for it. The facility's policy indicated that restraints should be initiated or continued only with a physician's order.
Failure to Elevate Head of Bed During G-Tube Feeding
Penalty
Summary
The facility failed to ensure the head of bed was raised at least 35 degrees while a resident was receiving gastrostomy tube (g-tube) feedings. During an observation, the resident's head of bed was noted to be at a 25-degree position while the g-tube feeding was being administered. This was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged that the head of bed should be at least 35 degrees to reduce the risk of aspiration. The resident's physician's order and the facility's policy both indicated that the head of bed should be elevated to 30-35 degrees during feeding. The failure to comply with these instructions had the potential for aspiration and respiratory infection.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered medication, Pantoprazole (Protonix), was available for administration to Resident 17, who required the medication to reduce excessive stomach acid. The Active Orders for Resident 17 indicated a daily dose of Pantoprazole 40 mg via gastric tube. During an observation and interview, an LVN stated that the medication was not available in the facility. Further review revealed that the medication had been ordered from the pharmacy two days prior but had not yet been received. The facility's policy on medication administration emphasizes the importance of timely and accurate drug administration, which was not adhered to in this instance.
Failure to Include Required Language in Arbitration Agreements
Penalty
Summary
The facility failed to ensure the required language was included in signed arbitration agreements for two residents, potentially affecting their awareness of their rights to communicate with federal, state, or local officials. During an interview, the Administrator/Director of Nursing (Admin/DON) stated that the facility does not offer arbitration agreements. However, a review of Resident 10's medical record revealed a signed arbitration agreement dated 6/29/19, which lacked the necessary language regarding the right to communicate with officials. This discrepancy was confirmed during a concurrent interview and record review with the Admin/DON, who acknowledged the existence of the signed arbitration agreement despite the facility's stated policy of not offering them. Similarly, during a concurrent interview and record review with Social Services (SS), it was found that Resident 12 also had a signed arbitration agreement that did not include the required language about the right to communicate with officials. The facility was unable to provide a copy of the policy and procedure for arbitration agreements when requested. This failure to include the necessary language in the arbitration agreements could lead to residents and their representatives being unaware of their rights to communicate with various officials.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sequoia Transitional Care | 0.2 mi | ★★★★★ | 12 | 0 |
| Sierra Valley Rehab Center | 0.6 mi | ★★★★★ | 1 | 0 |
| River Walk Care Center | 0.6 mi | ★★★★★ | 17 | 0 |
| Gateway Post Acute | 1.2 mi | ★★★★★ | 0 | 0 |
| Lindsay Gardens Nursing & Rehabilitation | 10.7 mi | ★★★★★ | 21 | 0 |
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