Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sierra Vista Healthcare during CMS and state inspections, most recent first.
Food and ice were not stored and sanitized according to standards when the kitchen ice machine had removable black residue, the maintenance staff did not run sanitizer through the machine as directed, and the food prep sanitizer tested below the required quaternary ammonium concentration. Staff also found an open high-calorie/protein supplement in a station refrigerator with no open date marked, despite directions to refrigerate after opening and use within 3 days.
Menu portions were not followed for three residents on large portion diets during lunch service. One resident received 3 oz of meatloaf instead of the ordered 4 oz large portion, and two other residents received 4 oz portions when their large portion diets required 6 oz for the entree. Record review showed the residents were ordered large portion diets with different textures, and the RD confirmed large portion diets should receive 1 1/2 servings of the entree.
The facility failed to maintain infection control practices for several residents. A resident with a Foley catheter had the drainage bag on the floor, and an LPN entered the room on EBP without a gown before handling the catheter. Two residents had O2 NC tubing left unbagged on the bed rail or oxygen concentrator instead of being stored properly. Another resident with a cough and suspected respiratory infection was not placed on TBP while testing was pending, and staff entered the room without the required PPE; the resident later tested positive for Influenza A.
Two residents had uncovered urinary drainage bags visible on their beds, including one resident with an indwelling catheter and another resident with both an indwelling catheter bag and a nephrostomy urine bag. Staff interviews confirmed the bags should have been covered to protect privacy and dignity, and the facility dignity policy stated urinary catheter bags should be kept covered.
Unsafe Bedside Storage of Self-Administered OTC Medications: A cognitively intact resident who self-administered her own meds kept nine OTC medications on her bedside table, and multiple observations confirmed the meds were left unsecured and accessible. The CNA, LVN, DON, and pharmacist consultant all stated the storage was not safe or secure, and the DON noted the resident was known to be noncompliant with bedside medication storage despite prior SAM documentation and education.
A resident with dementia, depression, PTSD, severe cognitive impairment, wandering, and elopement behaviors had a positive PASARR Level I screen, but the facility did not ensure a PASRR Level II evaluation was completed. The DHCS letter stated the case was closed after the resident was isolated as a health or safety precaution, and the DON confirmed no new Level I screening was scheduled and that the Level II follow-up should have occurred.
Failure to include a known hernia in the care plan. A resident with a documented abdominal/hiatal/ventral hernia had a visible abdominal mass and reported discomfort after meals, but the baseline care plan and subsequent records did not address the condition. The LVN was unaware of the hernia, the SSD noted surgery had been denied by insurance, and the DON acknowledged the active diagnosis should have been assessed, documented, and included in the care plan with appropriate interventions.
A resident with intact cognition was observed self-administering and storing ferrous sulfate, vitamin D3, and guaifenesin at bedside. The resident had no order for vitamin D3 or guaifenesin, and the ferrous sulfate order did not indicate bedside self-administration. Staff, including a CNA, LVN, PC, and DON, confirmed the medications were at bedside and that all self-administered medications required orders and order instructions.
Improper Medication Disposal Practices: Two med carts contained unlabeled denture cups being used to collect discarded medications during med passes. An LPN placed dropped thiamine and folic acid tablets into a denture container, and another LPN stated medications were held there until the end of the med pass or shift instead of being discarded in the proper designated container at the time they were wasted.
A resident's fluticasone propionate nasal spray in a medication cart was found without resident identifier information. An LVN confirmed the bottle was unlabeled, the PC stated it needed resident identifiers to avoid mix-ups, and the IP and DON said the patient name should have been on the bottle. The facility policy required individual drug containers to be properly labeled with the resident's name.
Pureed Diets Served Without Proper Consistency: A facility failed to prepare pureed meals in the correct form for three residents with dysphagia and pureed diet orders. During meal observations, pureed meat, vegetables, pasta, and breadstick items were too thin, ran together, and did not hold shape. Dietary staff said they blended food until lump free, but recipes did not specify liquid or thickener amounts, and staff did not test consistency for adequacy.
Incomplete and Unavailable Bed Rail Consents: Two residents had bed rail consent records that were incomplete, inaccurate, or not readily accessible. One resident's consent lacked key details such as the indication for use, nurse signature, and dates, while another resident's consent could not be found in the chart and later retrieved from off-site storage was tied to an older order and missing required information. Staff confirmed the consents were not complete and did not match the active bed rail orders.
A resident with acute encephalopathy, severe cognitive impairment, and a history of wandering eloped from the facility after staff failed to respond promptly to a triggered security bracelet alarm at the front door. The resident, who was independently mobile and assessed as high risk for elopement and falls, was later found at a family member's home and returned to the facility with the security bracelet still in place. Facility leadership confirmed that the alarm was not answered immediately, and several other residents at high risk for elopement were also present in the facility.
A resident with a fractured ankle and suspected surgical site infection did not receive a prescribed antibiotic because the physician's order, received via fax, was not provided to clinical staff as required. The breakdown in communication led to the resident missing the ordered treatment.
A resident with cognitive and physical impairments fell and fractured his hip after attempting to self-transfer from a bed with unlocked wheels. The bed had been moved by a CNA to assist the resident's roommate, and the wheels were not locked afterward. Staff interviews confirmed that bed wheels should be locked when residents are in bed.
The facility did not post the most recent survey results in an accessible location for residents and their representatives. A binder labeled CDPH Survey Results was missing the last recertification survey results. Interviews with the DON and ADM revealed a misunderstanding about the requirement to include survey results from 2022. The facility's policy on Resident Rights states that residents have the right to examine survey results, which was not met.
The facility failed to properly store and label medications, with two medication carts found unlocked and unattended, posing a risk of unauthorized access. A bottle of polyethylene glycol 3350 was left unattended on a cart, and an expired bottle of Lactulose was found in another cart, indicating lapses in adherence to storage and expiration policies.
The facility failed to maintain an infection prevention and control program, with deficiencies in sharps storage and oxygen equipment maintenance. Sharps containers were improperly stored in an accessible room, posing a risk of injury. Oxygen concentrator filters for several residents were dirty, and there was confusion about cleaning responsibilities. Additionally, a resident's oxygen tubing was not labeled with the change date, risking infection. These issues indicate a lack of adherence to infection control policies and inadequate staff training.
Five residents experienced a delay of up to 30 minutes in receiving their lunch trays while watching others eat, due to a lack of communication between nursing and dietary staff. This affected their dining experience and violated their right to dignity. The facility's policy emphasizes treating residents with dignity and respect, which was not upheld in this instance.
The facility failed to implement resident-centered care plans for three residents, leading to potential risks and unmet medical needs. A resident lacked a care plan for prescribed medication, another had exposed bedrail padding despite a seizure risk, and a third had no care plan for a change in condition related to diarrhea. Staff acknowledged these oversights, which were confirmed through observations and interviews.
A resident with a fluid restriction order was allowed to consume more fluids than prescribed during a meal, leading to a deficiency in care. Staff acknowledged the oversight, and the facility's policy to check trays for correct diets was not effectively followed.
The facility exceeded the acceptable medication error rate with two incidents involving improper administration. An LVN gave a resident glucophage and methenamine without food, against instructions, risking GI distress. Another LVN mixed Polyethylene Glycol with insufficient water, leading to potential discomfort. Both errors were acknowledged by staff and highlighted the need for adherence to medication instructions.
A dietary staff member failed to check the internal temperature of pork loins before serving, as observed during a survey. The staff member admitted to not knowing the required temperature, and both the Dietary Service Manager and Dietitian confirmed the importance of this step to prevent foodborne illness. Facility policies and professional guidelines emphasize the necessity of using a food thermometer for safety.
The facility failed to ensure sanitary food preparation and storage, affecting 87 residents. A serving cart was found with a white powdered substance and other items, while a kitchen storage room had dirt, debris, and a missing baseboard. The Dietary Manager Supervisor, Registered Dietitian, and Administrator acknowledged the importance of cleanliness to prevent contamination and pest attraction.
A resident's POLST form was not completed and signed by a physician for over eleven days after admission, contrary to facility policy. Staff interviews indicated the form should have been completed upon admission and signed within 72 hours. The resident, with multiple diagnoses and moderate cognitive impairment, was automatically considered full code due to the incomplete form.
A resident's personal information was exposed when an LVN left a computer screen open and unattended, violating privacy protocols. Facility staff confirmed that this action breached HIPAA regulations and contradicted the facility's policy on maintaining residents' confidentiality.
Two residents experienced an unclean and cluttered environment due to one resident's food hoarding habits. Despite being cognitively intact, the resident continued to store various food items improperly, leading to potential risks of pest infestation and foodborne illness. Facility staff attempted to manage the situation through education and alternative storage solutions, but the resident often refused assistance.
A facility failed to accurately complete the PASRR for a resident admitted with unspecified psychosis and depression, who was on psychotropic medications. The PASRR from the hospital inaccurately indicated no need for Level II screening and no mental illness diagnosis, which was not corrected by the facility. The DON acknowledged the oversight, which could affect the resident's psychiatric care.
A resident with diabetes and other conditions had long, thick, and crooked toenails due to the facility's failure to ensure proper foot care. Despite the resident's refusal of podiatry visits, staff did not take further action to address the issue, which was contrary to the facility's foot care policy.
A resident with no cognitive impairment did not have his meal preferences documented, leading to him not eating his lunch due to a dislike for Italian food. Despite the facility's policy to accommodate preferences, staff failed to ensure meal tickets were accurate, resulting in the resident not receiving a meal he would eat.
A resident with psychosis and muscle weakness was not provided with the necessary built-up utensils on her meal tray, as required by her care plan. Despite the facility's policy and staff responsibilities, the dietary aides failed to ensure the correct utensils were placed, leading to the deficiency.
A resident with dementia, known for wandering, exited a facility unsupervised and was found in a rose garden during extreme heat, resulting in second-degree burns and an acute kidney injury. The resident, who had severe cognitive impairment and was a fall risk, required hospitalization for treatment. Staff interviews confirmed the resident needed constant supervision, which was not provided, leading to the incident.
Food and Ice Storage and Sanitization Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food and ice in accordance with professional standards when the kitchen ice machine was found with several areas of removable black substance. During observation, dietary staff were seen pouring ice from the machine into pitchers of water for resident use, and a paper towel wiped inside the ice chute and water curtain showed visible black residue. The maintenance assistant stated he cleaned the ice machine monthly and last cleaned it on 12/30/25, but he did not run the required sanitizer through the machine as part of the cleaning process, despite the manufacturer’s instructions posted on the machine directing sanitizer to be added through the system. The facility’s sanitizer solution for the food preparation area was also not at the required concentration. During observation, a dietary staff member cleaned a stainless-steel food preparation counter after preparing minced and moist chicken and then used the red sanitation bucket containing quaternary ammonium solution to wipe the counter. The staff member tested the solution and stated it was 100 ppm, which was not acceptable, and that the sanitizer needed to be 200 ppm. The facility policy required environmental surface sanitizing with 150–200 ppm quaternary ammonium compound. In addition, an open high calorie/protein nutritional supplement drink was observed in a station refrigerator, half full and without an open date written on the carton. A LVN stated the drinks were good for three days after opening and said the carton had no open date and would be discarded immediately. The product’s storage and handling directions stated it should be refrigerated after opening and used within 3 days.
Menu Portions Not Followed for Residents on Large Portion Diets
Penalty
Summary
The facility failed to ensure residents’ nutritional needs were met when the menus were not followed for three residents on large portion diets during lunch service. Resident 21 received 3 ounces of meatloaf instead of the 4-ounce large portion listed on the Diet Spreadsheet, while Residents 7 and 55 each received 4 ounces of meatloaf even though their large portion diets required 6 ounces for the entree. The meal service observations showed Dietary Manager and Dietary staff preparing the trays in the kitchen and serving the incorrect portions to the residents. Record review showed Resident 7 was ordered a regular large portions diet with minced and moist texture, Resident 21 was ordered a regular large portions diet with regular texture, and Resident 55 was ordered a regular large portions diet with pureed texture. The facility’s Dining Service Menu Guide stated that large portions diets for lunch and supper should receive 1 1/2 servings of the entree. During interview, the RD stated that large portions for puree and minced and moist diets should receive more than the regular portion and confirmed that if the residents only received the regular size portion, that was incorrect.
Infection Control Failures With Catheter Care, Oxygen Storage, and Respiratory Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for five sampled residents. One resident had a Foley catheter drainage bag lying on the floor in the room, and an LVN entered the room on enhanced barrier precautions without donning a gown before handling the catheter. The resident had been admitted with a UTI, and the facility’s infection preventionist and DON stated the catheter bag should not have been on the floor and staff needed to wear a gown and gloves when touching or manipulating the catheter. Two residents had oxygen nasal cannulas and tubing found not in use and not stored in a plastic bag. In one room, the oxygen tubing and nasal cannula were wrapped around the bed rail. In another room, the tubing was laying on top of the oxygen concentrator. Staff interviewed about both residents stated the tubing should have been placed in a bag when not in use for infection control, and the DSD stated the tubing should not have been left on the bed rail or concentrator. Another resident was symptomatic with a dry, intermittent non-productive cough and was suspected of having a transmissible respiratory infection, but transmission-based precautions were not initiated while lab results were pending. The resident was observed wearing a mask in the room without precaution signage or PPE at the entrance, and staff entered the room without mask, goggles, gown, or gloves. The resident later tested positive for Influenza A. The IP and DON stated the resident should have had transmission-based precautions and PPE in place while the respiratory infection was being evaluated.
Uncovered urinary drainage bags left visible
Penalty
Summary
The facility failed to provide care in a manner that maintained resident privacy, dignity, and respect when the foley catheter drainage bags for two sampled residents were left uncovered. During observation, one resident was seen in bed with an uncovered urine bag hanging on the lower side rail of the bed, and another resident was seen with two uncovered urine bags hanging on opposite sides of the bed. Both residents were observed sleeping in bed and wearing gowns at the time of the observations. Resident 95 was admitted from an acute care hospital with diagnoses including hemiplegia, hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and gastrostomy. The resident's MDS dated 12/24/25 showed a BIMS score of 3, indicating severe cognitive impairment. During a concurrent observation and interview, CNA 1 stated the urine bag should have had a cover to protect the resident's privacy and dignity and that the resident did not need people seeing their urine. The RN also stated the bag should have been covered for privacy. Resident 14 was admitted from an acute care hospital with diagnoses including sepsis, obstructive and reflux uropathy, and dementia. The resident's MDS showed a BIMS score of 8, indicating moderate cognitive impairment. During interview, CNA 2 stated the urine bag should have had a cover over it, including the nephrostomy urine bag, to protect privacy and dignity. The DSD stated the expectation was that all residents with an indwelling urinary catheter have a privacy bag on the drainage bag, and that the same dignity bag should have been provided for the nephrostomy urine bag because it also collected urine. The facility policy on dignity stated staff shall promote, maintain, and protect resident privacy and help residents keep urinary catheter bags covered.
Unsafe Bedside Storage of Self-Administered OTC Medications
Penalty
Summary
The facility failed to ensure that one of seven sampled residents, Resident 96, safely and securely stored self-administered medications at bedside. Resident 96 was admitted with diagnoses including atrial fibrillation, type 2 diabetes mellitus, anemia, and hyperlipidemia. Her MDS dated 12/24/25 showed a BIMS score of 15, indicating she was cognitively intact. During observations on 1/6/26, 1/8/26, and 1/9/26, nine OTC medications were seen on her bedside table, including calcium, cranberry concentrate with acerola, D-Mannose, GOLO release, hyaluronic acid with MSM, ferrous sulfate, vitamin D3, guaifenesin ER, and dextromethorphan polistirex ER. Resident 96 stated she self-administered her own medication and had always stored her OTC medications on her bedside table. CNA 4 and LVN 3 both observed the medications on the bedside table and stated the medications were not being stored safely or securely. LVN 3 stated Resident 96 had completed a SAM on 12/25/25 indicating she verbalized the need for safe storage and agreed to the facility's terms and policies for self-administration, but also stated that if she could not safely store her medication at bedside and agree to the policies, she would not be an appropriate candidate for self-administration. LVN 3 further stated Resident 96 was not safely or securely storing her OTC medications and was known to refuse safe storage. The DON stated Resident 96 was known to be noncompliant with safe storage of self-administration medication at bedside and had left her bedside table with medications in the hallway. The DON stated she had documented the non-compliance and education in progress notes and stated the SAMs were not assessed appropriately if the resident was known and documented to be noncompliant. The pharmacist consultant stated residents who were known or observed to be non-compliant with bedside storage were not appropriate candidates to keep medication at bedside, and that storing nine OTC medications on the bedside table was not safe or secure. The facility policy stated self-administered medications must be stored in a safe and secure place not accessible by other residents, or otherwise stored on a central medication cart or in the medication room.
PASARR Level II Evaluation Not Completed After Positive Level I Screen
Penalty
Summary
The facility failed to ensure that one resident with a positive PASARR Level I screening for serious mental illness received a PASARR Level II evaluation by the designated entity. Resident 53 was admitted from an acute care hospital with diagnoses including dementia, repeated falls, major depressive disorder, and post-traumatic stress disorder. A DHCS letter dated 1/4/22 documented a Level I date of 08/16/2021 and stated that a Level II evaluation was not scheduled because the individual was isolated as a health or safety precaution, and the case was closed with instruction to submit a new Level I screening to reopen it. Resident 53’s record showed severe cognitive impairment, with a BIMS score of 3 on the 12/4/25 MDS. The care plan documented behaviors related to dementia, including getting out of bed unassisted, walking around the hallway, angry outbursts, hoarding food and drinks, and trying to get out of the facility. The care plan also documented wandering and elopement risk, frequent requests to go out, use of a wander guard, and use of bed and wheelchair sensor alarms and a fall mat. During interviews, the DON reviewed the DHCS letter and stated that a new Level I screening was not scheduled. The DON stated the resident’s Level II screening should have been followed up and a new Level I screening should have been scheduled. The DON also stated the resident should have had a Level II evaluation if he triggered a positive Level I screening, and that the facility could not verify whether a positive PASARR Level II screening indicated specialized services were needed. The facility policy stated that a positive Level I screen necessitates a PASRR Level II evaluation prior to admission and that residents who remain in the facility longer than 30 days after an exception should be screened using the State’s Level I process and referred for Level II evaluation.
Failure to Include Known Hernia in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 6, who had a known abdominal hernia that was not addressed in the care plan. Resident 6’s record showed diagnoses including adult hypertrophic pyloric stenosis, gastrointestinal hemorrhage, type 2 diabetes mellitus, anemia, and abdominal hernia. During observation and interview, Resident 6 pointed out a large visible mass in the middle of the stomach, stated it was a hernia that had been present for years, and said the facility knew about it. Resident 6 also stated the hernia caused discomfort after meals and that surgery had been scheduled but insurance had denied it. Record review showed the admission/readmission screen and baseline care plan documented admission from a hospital with gastric outlet obstruction, but the gastrointestinal history/comments section did not note the hernia, and the skin and wound assessment section also did not include it. Additional records showed a discharge summary identifying a 2 cm hiatal hernia after an EGD, progress notes acknowledging a small hernia, an after-visit summary listing ventral hernia without obstruction, and a later discharge summary noting a hernia containing loops of small bowel that may have been causing a component of gastric outlet obstruction. Resident 6 returned to the facility with a diagnosis of abdominal hernia without obstruction, but the condition was still not reflected in the care plan. Staff interviews confirmed the hernia was not being addressed in the resident’s plan of care. An LVN stated they were not aware of the abdominal hernia and said an assessment would have been done if the resident had complained of abdominal pain. The SSD stated the resident had the hernia since 10/24, that insurance had denied surgery, and that the referral was being processed, but there was no mention of the hernia upon return from the hospital. The DON acknowledged the hernia was an active diagnosis that should have been assessed, documented, and included in the care plan with appropriate interventions, and stated the medical record should reflect accurate assessments and monitoring.
Self-Administered Medications at Bedside Without Proper Orders
Penalty
Summary
The facility failed to ensure professional standards of practice for one resident who self-administered medications at bedside. Resident 96 was admitted with diagnoses including atrial fibrillation, type 2 diabetes mellitus, anemia, and hyperlipidemia, and had a BIMS score of 15 on the MDS, indicating intact cognition. The resident was observed with ferrous sulfate 325 mg, vitamin D3 10,000 IU, and guaifenesin extended-release 1200 mg on the bedside table and stated she self-administered and stored these medications at bedside every day. Record review showed the resident did not have an order for vitamin D3 10,000 IU or guaifenesin extended-release 1200 mg. The resident did have an order for ferrous sulfate 325 mg, but the order did not indicate that it could be self-administered at bedside. During interviews, the resident, CNA, LVN, pharmacist consultant, and DON all confirmed that the medications were being kept and self-administered at bedside, and that all medications being administered required an order. The LVN and DON stated the facility policy and procedure was not followed when the resident self-administered vitamin D3 and guaifenesin without orders and ferrous sulfate without order instructions for bedside self-administration. The facility policy titled, Medications Brought to the Facility by the Resident/Family, required medications brought in from outside to be ordered by the attending physician and documented on the physician's order sheet. The Self-Administration of Medications policy required staff to identify medications found at the bedside that were not authorized for self-administration and to routinely check self-administered medications. The report states the resident was self-administering medications at bedside without complete and accurate provider orders, and the DON stated this created a risk for inadequate monitoring, adverse side effects, and duplicate therapy.
Improper Medication Disposal Practices
Penalty
Summary
The facility failed to properly follow medication disposal procedures when two medication carts contained unlabeled denture containers being used to discard medications. During observation of an LVN's medication pass, a thiamine 100 mg tablet and later a folic acid 1 mg tablet were dropped and then placed into a denture container rather than an appropriate medication disposal container. The LVN stated the denture container was being used to discard medications during the med pass and that tablets, capsules, and liquids were collected there before being placed in the actual medication disposal container at the end of the shift. During review of the second medication cart in station one, another LVN stated the cart also contained a denture container used for disposing medications and that discarded medications were placed there until the end of the medication pass. The LVNs stated medications should have been placed in the proper disposal container at the exact time they needed to be discarded, not at the end of the medication pass or shift. The Pharmacy Consultant and DON both stated medications should be disposed of in an appropriate designated container, and the Pharmacy Consultant stated proper tamper-proof disposal containers were available in sizes that could fit in the medication carts.
Unlabeled Nasal Spray in Medication Cart
Penalty
Summary
The facility failed to label medications in accordance with accepted professional principles for one of two nasal spray medications located in station 1's medication cart 1. During observation and interview, Resident 102's fluticasone propionate nasal spray bottle was found without resident identifier information on the bottle. Resident 102's Order Summary Report showed the resident was prescribed fluticasone propionate 50 MCG to be given once a day in each nostril. During the concurrent observation, LVN 5 stated the medication was a nasal spray used by inserting the tip of the bottle into Resident 102's nose to deliver the medication, and confirmed the resident's name was not on the bottle. LVN 5 stated fluticasone was a common medication and that not labeling the bottle could cause confusion if another resident had the same medication. The Pharmacy Consultant stated the bottle needed resident identifiers to avoid giving the medication to another resident who could be prescribed the same medication. The Infection Preventionist and DON both stated the bottle should have had the patient name on it, and the facility's policy required individual drug containers to be properly labeled with the resident's name.
Pureed Diets Served Without Proper Consistency
Penalty
Summary
The facility failed to ensure that pureed foods were prepared in a form designed to meet individual resident needs for three sampled residents with dysphagia. Resident 5, Resident 55, and Resident 84 each had physician-ordered pureed diets, and the facility’s menu for the lunch meals on 1/6/26 and 1/7/26 included pureed items such as meat loaf, potato gratin, spinach, grilled chicken, vegetable pasta, and breadstick. During lunch meal service observations, the pureed foods for Resident 5 and Resident 55 were touching and unable to hold their shape or form when plated, and Resident 84’s pureed grilled chicken and vegetable pasta ran into each other and did not hold form. During a concurrent observation of sample meal trays, the pureed Italian grilled chicken, vegetable pasta, and breadstick were also observed running into each other and not holding their shape or form. The Dietary Manager and Corporate Registered Dietitian stated the pureed food on the sample tray was not holding its shape or form, and the Dietary Manager stated the pureed foods were too thin. Interviews and record review showed staff knew pureed food should be smooth and hold its shape, but the facility’s recipes did not state how much liquid or thickener to add. Dietary staff stated they blended food until it was lump free and wanted it smooth and able to hold shape, but they did not perform testing to check adequacy of consistency. The facility’s documents described pureed food as smooth and pudding-like or smooth mashed potato consistency, and the Proper Puree Consistency document showed that food that is too thin can increase the risk of aspiration and choking and can also lead to inadequate nutrition due to decreased flavor, which may result in weight loss and malnutrition.
Incomplete and Unavailable Bed Rail Consents
Penalty
Summary
Medical records for two residents were incomplete and not readily accessible for bed rail use. For Resident 12, the record showed an active order for bilateral 1/2 side rails to aid bed mobility, turning, repositioning, and transfers, and the resident was observed sitting in bed with both upper rails up. However, the informed consent form for bed rail use was undated and did not list the specific medical or clinical condition requiring the rails, who the consent was discussed with, the licensed nurse signature, or the dates of the signatures. During interview and record review, facility staff confirmed that Resident 12's consent was not completed. The LVN stated the consent was missing the reason for bed rail use, who the information was discussed with, the nurse signature, and the dates the resident and ordering physician signed. The MRD also stated the record was incomplete and that bed rails should not have been implemented until the medical record was properly completed. Facility policies required informed consent before processing a new order and before use of side rails, and required documentation to be complete and accurate. For Resident 10, the informed consent for bed rail use could not be located in the electronic or paper chart for over 24 hours and had to be retrieved from off-site storage. The consent found in the off-site folders was incomplete and inaccurate because it did not include the full year for the representative's verbal consent, did not have the permission box checked, and was tied to an older bed rail order rather than the current order. Staff, including the LVN, MR, MRD, and DON, stated the consent should have been readily accessible and that a new consent was required for the new bed rail order, but the available document did not match the active order.
Failure to Respond to Elopement Alarm Results in Resident Leaving Facility
Penalty
Summary
A deficiency occurred when staff failed to respond promptly to a security elopement alarm, resulting in a resident eloping from the facility. The resident had been admitted with acute encephalopathy, severe impairment affecting judgment, and a history of wandering and elopement. Assessments indicated the resident was independently mobile, at high risk for both elopement and falls, and had a physician's order for a security bracelet to be worn on the right ankle. The care plan included interventions such as applying the security bracelet and checking its function and placement per protocol. On the day of the incident, the resident was last seen by staff outside his room during breakfast service. When the resident could not be located, a search was initiated inside and outside the facility. The security bracelet alarm at the front door was triggered, but staff did not respond to the alarm in a timely manner. The resident was eventually found at a family member's home approximately one mile away and was returned to the facility. At the time of his return, the security bracelet was still in place and functioning. Interviews with facility leadership confirmed that the alarm at the front door was sounding but was not answered immediately, as the receptionist who typically monitors the area was not on duty at the time. The facility had six other residents identified as high risk for elopement, all with physician's orders for security bracelets due to wandering or exit-seeking behaviors. Facility policies required adequate supervision and timely response to alarms for residents at risk of elopement, but these protocols were not followed during the incident.
Failure to Administer Prescribed Antibiotic Following Physician Order
Penalty
Summary
A deficiency occurred when a resident who was admitted for aftercare following a fractured left ankle did not receive a prescribed antibiotic for a suspected surgical site infection. The surgeon ordered Bactrim DS to be administered twice daily for ten days, starting on 3/3/25, after a follow-up visit raised concerns about infection. However, the antibiotic was not administered as ordered. The failure was traced to a breakdown in the facility's process for handling physician orders received via fax. The surgeon's progress note, which included the antibiotic order, was faxed to the facility and received by medical records staff, but it was not provided to the clinical staff as required. The Director of Nursing confirmed that the process in place to start antibiotics within four hours of receiving an order was not followed, resulting in the resident not receiving the medication as prescribed.
Resident Falls Due to Unlocked Bed Wheels
Penalty
Summary
The facility failed to ensure a resident was free from injury when he attempted to self-transfer out of his bed with the bed's wheels unlocked, resulting in a fall and fracture to his left hip. The resident, who was cognitively intact but had impairments in both lower extremities and required substantial assistance for transfers, attempted to transfer himself to his wheelchair. During this attempt, the unlocked wheels caused the bed to move, leading to the fall. The resident had been admitted to the facility with diagnoses including neurocognitive disorder with Lewy bodies, bipolar disorder, and dementia. Despite being wheelchair-bound and needing maximal assistance for transfers, the resident attempted to transfer himself after a CNA had moved his bed to assist his roommate and forgot to lock the bed's wheels. This oversight was confirmed by the resident, who stated that the CNA had asked for permission to move the bed but did not lock the wheels afterward. Interviews with staff, including CNAs and nurses, confirmed that the bed's wheels should have been locked when the resident was in bed. The bed was found moved from its normal position, and the resident was discovered on the floor by a nurse. The staff acknowledged that the bed would not have moved if the brakes were locked, indicating a failure to follow safety protocols regarding bed wheel locks.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that was easily accessible to all 91 residents, their families, and legal representatives. During an observation, a binder labeled CDPH Survey Results was found in a hallway near the main entrance, but it did not contain the results of the last recertification survey conducted on September 22. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that the survey results were not included in the binder. The ADM mistakenly believed that only results from the previous year needed to be stored, and since the survey was conducted in 2022, it was not included. The facility's policy on Resident Rights, dated August 22, indicated that residents have the right to examine survey results, which was not upheld in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional standards. Two of four medication carts were found unlocked and unattended by licensed nurses, which posed a risk of unauthorized access by residents, staff, and visitors. During observations, Licensed Vocational Nurses (LVNs) were seen leaving medication carts unlocked while attending to residents in their rooms, acknowledging that the carts should have been locked to prevent access to medications by unauthorized individuals. Additionally, a bottle of polyethylene glycol 3350 was left unattended on top of a medication cart, creating a potential risk for unauthorized access and misuse. The LVN responsible admitted to leaving the medication unattended and acknowledged the risk of it being accessed by residents, staff, or visitors. The Director of Nursing (DON) confirmed that leaving medications unattended on top of carts was against facility policy and posed a risk of unauthorized access and potential harm. Furthermore, an expired bottle of Lactulose was found in a medication cart, indicating a failure to adhere to the facility's policy of checking expiration dates before administering medications. The LVN and Assistant Director of Nurses (ADON) acknowledged that expired medications should not be present in the cart and could lead to ineffective treatment or harmful side effects. The facility's policies clearly stated that expired medications should be removed and destroyed, highlighting a lapse in adherence to these procedures.
Infection Control Deficiencies in Oxygen Equipment and Sharps Storage
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the improper storage of sharps containers in a room accessible to residents. The room contained five full sharps containers, one of which was uncovered, posing a risk of injury and cross-contamination. The room was used by an outside lab company, but the facility staff did not monitor or report the unsafe condition, despite the potential for residents to access the room and harm themselves. Another deficiency involved the maintenance of oxygen concentrators for multiple residents. Resident 58's oxygen concentrator filter was found covered in dirt, dust, and lint, which could introduce contaminants into the oxygen supply. Similarly, the oxygen concentrator filters for Residents 61 and 3 were covered with grayish-white material, indicating they were not cleaned regularly. There was confusion among staff about who was responsible for cleaning these filters, leading to a lack of proper maintenance and increased risk of respiratory issues for the residents. Additionally, Resident 345's oxygen tubing was not labeled with the date it was changed, which is necessary to ensure timely replacement and prevent respiratory infections. The facility's policies required nasal cannula tubes to be changed weekly and labeled with the date, but this was not adhered to, putting the resident at risk. These deficiencies highlight a lack of adherence to infection control policies and procedures, as well as inadequate staff training and communication regarding responsibilities for maintaining medical equipment.
Delayed Meal Service Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure a dignified dining experience for five residents, as they were made to wait up to 30 minutes for their lunch trays while observing other residents eat. This incident involved Residents 68, 81, 245, 246, and 350, who were left without their meals in the dining room on two separate occasions. The delay in serving these residents was attributed to a lack of communication between the nursing and dietary staff, as the lunch trays for these residents were mistakenly sent to their rooms instead of the dining room. Resident 68, who has a severe cognitive deficit, and Resident 81, with a moderate cognitive deficit, were among those affected. Resident 245, with no cognitive deficit, and Resident 246, with a severe cognitive deficit, also experienced the delay. Additionally, Resident 350, who has no cognitive deficit, was affected, and a family member expressed discomfort with the situation. The staff's failure to communicate effectively resulted in these residents being served significantly later than others, impacting their dining experience. Interviews with various staff members, including CNAs, the Dietary Service Manager, the MDS Coordinator, and the Director of Nursing, revealed that the standard practice was to serve one table at a time. However, due to a lack of communication, the dietary staff was not informed of the residents' presence in the dining room, leading to the delay. The facility's policy emphasizes treating residents with dignity and respect, which was not upheld in this instance.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for three residents, leading to potential risks and unmet medical needs. For Resident 31, there was no care plan for the use of clotrimazole medication, which was prescribed for a fungal infection on the toenails. This oversight was identified during a review of the resident's order summary and confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that a care plan should have been initiated immediately upon receiving the order. Resident 1's care plan was not properly implemented, as the padding on the left bedrail was not intact, exposing a metal bar. This was observed during room inspections and interviews with Certified Nursing Assistants (CNAs) and a Registered Nurse (RN). The care plan indicated the need for padded side rails due to the resident's history of seizures, but the nursing staff failed to ensure the padding was maintained, potentially putting the resident at risk of injury during a seizure. For Resident 53, there was no care plan developed for a change in condition related to diarrhea, which was documented in the SBAR communication form and progress notes. Despite the physician ordering tests to rule out C-Diff, the DON and other staff members confirmed that a care plan should have been created to address this change in condition. The absence of a care plan meant that the resident's medical needs might not have been adequately met.
Failure to Follow Fluid Restriction Order
Penalty
Summary
The facility failed to adhere to professional standards of quality care for a resident by not following the physician's fluid restriction order. The resident, who was admitted with diagnoses including psychosis and muscle weakness, was observed consuming more fluids than the prescribed limit during a meal. Specifically, the resident was allowed to consume 28 ounces of fluid in one meal, exceeding the allowed 10 ounces per meal as per the physician's order. This oversight was confirmed by multiple staff members, including a CNA, the Assistant Dietary Service Manager, and the Dietary Service Manager, who acknowledged that the resident received more fluid than ordered. Interviews with staff revealed a lack of compliance with the fluid restriction order, which was crucial to prevent potential health issues such as fluid overload. The Director of Nursing noted that the resident was confused and frequently requested more coffee, indicating a need for staff to consistently explain the fluid restriction to the resident. The facility's policy required the Food Service Manager or designee to check trays for correct diets before distribution, but this protocol was not effectively followed, leading to the deficiency.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11.54%. This deficiency was observed in two separate incidents involving medication administration. In the first incident, an LVN administered glucophage and methenamine to a resident without food, contrary to the medication instructions that specified administration with food. The LVN acknowledged the error, noting that the resident had eaten breakfast earlier, but did not provide food at the time of medication administration. The Assistant Director of Nursing and the Director of Staff Development confirmed that the medication orders should have been followed to prevent gastrointestinal distress. In the second incident, another LVN did not adhere to the medication instructions for administering Polyethylene Glycol to a different resident. The LVN mixed the medication with only four ounces of water instead of the prescribed eight ounces, resulting in a more concentrated solution. This deviation from the prescribed method was acknowledged by the LVN and confirmed by the Director of Staff Development, who noted that the error could lead to gastrointestinal discomfort and inefficient absorption. The facility's policy on medication errors emphasizes the importance of following physician orders and manufacturer instructions to prevent adverse consequences.
Failure to Ensure Competency in Food Temperature Checks
Penalty
Summary
The facility failed to ensure that a dietary staff member was competent in carrying out the functions of the food and nutrition services safely and effectively. During an observation, the dietary staff member was seen removing a baking tray containing three pork loins from the oven without checking their internal temperature. The staff member then proceeded to the prep area to slice the pork loins for service without verifying if they were cooked to the required temperature. In an interview, the staff member admitted to not checking the internal temperature and was unsure of what it should have been, acknowledging that he should have checked it upon removal from the oven. Further interviews with the Dietary Service Manager and the Dietitian confirmed that the staff member should have checked the temperature to ensure the pork loins were properly reheated, as per the facility's policy. The Dietary Service Manager stated that the pork loins were precooked but emphasized the importance of verifying the temperature to prevent foodborne illness. The Dietitian reiterated the necessity of following the recipe's temperature requirements and indicated that the Dietary Service Manager was responsible for training the staff member. The facility's policy and professional references reviewed highlighted the importance of using a food thermometer to ensure food safety.
Sanitation Deficiencies in Food Preparation and Storage
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices, affecting 87 of 91 residents. During an observation, a serving cart was found with a white powdered substance scattered across its surface, alongside items such as serving trays, gloves, aprons, garbage bags, and a utensil holder. The Dietary Manager Supervisor (DMS) acknowledged that the cart should be cleaned daily to prevent contamination and infection, and that it was the responsibility of the dietary aide to maintain its cleanliness. Additionally, a storage room in the kitchen was observed to have dirt and debris on the floor, with a missing baseboard on one wall. The DMS stated that maintenance was responsible for fixing the floors and baseboards, and acknowledged that the area was not clean. The Registered Dietitian (RD) and the Administrator (ADM) both confirmed the importance of maintaining cleanliness to prevent cross-contamination and pest attraction. The facility's policy and the USFDA Food Code emphasize the need for cleanliness in food-contact and non-food-contact surfaces, as well as proper storage of maintenance tools.
Failure to Timely Complete POLST Form
Penalty
Summary
The facility failed to ensure that a resident's code status was documented upon admission on the Physician Order for Life Sustaining Treatment (POLST) form. The POLST form for the resident was not completed and signed by the physician for more than eleven days after admission, which was not in accordance with the facility's policy and procedure. This oversight had the potential to result in the resident's wishes not being honored and unnecessary medical interventions being administered. Interviews with staff revealed that the POLST form should have been completed upon admission, with the physician or nurse practitioner required to sign it within 72 hours. The admission nurse was responsible for completing the POLST form and communicating the resident's wishes to the physician. However, the form was not signed by the physician until much later, and the resident was automatically considered a full code due to the incomplete POLST form. The resident involved was admitted with diagnoses including COVID-19, polyneuropathy, depression, hypertension, and constipation. The resident was moderately cognitively impaired but was her own responsible party. The facility's policy stated that the POLST form is not valid until signed by both the resident and a physician, and the failure to complete this process in a timely manner was a clear deficiency in the facility's adherence to its own procedures.
Privacy Breach Due to Unattended Computer Screen
Penalty
Summary
The facility failed to protect the privacy of a resident's personal information when a Licensed Vocational Nurse (LVN) left her workstation computer open and unattended, exposing the resident's information to public view. This incident involved Resident 34, whose personal and medical information was left visible on the computer screen outside their room. The LVN acknowledged that leaving the computer screen open was inappropriate and that it allowed any passing residents, staff, or visitors to potentially view the resident's private information. Interviews with facility staff, including the Assistant Director of Nursing (ADON), the Director of Staff Development (DSD), and the Director of Nursing (DON), confirmed that the facility's practice and expectation were to always close computer screens when not in use to protect residents' information. The DSD identified this incident as a violation of the Health Insurance Portability and Accountability Act (HIPAA), which mandates the protection of sensitive health information. The facility's policy and procedure document also emphasized the residents' rights to privacy and confidentiality, which were not upheld in this instance.
Failure to Maintain a Clean and Homelike Environment Due to Food Hoarding
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents, Resident 16 and Resident 39, due to the improper storage of personal food items. Resident 16 had a collection of fresh produce, canned goods, and various food items stored in their room, including on the floor and shelves, which created clutter and an unclean environment. This situation was observed during multiple visits, and Resident 39, who shared the room, expressed that the clutter made it impossible to use the shared sink. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), Resident 16 continued to hoard food despite repeated discussions and education from facility staff, including the Infection Preventionist, Director of Staff Development, and Registered Dietitian. The staff explained the risks of food hoarding, such as pest infestation and foodborne illness, but Resident 16 and their family persisted in bringing food into the facility. The facility staff attempted to manage the situation by checking expiration dates and offering to store food in a refrigerator, but Resident 16 often refused these measures. Housekeeping staff were observed cleaning the room but stated that their responsibilities did not include managing the food clutter. The Director of Nursing and other staff members acknowledged the ongoing issue and the potential risks it posed to the facility. Despite efforts to educate and offer alternative solutions, Resident 16's preference to remain in the facility with friends and continue their habits contributed to the deficiency in maintaining a clean and homelike environment.
Inaccurate PASRR Completion for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accurate completion of the Level I Preadmission Screening and Resident Review (PASRR) for a resident upon admission. The resident, who was admitted with diagnoses of unspecified psychosis and depression, was also on psychotropic medications. However, the PASRR completed at the general acute care hospital inaccurately indicated that the resident did not require a Level II screening and did not have a diagnosis of mental illness or prescriptions for psychotropic medications. This discrepancy was not identified or corrected by the facility upon the resident's admission. During a review, the Director of Nursing (DON) acknowledged that the PASRR assessment was not accurate and should have been reviewed and updated to reflect the resident's mental health diagnoses and medication needs. The facility's policy required confirmation and review of PASRR documentation from the hospital, which was not adequately followed in this case. This oversight had the potential to impact the resident's receipt of necessary psychiatric treatment and evaluation.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident 3, whose toenails were observed to be long, thick, and crooked. This condition was noted during an observation and interview with a registered nurse, who acknowledged that the toenails were not in an acceptable condition and should have been reported by certified nursing assistants (CNAs). Despite being aware of the condition, CNA 1 stated that Resident 3 had refused nail care, and no report was made to the nurse. The resident's refusal of podiatry visits was documented in the podiatry notes, and the Social Services Director indicated that if staff had alerted her, alternative arrangements could have been made. Interviews with various staff members, including a licensed vocational nurse, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing, revealed a consensus that the resident's refusal of nail care should have prompted further action. The staff acknowledged the potential risks associated with the resident's diabetic condition, which could lead to complications such as skin breakdown or infection. The facility's policy on foot care emphasized the importance of maintaining foot health, particularly for residents with medical conditions like diabetes, but the policy was not effectively implemented in this case.
Failure to Document and Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to document and accommodate a resident's meal preferences, resulting in the resident not eating his lunch. The resident, who had no cognitive impairment, expressed a dislike for Italian food, which was not documented on his meal ticket. On the day of the incident, the resident was served a meal consisting of spaghetti and zucchini, which he refused to eat due to his dislike for Italian food. Despite the availability of meal alternatives, the resident's appetite was ruined, and he did not request a different meal. Interviews with facility staff revealed a lack of communication and responsibility in ensuring meal preferences were documented and respected. The Certified Nursing Assistant (CNA) and Registered Nurse (RN) acknowledged their roles in checking meal tray accuracy and addressing resident meal preferences. The Dietary Services Manager and Assistant Dietary Services Manager stated that it was the dietary department's responsibility to document food preferences, and the Registered Dietitian emphasized the importance of providing alternate meals if a resident's meal was untouched. The facility's policy indicated that residents should receive meals according to their preferences, but this was not adhered to in this case.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment for a resident, identified as Resident 68, who required built-up utensils to feed herself independently and safely. During an observation in the dining room, it was noted that Resident 68's meal tray contained regular utensils instead of the prescribed built-up utensils. The resident's admission record and order summary report indicated the need for adaptive equipment, including a divided plate and built-up utensils, due to her diagnoses of psychosis and muscle weakness. Interviews with various staff members, including a Certified Nurse Assistant, Assistant Dietary Service Manager, Dietary Aide, Dietary Service Manager, and Registered Dietitian, revealed that the dietary aides were responsible for ensuring the correct utensils were placed on meal trays. However, the dietary aides failed to perform a final check before sending out the tray cart, resulting in the omission of the necessary adaptive utensils. The facility's policy and procedure on self-feeding devices stated that such devices should be provided with each meal, but this was not adhered to in the case of Resident 68.
Resident with Dementia Sustains Burns Due to Lack of Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accident hazards for a resident with dementia, who was known to independently move around the facility in a wheelchair. The resident, who had severe cognitive impairment and was a fall risk, managed to exit the facility unsupervised and was found in the rose garden exposed to extreme heat. The temperature on that day reached up to 108 degrees Fahrenheit, and the resident was outside for an unknown amount of time. As a result of this lack of supervision, the resident sustained second-degree burns on multiple parts of the body, including the scalp, right ear, neck, left shoulder, and both knees. Additionally, the resident suffered an acute kidney injury, likely due to dehydration from prolonged sun exposure. The resident required treatment at an acute care hospital for these injuries. Interviews with facility staff revealed that the resident had a history of wandering and required constant supervision. Staff members acknowledged that the resident should not have been left unattended outside, especially given the high temperatures. The facility's policy emphasized the importance of making the environment free from accident hazards and providing adequate supervision based on individual resident needs, which was not adhered to in this case.
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Illustrative
What surveyors actually found near you
We read the 380 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fresno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twilight Haven | 1.1 mi | — | 0 | 0 |
| Stonehaven Senior Living | 1.1 mi | — | 0 | 0 |
| Orchard Post Acute | 1.6 mi | ★★★★★ | 2 | 0 |
| Pacific Gardens Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 30 | 0 |
| Evergreen Care Center | 1.9 mi | ★★★★★ | 2 | 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.