Landmark Medical Center: Hourly Safety Checks Skipped - CA
The violation was tagged under F0689, the federal standard governing protection from accident hazards and supervision. Inspectors classified it as having minimal harm or potential for actual harm, and noted that some residents were affected. But the staff members who explained what hourly checks were actually for made clear what the stakes looked like from the inside.
"We need to make sure they're alive and assess their behavior," said Licensed Psychiatric Technician 1, interviewed by inspectors on October 22, 2025. The LPT said CNAs were responsible for the hourly visual checks and described the specific scenarios that made missing them dangerous: suicide, resident-to-resident abuse. Not abstractions. Things that could happen in the gap between one logged check and the next.
The Director of Nursing used a specific phrase when inspectors asked what proper documentation meant. Whoever entered the check into the electronic record had to "lay eyes" on the resident, the DON said. To see them. To look at them. "To make sure they were okay." If that wasn't happening every hour, the DON said, residents could fall and be unable to call for help. They could wander into another resident's room. They could be hurt by a roommate with no staff witness and no staff response.
The Director of Staff Development said something similar. It was possible, the DSD told inspectors, that a resident could abuse their roommate if staff weren't checking every hour. The facility's own policy, written in May 2024, was explicit on this point: when a CNA entered a resident's location into the electronic health record, that entry was "an honest and accurate entry that they visually saw and identified the resident." The documentation wasn't a formality. It was supposed to be evidence that a human being had looked at another human being and found them safe.
What inspectors found was that the entries existed without the looking.
The facility operates at 2030 N. Garey Avenue in Pomona, licensed under CMS provider number 05A134. The inspection was complaint-driven, meaning someone had raised a concern before surveyors arrived. The inspection report does not identify who filed the complaint or what specific incident prompted it.
What the report does describe is a facility where the gap between what was recorded and what was done had grown wide enough that multiple staff members, when asked directly, could explain in detail why the checks mattered, what could go wrong without them, and what the policy required. The knowledge was there. The hourly walk-throughs, at least for some residents on some shifts, were not.
Psychiatric facilities carry a particular weight when it comes to supervision. The Licensed Psychiatric Technician who spoke to inspectors didn't reach for a generic example when asked about the risks of skipped checks. The first word was suicide. The second concern was resident-to-resident abuse. These were not hypothetical framings offered by a lawyer or a compliance officer. They were the words of a licensed clinician describing what they believed could happen, and had perhaps seen happen, in facilities like this one.
The Director of Nursing's list was concrete in a different way. Falls where a resident couldn't call for help. A resident moving into another resident's room undetected. Abuse with no one present to intervene. Each scenario depends on the same failure: a resident is somewhere, in some condition, and no staff member knows it because no staff member looked.
The facility's May 2024 policy described the purpose of hourly monitoring plainly. Each CNA was assigned a zone. Each hour, they were to observe the location of every resident in their section. Each entry in the electronic health record was a representation, a sworn statement in effect, that the CNA had seen that resident with their own eyes. The policy said the monitoring "allowed the staff to account for each resident" and "ensured that each resident was free from distress."
The inspection report does not say how many checks were falsified, on how many shifts, or for how many residents. It does not name the CNAs involved or describe what they were doing instead. It does not say whether any resident was harmed during a period when checks were being logged but not performed. The harm level was assessed as minimal or potential, which means inspectors either found no documented injury or could not connect a specific injury to the missed checks.
That assessment does not answer the question of what happened during the hours that were logged but not observed. It means only that inspectors could not prove harm had occurred. In a facility where a licensed psychiatric technician's first instinct, when asked about the importance of hourly checks, was to say "incidents like suicide could happen," the absence of documented harm is not the same as the absence of risk.
The Director of Nursing's phrase stays with you. Lay eyes. It is not a technical term. It does not appear in federal regulations in those words. It is the phrase a person uses when they want to be absolutely clear that they are not talking about paperwork, not talking about a system, not talking about a policy. They are talking about one person walking down a hallway and looking at another person and confirming, with their own eyes, that the person is still there and still breathing and still safe.
At Landmark Medical Center, for some residents on some shifts, that walk didn't happen. The entry in the electronic record appeared anyway.
The inspection was completed November 26, 2025. The facility's plan of correction was not included in the inspection report reviewed for this article.
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 violation was tagged under F0689, the federal standard governing protection from accident hazards and supervision.
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.