Landmark Medical Center: Hourly Safety Checks Falsified - CA
The facility's own Director of Nursing described what those missed checks could mean. Falls where a resident couldn't call for help. A resident wandering into someone else's room. Resident-on-resident abuse. Suicide.
Those weren't hypotheticals invented by inspectors. They were the examples the Director of Nursing gave when asked why hourly visual checks mattered.
The violation was tagged at the level of minimal harm or potential for actual harm, and inspectors noted that some residents were affected. What the report does not say is how many hours passed between when a resident was last seen and when someone finally looked. The electronic record, in those cases, would have shown everything was fine.
The facility is a licensed psychiatric treatment center. The Licensed Psychiatric Technician who spoke with inspectors, identified in the report only as LPT 1, was direct about the stakes. "We need to make sure they're alive and assess their behavior," LPT 1 said. The hourly visual check, LPT 1 explained, existed precisely because incidents like suicide could happen, and because resident-to-resident abuse was a real risk when staff weren't regularly laying eyes on the people in their care.
That framing matters. This is not a general-population nursing facility where the primary concern is a resident who fell and couldn't reach the call button. The residents at Landmark are psychiatric patients. The checks are designed, at least in part, to keep people alive.
The Director of Nursing, interviewed on October 22, 2025, confirmed that the facility's standard required staff to check on residents every hour. She was specific about what "check" meant. Whoever documented the monitoring, she said, "must lay eyes on the resident or visualize the resident." Documentation in the electronic health record was not supposed to be a box someone clicked from the nurses' station. It was supposed to be proof that a staff member had physically seen the person and confirmed they were okay.
"To make sure they were okay," the DON said.
The facility's own written policy said the same thing, in writing that left no room for interpretation. The policy, titled "Policy for Hourly Monitoring of Residents" and dated May 2024, assigned each certified nursing assistant a zone or section of the unit. Every hour, those CNAs were supposed to observe the location of every resident assigned to their area and document it in the electronic health record. The policy stated explicitly that by entering a resident's location in the system, the staff member was making "an honest and accurate entry that they visually saw and identified the resident."
Not that they planned to check. Not that they assumed the resident was still where they had been an hour ago. That they had seen the person.
A second policy, governing documentation in the facility's electronic records system, Point Click Care, stated that all entries were to be made by the nurse who provided the nursing care or made the observation.
Together, those two policies described a system with a clear purpose and a clear standard. What inspectors found was that the standard wasn't being met, and the records didn't reflect that.
The inspection was triggered by a complaint, not a routine survey. That means someone, whether a resident, a family member, or a staff member, contacted regulators with a concern specific enough to send inspectors to Pomona. The report does not identify who filed the complaint or what specifically they reported. What it documents is what inspectors found when they got there: hourly monitoring logs that did not match reality.
The DON, when interviewed, did not dispute the importance of the checks. She articulated the risks with precision, the same risks LPT 1 had described. Residents could fall and be unable to ask for help. Residents could enter another resident's room. Residents could be harmed by other residents. These were not edge cases. They were the reasons the policy existed.
What the DON did not explain, at least not in what the inspection report captured, was how entries had been appearing in the electronic health record for checks that weren't being done. The policy was clear. The training, to whatever extent it was provided, was presumably consistent with the policy. And yet the entries were there, and the visual checks were not.
Falsified monitoring records in a psychiatric facility create a specific kind of danger that's worth naming plainly. If a resident is in distress, or has been harmed, or has harmed themselves, the electronic record showing an hourly check at 2 p.m. means nothing. It means a staff member clicked something. It does not mean anyone walked down the hall. In the gap between what the record shows and what actually happened, a psychiatric patient can deteriorate, or be hurt, or hurt someone else, and the documentation will suggest that staff were right there, watching, every hour, all shift long.
The inspection covered some residents, in the language of the report. Not all. Some. The report does not specify how many CNAs were involved, how many shifts the falsified entries spanned, or whether the pattern was isolated to a single zone or spread across the unit. Those details, if inspectors gathered them, did not make it into the narrative excerpt available for this report.
What is available is this: the facility had a written policy requiring honest documentation of visual checks. The facility's nursing director understood the policy and could explain exactly why it existed. A licensed psychiatric technician could explain it too, in terms that included the word suicide. And staff were entering records that said they had seen residents they had not seen.
The Director of Nursing put it simply, in the way that people sometimes do when they're describing something they know is serious. If staff were not visualizing residents every hour, she said, it posed a safety risk to the residents.
She was right. The records said they were.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Landmark Medical Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
LANDMARK MEDICAL CENTER in POMONA, CA was cited for violations during a health inspection on November 26, 2025.
The facility's own Director of Nursing described what those missed checks could mean.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.