Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 La Sierra Care Center during CMS and state inspections, most recent first.
Nursing staff did not complete required documentation or head-to-toe assessments for a resident repeatedly found on the floor, contrary to facility policy, and failed to notify the physician or update care plans. Additionally, two CNAs were observed working without visible ID badges, in violation of facility procedures for staff identification.
The facility did not assess dietary preferences for several residents within 48 hours of admission, leading to meals being served without considering their preferences. This delay was acknowledged by the RD and DM, who noted potential negative effects on residents' recovery and nutritional status.
The facility failed to provide palatable meals, with residents reporting cold, tasteless food. Observations showed food served at inadequate temperatures, and residents expressed dissatisfaction with meal quality. The Dietary Manager acknowledged temperature complaints, attributing them to slow tray distribution.
The facility failed to ensure proper food safety and hand hygiene practices. Meal service temperatures were documented before food was placed on the steam table, contrary to protocol. Additionally, a dietary staff member did not change gloves after touching clothing during food preparation, violating hygiene standards.
The facility did not comply with room size requirements, as 19 out of 23 rooms failed to meet the minimum square footage per resident. Despite this, staff and administration reported no complaints or concerns about room sizes, and waivers were mentioned for some rooms.
A long-term care facility failed to maintain a medication error rate below 5%, with errors affecting two residents. One resident received atenolol without a required blood pressure check, while another was given lisinopril and amlodipine without a pulse check. The errors were attributed to incomplete adherence to physician orders and MAR prompts.
The facility failed to ensure that three residents were free from significant medication errors. For two residents, the facility did not obtain all required vital signs before administering antihypertensive medications, as the electronic MAR did not prompt for all necessary checks. Another resident received medications despite vital signs being outside physician-ordered parameters. The DON emphasized the importance of following physician orders to ensure resident safety.
The facility failed to ensure accurate MDS assessments for two residents. One resident was documented as using hearing aids, which they did not have, and another resident's discharge disposition was incorrectly recorded. Staff interviews revealed a lack of awareness and verification, leading to these inaccuracies.
A facility failed to submit an accurate PASRR for a resident with bipolar disorder, major depressive disorder, and anxiety disorder. The resident's PASRR Level I Screening inaccurately indicated negative results for serious mental illness, omitting key diagnoses and medication use. Staff interviews revealed a lack of formal PASRR policy and reliance on hospital-provided screenings, with the MDS Coordinator missing the inaccuracies. The DON acknowledged frequent issues with hospital PASRRs, requiring resubmission, which was not done in this case.
A resident with a history of hemiplegia and a contracted left hand had an outdated care plan that was not revised to reflect their current needs. Despite the resident's ability to communicate, the care plan included interventions that were no longer relevant, such as range-of-motion exercises and the use of a brace, which were not being performed or provided. Staff interviews confirmed the lack of updates to the care plan, and facility leadership acknowledged the need for revisions.
A resident with protein-calorie malnutrition did not receive fortified food as recommended by the RD due to a failure in entering the diet order. The SLP omitted the fortified portion from the order, and the DM was unaware of the need for fortified foods. Interviews revealed that staff did not ensure the correct diet orders were entered, leading to the resident not receiving the necessary nutritional supplementation.
A resident with COPD did not receive proper monitoring during nebulizer treatments, as required by facility policy. Observations showed the resident was left unattended, and medication was not fully administered. Interviews confirmed that staff should have stayed with the resident to ensure effective treatment and monitor for side effects.
Two residents in the facility did not receive their prescribed medications due to unavailability and lack of timely follow-up by staff. One resident, with a history of heart disease and depression, missed doses of escitalopram and prazosin, while another resident with major depressive disorder did not receive clonazepam, alpha-lipoic acid, and FiberChoice. The facility's protocol for obtaining medications was not adequately followed, leading to this deficiency.
The facility failed to transcribe physician orders for vital signs to the MAR for two residents, leading to incomplete monitoring before administering antihypertensive medications. One resident's atenolol order required blood pressure and pulse checks, but only pulse was documented. Another resident's orders for lisinopril and amlodipine required both blood pressure and pulse checks, but only blood pressure was recorded. This resulted from incomplete transcription and misunderstanding of the orders by LVNs.
The facility failed to maintain copies of daily staffing numbers, potentially affecting all residents. The Staffing Coordinator did not have records for a specific period due to a system glitch and did not keep handwritten forms. The Administrator confirmed that these records should be kept for at least a year for the facility's annual PPD review.
Failure to Document Falls and Ensure Staff Identification
Penalty
Summary
The facility failed to follow its own policies and procedures that meet professional standards of quality in two key areas. First, nursing staff did not complete required nursing documentation or head-to-toe assessments for a resident who was found on the floor 346 times within a month. Although the resident had diagnoses including Parkinsonism, persistent mood disorder, muscle spasms, difficulty walking, and lack of coordination, and was cognitively intact, only eight of the 354 episodes of being found on the floor were documented in the progress notes. Interviews with staff revealed that these incidents were not considered falls by the Director of Nursing, but rather resident behaviors, and thus were not assessed or documented according to facility policy. Both the facility's policies and staff interviews confirmed that each incident should have been documented, assessed, and communicated to the physician, but this did not occur. Further review of the facility's policies, including those on assessing falls and their causes, and behavior assessment, confirmed that staff are required to document all falls or incidents of residents being found on the floor, conduct head-to-toe assessments, notify the physician, and update care plans as needed. However, interviews with licensed nursing staff indicated that these protocols were not followed for the resident in question. Staff admitted that full assessments, documentation, and notifications were not completed, and that the resident was not placed under observation or had care plans updated as required by policy. Additionally, the facility failed to ensure that all Certified Nursing Assistants (CNAs) wore identification badges while on duty, as required by facility policy. During observations, two CNAs were found not wearing their ID badges and admitted to not having them at work, despite understanding the importance of proper identification for residents and families. The Director of Nursing confirmed that this was a violation of facility policy and could potentially cause confusion or delay in care if staff could not be properly identified.
Failure to Assess Dietary Preferences Timely
Penalty
Summary
The facility failed to assess dietary preferences for seven out of ten sampled residents within 48 hours of their admission, as required by their policy. This oversight resulted in the dietary preferences of these residents not being considered when meals were provided. For instance, one resident repeatedly informed staff that she does not drink milk, yet milk continued to be served to her. The Registered Dietitian (RD) and Dietary Manager (DM) acknowledged that the dietary profiles for several residents were either incomplete or delayed beyond the 48-hour window post-admission. The RD and DM both stated that the delay in completing dietary preferences could lead to negative side effects such as delayed wound healing, slower recovery, increased length of stay, and weight loss. The Director of Nursing (DON) confirmed the expectation for dietary preferences to be completed within 48 hours of admission, emphasizing the potential impact on residents' recovery and nutritional status. The facility's policy and procedure document also highlighted the importance of considering residents' food preferences to provide a well-balanced diet that meets their nutritional needs.
Deficiency in Meal Palatability and Temperature
Penalty
Summary
The facility failed to provide palatable meals to its residents, as evidenced by multiple observations and resident complaints. The facility's policy on Food and Nutrition Services, revised in 2017, mandates that each resident is provided with a nourishing, palatable, well-balanced diet that meets their nutritional and dietary needs. However, during a lunch meal service, the food was observed to be served at inadequate temperatures, with the rosemary roast pork at 90 degrees, mashed potatoes at 100 degrees, and zucchini/tomatoes at 100 degrees by the time the last resident tray was served. Residents reported the food as cold, tasteless, and unappetizing, with some stating they could not identify the vegetables served. The Dietary Manager acknowledged awareness of complaints about food temperatures but attributed the issue to slow meal tray distribution by staff. Several residents, including those with intact cognitive status, expressed dissatisfaction with the meals, citing issues such as cold temperatures, lack of seasoning, and unappetizing presentation. During a Resident Council Meeting, attendees reported the need for more seasoning and less spice in meals, and specific complaints were made about the lunch meal's lack of flavor and warmth. The Director of Nursing and the Administrator both expressed expectations for food to be served at appropriate temperatures and to be visually and tastefully appealing, indicating a disconnect between expectations and the actual service provided.
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper documentation and adherence to food safety protocols during meal service. During an initial tour of the facility's kitchen, it was observed that the meal service temperature logs for lunch were documented before the food was placed on the steam table. The Dietary Manager and staff confirmed that this practice was unacceptable and acknowledged that meal service temperatures should only be recorded when the food is placed on the steam table. Dietary Staff #15 admitted to pre-filling the temperature logs based on assumptions rather than actual measurements, despite knowing the importance of accurate temperature documentation to ensure food safety. Additionally, the facility failed to maintain proper hand hygiene during meal preparation. Dietary Staff #14 was observed wearing gloves while handling various surfaces and then preparing food without changing gloves. The staff member touched her clothing and continued food preparation without changing gloves or washing hands, which was against the facility's policy. Both the Dietary Manager and the Director of Nursing expressed that they expected staff to change gloves when necessary, especially after touching clothing or other surfaces, to prevent contamination.
Deficiency in Resident Room Size Compliance
Penalty
Summary
The facility failed to ensure that resident rooms met the required square footage per resident, as outlined in their policy and federal and state requirements. Specifically, 19 out of 23 resident rooms did not provide the minimum 80 square feet per resident in multiple occupancy rooms. The Client Accommodations Analysis, signed by the Maintenance Supervisor, documented that several rooms provided less than the required space, with measurements ranging from 70 to 78 square feet per resident. Interviews with facility staff, including the Maintenance Supervisor, Director of Nursing, and Administrator, revealed a lack of awareness or concern regarding the room sizes. The Maintenance Supervisor mentioned that waivers were in place for some rooms, and no complaints had been received from staff or residents. Similarly, the Director of Nursing and Administrator reported no complaints about room sizes, and the Administrator stated that as long as residents were comfortable and staff could provide care, he did not see an issue with the room sizes.
Medication Administration Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by observations during medication administration. Out of 28 opportunities, there were 3 medication errors, resulting in a 10.71% error rate. This affected two residents, one of whom was administered atenolol without the required blood pressure check, and another who received lisinopril and amlodipine without a pulse check. Resident #9, admitted in 2017 with a history of hypertension, had an order for atenolol with specific instructions to hold the medication if the systolic blood pressure was below 110 mmHg or the pulse was below 60 BPM. On a specific date, an LVN administered atenolol after checking only the resident's pulse, which was 84 BPM, but failed to check the blood pressure as required by the order. The LVN later acknowledged the oversight, realizing the need to read the full order and obtain all necessary vital signs. Resident #32, admitted in 2020 with chronic ischemic heart disease and hypertension, had orders for lisinopril and amlodipine with instructions to hold the medications if the pulse was below 60 BPM, SBP below 110 mmHg, or DBP below 60 mmHg. An LVN administered these medications after checking only the blood pressure, which was 122/78 mmHg, without obtaining the pulse. The LVN admitted to not checking the pulse, as the MAR only prompted for a blood pressure reading. Both the DON and the Administrator emphasized the importance of following physician orders and obtaining all necessary vital signs before medication administration.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors during medication administration. For Resident #9, the facility did not obtain the required vital signs before administering atenolol, an antihypertensive medication. The order specified that the medication should be held if the resident's pulse was less than 60 BPM or if the systolic blood pressure was less than 110 mmHg. However, the Licensed Vocational Nurse (LVN) administering the medication did not check the resident's blood pressure, as the electronic Medication Administration Record (MAR) only prompted for the pulse. This oversight was acknowledged by the LVN and the Director of Nursing (DON), who stated that all necessary vital signs should be obtained prior to medication administration. Resident #32 also experienced a similar issue where the facility did not obtain all required vital signs before administering lisinopril and amlodipine, both antihypertensive medications. The orders required that the medications be held if the resident's pulse was less than 60 BPM, systolic blood pressure was less than 110 mmHg, or diastolic blood pressure was less than 60 mmHg. During an observation, the LVN only obtained the resident's blood pressure and not the pulse, as the MAR only prompted for the blood pressure. The DON reiterated the importance of obtaining all necessary vital signs and following physician orders. For Resident #19, the facility failed to hold medications when the resident's vital signs were outside the physician-ordered parameters. The resident's MAR indicated that medications such as diltiazem, metoprolol tartrate, and hydrochlorothiazide should be held if the systolic blood pressure was less than 110 mmHg, diastolic blood pressure was less than 65 mmHg, or the pulse was less than 60 BPM. Despite this, the medications were administered on multiple occasions when the vital signs did not meet these parameters. Interviews with the LVNs involved revealed that they were aware of the parameters but did not hold the medications as required. The DON emphasized the importance of adhering to physician orders to ensure resident safety.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. Resident #46 was reported to have intact cognition and the use of a hearing aid in both annual and quarterly MDS assessments. However, interviews with the resident and staff revealed that the resident did not have hearing aids, contrary to what was documented. The MDS Coordinator and the Director of Nursing (DON) were unaware of this discrepancy, indicating a lack of communication and verification in the assessment process. Resident #69 was documented in the MDS assessment as having been discharged to a short-term general hospital. However, progress notes and a signed statement indicated that the resident left the facility against medical advice (AMA). The MDS Coordinator admitted to selecting the wrong discharge disposition, and the DON acknowledged the error, highlighting a failure in ensuring the accuracy of discharge information. Both cases demonstrate a deficiency in maintaining accurate resident assessments as per the facility's policy.
Inaccurate PASRR Submission for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a history of serious mental illness. The resident, admitted on 07/25/2024, had a medical history that included bipolar disorder, major depressive disorder, and anxiety disorder. Despite these diagnoses and the use of psychotropic medications, the PASRR Level I Screening dated 07/25/2024 indicated negative results for serious mental illness, failing to include the resident's actual diagnoses and medication use. Interviews with facility staff revealed a lack of a formal policy for PASRR, with reliance on a letter from the State Department of Health Care Services for guidance. The admissions department received the PASRR from the hospital, which was then reviewed by the Assistant Director of Nursing and Director of Nursing. However, the MDS Coordinator, responsible for ensuring the accuracy of the PASRR, admitted to missing the inaccuracies in the resident's Level I PASRR. The Director of Business Development and Marketing stated her role was limited to obtaining the Level I PASRR prior to admission, while the MDS Coordinator was tasked with reviewing it for accuracy. The Director of Nursing acknowledged issues with hospitals related to PASRRs, often requiring resubmission due to inaccuracies. The facility's Administrator confirmed that the interdisciplinary team should have reviewed the PASRR for accuracy upon receipt and resubmitted it if found inaccurate, which did not occur in this case.
Failure to Revise Resident's Care Plan
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #15, who was admitted with a medical history of hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, affecting the left nondominant side, and a contracted left hand. The care plan, which was supposed to be comprehensive and person-centered, included interventions for lymphedema and limited mobility that were outdated and no longer relevant to the resident's current condition. Despite the resident's intact cognition and ability to communicate, the care plan had not been updated to reflect the resident's current needs, such as the absence of a brace for the left wrist and fingers and the lack of range-of-motion exercises. Interviews with staff revealed that CNAs were not performing range-of-motion exercises on the resident's left hand due to contractures, and there was no documentation of such exercises in the resident's electronic medical record. The MDS Coordinator and the Director of Nursing acknowledged that the care plan should have been revised to reflect the resident's current status, including the removal of interventions related to a brace, assistive device, ROM, and compression stockings. The Administrator also confirmed that care plans should be updated when a resident's status changes, indicating a lapse in the facility's adherence to its policy on maintaining current and relevant care plans.
Failure to Provide Fortified Food for Nutritional Supplementation
Penalty
Summary
The facility failed to provide fortified food intended for nutritional supplementation to a resident diagnosed with protein-calorie malnutrition. The resident, who had a medical history including hyperlipidemia, peripheral vascular disease, hypertension, and other conditions, was admitted with a nutritional risk. The Registered Dietician recommended fortifying the resident's diet to prevent further weight loss. However, the Speech Language Pathologist did not include the high protein/fortified portion in the diet order, and the Dietary Manager was unaware of the need for fortified foods. The deficiency was identified during interviews and record reviews, which revealed that the diet order for high protein/fortified foods was not entered into the system. The Director of Nursing and the Administrator both expressed expectations that staff should ensure diet orders are correctly entered and residents receive the appropriate diet. Despite these expectations, the oversight resulted in the resident not receiving the necessary fortified foods as part of their nutritional care plan.
Failure to Monitor Nebulizer Treatment
Penalty
Summary
The facility failed to provide proper monitoring during the administration of a nebulizer treatment for a resident with chronic obstructive pulmonary disease (COPD) and other respiratory conditions. The facility's policy required staff to remain with the resident during the treatment, monitor for side effects, and ensure the medication was fully administered. However, observations revealed that the resident was left unattended during nebulizer treatments, with the nurse leaving the room before the medication was completely nebulized. The resident, who had a medical history of COPD, pneumonia, and shortness of breath, was observed on multiple occasions with a nebulizer machine on the nightstand and a medication cannister that was not fully utilized. On one occasion, the resident reported not receiving a nebulizer treatment that day, despite the medication cannister being partially full. This indicated a lack of adherence to the prescribed treatment schedule and monitoring requirements. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy required nurses to stay with the resident during nebulizer treatments to ensure the medication was administered effectively and to monitor the resident's response. The failure to adhere to these procedures resulted in a deficiency in providing safe and appropriate respiratory care for the resident.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure prescribed medications were available for two residents, leading to a deficiency in pharmaceutical services. Resident #2, who was admitted with a history of hypertensive heart disease and depression, did not receive their prescribed medications, escitalopram and prazosin, on multiple occasions. The Medication Administration Record (MAR) indicated that these medications were coded as 'Other,' meaning they were not administered due to pending pharmacy delivery. Despite the resident's statement that they had not refused any medications, the medications were not available on the medication cart, and the staff failed to follow the facility's policy for obtaining medications from the pharmacy or using the emergency medication kit. Resident #29, who had a history of major depressive disorder, also experienced a lack of medication availability. The resident's prescribed medications, including clonazepam, alpha-lipoic acid, and FiberChoice, were not administered as they were pending delivery from the pharmacy. The MAR and progress notes documented that these medications were on hold or coded as 'Other' due to unavailability. The central supply person informed the nurse that FiberChoice was not on the formulary list, and the nurse was expected to contact the physician for an alternative or order the medication from the pharmacy, which was not done in a timely manner. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility's protocol required nurses to contact the pharmacy, physician, and DON if medications were not available. They were also expected to follow up until the medications were received. However, this protocol was not adequately followed, resulting in the residents not receiving their prescribed medications on time. The deficiency highlights a failure in the facility's medication management and communication processes.
Failure to Transcribe Physician Orders for Vital Signs
Penalty
Summary
The facility failed to ensure that physician orders for vital signs were accurately transcribed to the medication administration records (MAR) for two residents during medication administration. Resident #9, who was admitted with a diagnosis of primary hypertension and had moderate cognitive impairment, had an order for atenolol with specific instructions to monitor blood pressure and pulse before administration. However, the MAR only prompted staff to document the resident's pulse, leading to a lack of blood pressure monitoring prior to administering the medication. This oversight was identified when a Licensed Vocational Nurse (LVN) realized the full order required blood pressure monitoring as well. Similarly, Resident #32, with a history of primary hypertension and chronic ischemic heart disease, had orders for lisinopril and amlodipine that required monitoring of both blood pressure and pulse. The MAR, however, only prompted for blood pressure documentation, resulting in the omission of pulse monitoring. LVN #13 administered the medications without obtaining the resident's pulse, as she was unaware of the complete order requirements. Both instances highlight a failure in the transcription process and understanding of the complete physician orders, leading to potential medication administration errors.
Failure to Maintain Daily Staffing Records
Penalty
Summary
The facility failed to maintain copies of the posted direct care daily staffing numbers, which had the potential to affect all residents residing in the facility. According to the facility's policy, revised in August 2022, the facility was required to post daily nursing staff data for each shift and maintain these records for a minimum of eighteen months or as required by state law. However, during an interview, the Staffing Coordinator admitted that she did not have the daily staffing postings for the period from July 23, 2024, through July 30, 2024, due to a glitch in their system. Although she handwrote the staffing numbers, she did not keep the forms. The Administrator confirmed that the daily staffing postings should be kept for at least a year for the facility's annual PPD review from the State and should be accurate, maintained together, and organized.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Merced
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Merced Nursing & Rehabilitation Ctr | 0.1 mi | — | 1 | 0 |
| Golden Merced Care Center | 0.3 mi | — | 2 | 0 |
| Franciscan Post-acute Care Center | 0.8 mi | — | 3 | 0 |
| Merced Behavioral Center | 1.4 mi | — | 0 | 0 |
| Anberry Post Acute | 3 mi | — | 0 | 0 |
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