Sierra View Care Center

In the surveyor’s words

From the most serious findings on record at Sierra View Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF558Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of two sampled residents (Residents 5 and 12) in accordance with the facility's policy and procedure (P&P) titled Call lights: Accessibility and Timely Response. These failures had the potential for Residents 5 and 12 not to receive necessary care and services in a timely manner and placed the residents at risk for falls/injury Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 10/30/2025 and readmitted on [DATE] with diagnoses including unspecified glaucoma (condition that causes damage to the eye's optic nerve [carries electrical impulses from the eye to the brain, which converts the impulses into the… […]

• No harm, potential for more than minimal, patternF656Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans to meet the residents' needs for three of three sampled residents (Residents 13, 100 and 42) by failing to: a. Accurately identify specific activity intervention for Resident 13.b.1 and b.2. Identify and implement specific CP interventions that reflect Resident 100's actual and specific needs.c. Develop an individualized care plan to address scaling and stiffness of Resident 42's bilateral lower extremities (BLE) after application of A&D ointment on 3/18/2026. […]

• No harm, potential for more than minimal, patternF690Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to provide necessary care and services for residents with indwelling catheter (including suprapubic catheter [a thin, flexible tube inserted through a small abdominal incision into the bladder to drain urine], nephrostomy tube [a thin, flexible catheter inserted through the skin on the lower back into the kidney to drain urine], or a Foley catheter [a soft, flexible tube inserted through the urethra or abdominal wall into the bladder to continuously drain urine into an external bag] ) for two of three sampled residents (Residents 6 and 55) by failing to: a. Ensure Resident 6's suprapubic catheter tubing was secured on Resident 6's thigh.b. Ensure Resident 55's Foley catheter tubing was secured on Resident 55's thigh. […]

• No harm, potential for more than minimal, patternF693Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to: a. Provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition/medication directly to the stomach) site as ordered by the physician and as indicated in the plan of care for one of two sampled residents (Resident 3).b. Elevate the resident's head of the bed (HOB) while receiving feeding formula through the GT in accordance with the resident's plan of care and physician's order for one of two sampled residents (Resident 65). These failures had the potential to result in complications related to tube feedings for Residents 53 and 65. Findings: a. […]

• No harm, potential for more than minimal, patternF812Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to ensure safe food storage practices in one of one facility kitchen, by failing to: a. Discard an open loaf of wheat bread beyond its use-by-date (the last date the food was considered safe to eat) of 4/20/2026 in the kitchen bread storage area. b. Discard an open plastic container of baking soda beyond its use-by-date of 4/15/2026 in the kitchen dry storage area. c. Discard an open pack of tortilla beyond its use-by-date of 4/19/2026 in the kitchen walk-in refrigerator. d. Discard a tray of grilled cheese sandwiches and pizzas beyond its use-by-date of 4/20/2026 in the kitchen walk-in refrigerator. […]