Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Alta View Post Acute during CMS and state inspections, most recent first.
The facility failed to implement its Infection Prevention and Control Program and IGAS-specific policies during an invasive Group A Streptococcus outbreak involving two residents. Both residents had confirmed Streptococcus pyogenes infections and were receiving antibiotic and wound care, yet neither was placed on transmission-based precautions or cohorted, and no related physician orders were in place. Despite written guidance from public health authorities designating an IGAS outbreak and instructing the facility to post notification letters in common areas and follow recommended PPE and mask practices, staff were observed not wearing surgical masks and no outbreak notifications were posted. The DON acknowledged receipt of the public health letters, uncertainty about the need for transmission-based precautions, and that the facility’s own policies—which require Contact and Droplet Precautions, facemask use during wound care, and outbreak management steps—were not followed.
A resident with schizophrenia, bipolar disorder, and hypertension, who was cognitively intact and required maximal assistance for hygiene, was scheduled for a shower with a CNA. During the shower, the resident verbally refused care, threw a towel, and stood up from the shower chair; the CNA reported the refusal to an LVN and sought assistance from another CNA, who then assumed care and completed the shower without further refusal. Despite these events, there was no documentation in the medical record of the resident’s refusal, aggressive behavior, staff interventions, outcome of the incident, or the transfer of care between CNAs, contrary to facility policy requiring complete and accurate charting of services, refusals, and care-specific details.
A resident with HTN, HLD, epilepsy, and impaired mobility, who had capacity to make medical decisions, was discharged to a board and care with orders for a follow-up MD appointment, home health PT/OT, RN safety visits, and DME (wheelchair). The record lacked a documented post-discharge plan, and the DON confirmed there was no documentation verifying that home health services were arranged or that the follow-up appointment was communicated to the board and care, contrary to the facility’s transfer/discharge policy requiring nursing to prepare a post-discharge plan for each resident.
A resident with complex medical needs was not promptly readmitted after hospitalization, despite available beds, due to the facility's lack of a bariatric mattress and delayed communication between staff and the hospital. Facility policy required readmission upon bed availability, but the resident's return was delayed as staff cited equipment shortages and were not fully aware of the resident's readiness for discharge.
Surveyors found undated peanut butter and jellied sandwiches and expired deli turkey slices stored in the kitchen refrigerator. The Dietary Manager confirmed the lack of required labeling and failure to discard expired food, and the Registered Dietitian stated that proper labeling is necessary to prevent serving expired food to residents.
Kitchen freezers used to store food items were repeatedly observed with internal temperatures above the required 0 degrees F, with readings of 10 to 12 degrees F noted during multiple checks. The Dietary Manager and Registered Dietitian confirmed that these temperatures did not meet facility policy and could result in food spoilage if not corrected.
The facility did not inform residents about Medicaid/Medicare coverage or their potential financial liability for non-covered services, failing to provide the required notifications.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was administered PRN Lorazepam for anxiety episodes without staff first attempting nonpharmacological interventions, as required by facility policy. This practice continued for over a month, and staff interviews confirmed that nonpharmacological approaches should have been used prior to medication administration.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A resident with a history of malnutrition, dysphagia, and diabetes experienced significant unplanned weight loss after readmission. The facility did not follow the RD's recommendations for dietary changes, failed to notify the physician, and did not convene the IDT to address the weight loss. The Dietary Manager also did not obtain an updated weight, resulting in missed recognition of the resident's decline and lack of timely intervention.
The facility did not establish or maintain an infection prevention and control program, resulting in a deficiency related to infection control practices.
Three residents were not offered COVID-19 vaccine education or the opportunity to consent for vaccination upon admission, despite facility policy requiring this process. One resident with severe cognitive impairment and two residents with chronic medical conditions were not screened or provided information about the vaccine, and this was confirmed by both the IP and DON during interviews.
A resident with severe cognitive impairment and physical limitations was found unable to access their call light, which was left hanging out of reach after care. The resident, dependent on staff for most activities, was observed searching for the call light to request assistance. Facility staff confirmed that call lights are required to be within reach, and acknowledged lapses in this practice.
A resident with multiple comorbidities, including malnutrition and dysphagia, experienced a significant weight loss over 14 days. Despite facility policy requiring physician notification and interdisciplinary review for such changes, staff did not inform the MD or reassess the resident, as confirmed by record review and staff interviews.
A resident who was fully dependent on staff for activities of daily living and had a gastrostomy tube was found to have a thick, dried, brown-colored pasty substance on the right side bed rail in their room. A CNA acknowledged the unclean condition during an observation and interview, and the DON emphasized the importance of cleanliness for resident health. The facility's infection prevention policy requires staff training on maintaining a clean environment.
A resident was not assessed completely and in a timely manner upon admission and at the required 12-month interval, resulting in noncompliance with mandated assessment protocols.
A resident with multiple medical conditions, including malnutrition and dysphagia, experienced a significant weight loss that was documented in both the nutrition assessment and care plan. However, the MDS assessment was inaccurately coded to show no weight loss due to a misinterpretation by the MDS coordinator, despite facility policy requiring accurate certification of assessments.
A resident with malnutrition, dysphagia, and recent significant weight loss did not have a comprehensive care plan developed to address their nutritional needs. Despite facility policy requiring immediate multidisciplinary intervention for notable weight changes, the necessary care planning and notifications were not completed.
The facility did not provide pharmaceutical services to meet the needs of each resident and failed to employ or obtain the services of a licensed pharmacist, resulting in noncompliance with regulatory requirements.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident admitted with multiple medical conditions and prescribed several antibiotics did not have their antibiotic use properly documented or reviewed by the Infection Preventionist, as required by the facility's Antibiotic Stewardship Program. Staff interviews and record reviews confirmed that the necessary Infection Surveillance Outcome form was not completed for the resident's antibiotic therapy.
A resident with COPD, skin cancer, and recent scalp surgery, who was cognitively intact, consented to receive the PVC 20 vaccine but did not receive it within the facility's required timeframe. Review of records showed the vaccine was not ordered or administered for 25 days after consent, despite facility policy requiring administration within 72 hours.
A Restorative Nursing Assistant did not receive the required 12 hours of in-service training, including only 1 hour of dementia care and 9 hours of abuse prevention education, as confirmed by staff interviews and record review. The employee file lacked documentation of mandatory training, and the facility's policy requiring initial orientation and annual in-service education was not followed.
A facility failed to develop a care plan for a resident's Central Venous Catheter (CVC), despite the resident's complex medical needs, including COPD, diabetes, dementia, and pressure ulcers. The resident was dependent on staff for daily activities and had severely impaired cognition. The absence of a care plan for the CVC was confirmed by the DON, highlighting a failure to adhere to the facility's policy requiring care plans to incorporate goals and objectives for resident independence.
A facility failed to document care for a resident with a Central Venous Catheter (CVC), missing entries for monitoring and maintenance tasks in December. The resident had multiple health issues, including COPD and dementia, and required comprehensive care. The Director of Nursing acknowledged the documentation gaps, suggesting a possible issue with the order entry system. Facility policies stress the importance of care plans, but the lack of documentation left the completion of care unverified.
A resident experienced a significant weight loss, dropping from 126 to 118 pounds within a month. The facility failed to notify the resident's physician and NOK in a timely manner, as required by their policy. Despite the care plan's directive, the physician was informed four days after the weight loss was noted, and there was no evidence of NOK notification. Staff interviews revealed communication discrepancies, with incorrect information entered regarding family notification.
A resident with dementia and chronic kidney disease had a physician's order for a urine sample collection due to complaints of pain upon urination. The facility failed to collect the sample and did not document the failure or notify the physician, resulting in an inaccurate medical record.
The facility failed to maintain safe food storage and preparation practices, including inadequate dishware sanitization, unclean ice machines, and improper monitoring of thaw dates for juice and deli meats. These deficiencies could lead to cross-contamination and foodborne illness among residents.
A facility failed to accurately code the MDS for a resident regarding the Restorative Nursing Program. The resident, with conditions like neuralgia and a right-hand contracture, had a care plan involving a cock-up splint and passive range of motion exercises. Despite receiving these services, the MDS did not reflect them, as confirmed by staff interviews and record reviews.
A resident with multiple health issues, including aspiration pneumonia, did not receive chest physiotherapy on two occasions as ordered by a physician. The facility's failure to document the treatment on these dates suggests it was not performed, which could compromise the resident's respiratory status. The facility's policies require thorough documentation of all treatments, which was not adhered to in this case.
A facility failed to accurately account for a dose of lorazepam for a resident. An LVN administered the medication but did not document it in the Controlled Drug Record, leading to a discrepancy between the record and the medication card. This oversight increased the risk of medication diversion and incorrect dosage administration.
A resident experienced a delay in receiving dental services for dentures, despite having a physician order and a request noted in their nutritional assessment. The resident, with intact cognition and able to communicate needs, only saw a dental hygienist who could not address denture-related questions. The Social Services Director was unaware of the resident's request, and the Director of Nursing was unsure of the reason for the delay, which increased the resident's risk for weight loss.
Failure to Implement IGAS Outbreak Precautions and Notification
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Prevention and Control Program and disease-specific policies during an identified outbreak of invasive Group A Streptococcus (IGAS) involving two residents. Resident 1 was originally admitted with multiple diagnoses including Group A Streptococcus, hemiplegia and hemiparesis following cerebral infarction, and polyneuropathy, and had severely impaired cognitive skills per the MDS dated 3/11/2026. Resident 1 required maximal to total assistance with ADLs and had an Infectious Disease Progress Note dated 3/4/2026 showing a positive laboratory result for Streptococcus pyogenes. The resident’s care plan identified risk for body rashes related to Group A Streptococcus and included education interventions, and the admission nursing assessment documented cellulitis with bacteremia and antibiotic treatment. However, the assessment indicated the resident was not on any transmission-based precautions, and the order summary contained no physician orders for such precautions. Resident 2 was admitted and readmitted with diagnoses including Group A Streptococcus, COPD, heart failure, and cellulitis of the left lower limb, with an MDS indicating intact cognition and a need for moderate assistance with ADLs. An Infectious Disease Progress Note dated 4/11/2026 documented a positive Streptococcus pyogenes laboratory result. Progress notes showed episodes of low oxygen saturation and tachycardia and a subsequent readmission from an acute care hospital on IV antibiotics. The MDS coordinator/infection preventionist stated that Resident 2 was hospitalized and returned on antibiotic treatment and confirmed that Resident 2 was not placed on any transmission-based precautions upon readmission. On observation, both residents were not cohorted and were not in transmission-based precaution rooms, despite the facility being in an IGAS outbreak status as acknowledged by the infection preventionist. The facility received written guidance from the Los Angeles County Department of Public Health, Acute Communicable Disease Control, identifying two residents with invasive GAS infection and designating these cases as an IGAS outbreak. The letters instructed the facility to conduct a retrospective review, map resident locations, and post an IGAS notification letter about the increased occurrence of IGAS infections on facility letterhead in all common areas, and to consider distributing it to residents and staff. The letters also recommended mask usage, hand hygiene, PPE practices, environmental cleaning, and wound dressing procedures. During surveyor observation, staff were not using surgical masks throughout the facility, and no outbreak notification letters were posted at the entrance or in common areas. The DON confirmed receipt of the public health letters, stated uncertainty about the need for transmission-based precautions for IGAS, acknowledged that no notification letters were posted, and stated that staff should have been following the facility’s Infection Prevention and Control Program policy. The facility’s own IGAS policy required Contact and Droplet Precautions and specific PPE use during an outbreak, but these measures were not implemented for the affected residents or the facility at large. The facility’s Infection Prevention and Control Program policy described outbreak management steps, including determining the presence of an outbreak, managing affected residents, preventing spread to others, documenting and reporting, educating staff and the public, monitoring for recurrences, and reviewing care after the outbreak. It also emphasized implementing appropriate isolation precautions and following CDC and disease-specific guidelines. A separate IGAS-specific policy, reviewed by the facility in 4/2026, stated that in long-term care settings, outbreaks can occur due to lapses in infection prevention and control practices such as hand hygiene, PPE use, and wound care. It directed staff to use gloves and gowns for wound care under Enhanced Barrier Precautions, add face shields if splash was anticipated, have HCP wear facemasks during all wound care activities during an outbreak, maintain precautions for suspected or confirmed GAS until 24 hours after starting effective antibiotics, and use Contact and Droplet Precautions for wounds until drainage stopped or was contained and Droplet Precautions for throat infections. Despite these written policies and external public health guidance, the facility did not implement transmission-based precautions, did not cohort the affected residents, did not require surgical mask use for staff, residents, and visitors, and did not post the required IGAS outbreak notification letters in the facility. These observed inactions and omissions—failure to place the two IGAS-positive residents on transmission-based precautions, failure to cohort them, failure to implement recommended PPE and mask usage, and failure to post outbreak notification signage as directed by public health authorities and required by the facility’s own policies—constitute the core of the identified deficiency in the facility’s infection prevention and control program during an IGAS outbreak.
Failure to Document Shower Refusal, Behavioral Incident, and Care Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident in accordance with its Charting and Documentation policy. The resident, admitted with schizophrenia, bipolar disorder, and essential hypertension, was documented as cognitively intact and able to understand and make herself understood, and required maximal assistance for showers and hygiene. The facility’s shower schedule showed the resident was assigned to receive a shower from CNA 1 on the date of the incident. During the scheduled shower, CNA 1 reported that the resident verbally refused the shower, stating she did not want to shower, threw a towel toward CNA 1, and stood up from the shower chair. CNA 1 stated an LVN was outside the shower room, and she reported the refusal to the LVN and asked the LVN to monitor the resident while she sought assistance. CNA 1 then obtained help from CNA 2, who approached the resident and completed the shower without further refusal, with CNA 2 assuming care of the resident. CNA 2 confirmed that CNA 1 had told her the resident refused the shower and that she then offered and provided the shower, which the resident completed without complaints. Record review by the Medical Records Director and DON showed there was no documentation in the resident’s medical record of the shower refusal, the aggressive behavior (throwing the towel and standing up), the staff interventions, the outcome of the event, or the transfer of care from CNA 1 to CNA 2. The DON also reviewed an interview document from LVN 1 indicating that LVN 1 heard someone in the shower room yelling, “I don’t want to take a shower,” and that the resident later agreed to shower with CNA 2’s assistance, but this event was not documented in the progress notes or reported to the supervisor. These omissions conflicted with the facility’s Charting and Documentation policy, which requires that all services provided, refusals of care, changes in condition, and care-specific details, including who provided care and how the resident tolerated it, be objectively, completely, and accurately documented in the medical record.
Failure to Develop and Document Post-Discharge Plan for Resident Transferred to Board and Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its policy and procedure titled "Transfer or Discharge, Preparing a Resident for" for one of three sampled residents. The resident was admitted with diagnoses including HTN, HLD, epilepsy, and difficulty in walking, and the History and Physical documented that the resident had the capacity to understand and make their own medical decisions. The Order Summary Report showed a discharge-related order entered for a follow-up appointment with a doctor and a later order authorizing discharge to a board and care with home health services for PT, OT, RN safety visits, and DME in the form of a wheelchair. During an interview with concurrent record review, the DON confirmed that there was no post-discharge plan documented in the resident’s record, despite the facility’s policy requiring that a post-discharge plan be developed for each resident prior to transfer or discharge and assigning nursing services responsibility for preparing that plan. The DON acknowledged that, based on the documentation, there was no way to know if home health services were arranged or if the follow-up doctor’s appointment was communicated to the board and care. This lack of documented post-discharge planning and coordination constituted the cited failure to ensure the transfer/discharge met the resident’s needs and preferences and that the resident was prepared for a safe transfer/discharge.
Failure to Timely Readmit Resident Following Hospitalization
Penalty
Summary
The facility failed to allow a resident to return following a hospitalization, despite available beds, resulting in a delay of the resident's readmission. The resident, who had significant medical needs including hemiplegia, morbid obesity, type 2 diabetes, and functional quadriplegia, was transferred to a general acute care hospital and was ready for discharge back to the facility. Hospital discharge planners attempted to coordinate the resident's return, but facility staff repeatedly communicated that there were no available beds or mattresses, even though census records indicated open female beds during the relevant period. Interviews with facility staff revealed inconsistencies in communication and awareness regarding the resident's readiness for readmission. The admissions director stated that the first contact from the hospital was received several days after the hospital began attempting to arrange the resident's return, and cited a lack of a mattress as the reason for the delay, despite available beds. The director of social services and assistant director of nursing both indicated that the resident had a history of frequent hospitalizations and readmissions without prior issues, and acknowledged that the resident had the right to return to the facility after hospitalization. Facility policy required that Medicaid residents whose hospitalization exceeded the bed hold period be readmitted upon the first availability of a bed, provided certain criteria were met. Despite this policy, the resident's return was delayed due to the facility's failure to provide a necessary bariatric mattress and lack of timely communication between facility departments and with the hospital. This resulted in the resident not being readmitted as soon as a bed was available, contrary to facility policy and regulatory requirements.
Expired and Undated Food Items Found in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure expired and undated food items were not stored in the kitchen, affecting 76 of 84 residents who received food from the kitchen. During a kitchen tour with the Dietary Manager, undated prepared peanut butter and jellied sandwiches and expired deli turkey slices labeled with a past use-by date were found stored in one of the refrigerators. The Dietary Manager acknowledged that the sandwiches should have been labeled with preparation and use-by dates and that the expired turkey should have been discarded. The Registered Dietitian confirmed that food must be labeled to prevent serving expired items to residents. Review of the facility's policy indicated that all refrigerated or frozen foods must be labeled with a use-by date and either used or discarded by that date.
Failure to Maintain Freezer Temperatures at Required Levels
Penalty
Summary
The facility failed to maintain kitchen freezer #1 and freezer #2 at the required temperature of 0 degrees Fahrenheit or below while storing various food items, including hashbrowns, whipped topping, french fries, assorted vegetables, and sweet potato fries. Observations on multiple occasions showed that freezer #1, located outside the storeroom, had internal thermometer readings of 12 degrees F and 10 degrees F, while freezer #2, located inside the storeroom, also showed temperatures above the required range at times. The Dietary Manager (DM) explained that staff had been moving items to accommodate new food deliveries and had been opening the freezers for breakfast preparation, which contributed to the elevated temperatures. Interviews with the DM and the Registered Dietitian (RD) confirmed that the freezers should be maintained at 0 degrees F or below, as per facility policy revised in November 2024. Both acknowledged that failure to maintain proper freezer temperatures could result in food spoilage, which, if served, could negatively impact residents' health. The facility's monitoring logs indicated that temperatures are checked in the morning and afternoon to prevent food from entering the danger zone, but the observed temperatures did not meet the required standards during the survey.
Failure to Notify Residents of Coverage and Financial Liability
Penalty
Summary
The facility failed to provide residents with notice regarding Medicaid and Medicare coverage, as well as information about potential financial liability for services that are not covered. This deficiency occurred due to the facility's inaction in informing residents about their rights and responsibilities related to payment for care and services, as required by federal regulations. There is no mention of specific residents or medical conditions in the report, and the deficiency is based solely on the lack of required notification.
Failure to Provide Nonpharmacological Interventions Before PRN Psychotropic Medication Administration
Penalty
Summary
Facility staff failed to provide nonpharmacological interventions prior to administering Lorazepam PRN for anxiety to a resident with multiple psychiatric diagnoses, including anxiety, depression, psychosis, delusional disorders, and auditory hallucinations. The resident, who had severely impaired cognition and was dependent on staff for most activities of daily living, was prescribed Lorazepam via gastrostomy tube as needed for episodes of crying. Review of the Medication Administration Record and Order Summary Report showed that for 37 days, staff did not attempt or document nonpharmacological interventions before giving the medication. Interviews with the RN Supervisor and the Director of Nursing confirmed that nonpharmacological interventions should have been provided prior to administering psychotropic medications, as outlined in the facility's policy and procedure. The policy indicated that such approaches are to be used to minimize medication use, permit the lowest possible dose, and allow for discontinuation when possible. The failure to implement these interventions was not explained by staff, and the omission was acknowledged by facility leadership.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming.
Failure to Implement Timely Nutritional Interventions for Resident with Significant Weight Loss
Penalty
Summary
A resident with a history of protein-calorie malnutrition, dysphagia, pneumonitis due to inhalation, and diabetes mellitus experienced significant unplanned weight loss after readmission to the facility. The facility failed to follow the Registered Dietitian's (RD) interventions, including obtaining a dental evaluation, implementing a revised nutritional plan of care, and notifying the attending physician about the resident's significant weight loss. The RD's recommendations for a change in diet, double protein with meals, and daily multivitamins were not communicated or implemented. Additionally, the Dietary Manager did not obtain the resident's most current weight upon readmission, instead copying the previous admission weight, which led to missing the significant weight loss of 7.2 pounds in 14 days. The interdisciplinary team (IDT) did not convene to address, monitor, or intervene regarding the resident's undesirable weight loss as required by the facility's policy on unplanned weight loss. The resident was not accurately reassessed by the Dietary Manager, and the plan of care was not revised despite the documented weight loss. These actions and inactions resulted in the resident not receiving timely and appropriate nutritional interventions, as outlined in the facility's clinical protocol.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a structured program designed to minimize the risk of infection transmission among residents and staff. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Offer and Document COVID-19 Vaccination for New Admissions
Penalty
Summary
The facility failed to offer COVID-19 vaccines to three residents upon admission, as required by their policy and procedure. For each resident, record reviews and interviews revealed that they were not provided with education about the COVID-19 vaccine, nor were they screened or consented for vaccination at the time of admission. Specifically, one resident with severe cognitive impairment had not been screened or consented for the vaccine, despite having received a previous dose in 2022. Another resident, who was cognitively intact and able to make her own decisions, had no record of ever receiving the COVID-19 vaccine and was not offered information or the vaccine upon admission. The third resident, who was alert and oriented, had received a previous dose in 2023 but was also not screened or offered the vaccine or education upon admission. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the responsibility for screening, consenting, and administering the COVID-19 vaccine to residents upon admission lies with the IP. Both the IP and DON acknowledged that the three residents should have been screened and consented for the COVID-19 vaccine at the time of their admission, in accordance with the facility's policy. The facility's policy states that all residents are to be offered the COVID-19 vaccine unless medically contraindicated or already fully vaccinated, and that education regarding the vaccine's benefits, risks, and side effects must be provided.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
Staff failed to ensure that a resident's call light was within reach, as required by the resident's care plan and the facility's policy. The resident, who had a history of cerebral infarction resulting in severely impaired cognition and right-sided weakness, was dependent on staff for most activities of daily living, including toileting, hygiene, and mobility. During an observation, the resident was seen searching for the call light, which was found hanging against the wall and out of reach. The resident stated that they use the call light to call for help from staff. Interviews with facility staff, including the Assistant Director of Staff Development and the Director of Nursing, confirmed that the call light should always be accessible to residents, especially those with significant physical and cognitive impairments. The staff acknowledged that sometimes call lights are not placed within reach after care is provided. Review of the facility's policy also indicated that staff are required to ensure call lights are accessible from the bed, toilet, shower, and floor. This failure to provide reasonable accommodation for the resident's needs constituted a deficiency.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify and consult with a resident's physician regarding a significant change in the resident's physical status, specifically a weight loss of 7.2 pounds over 14 days. The resident, who had diagnoses including unspecified protein-calorie malnutrition, dysphagia, pneumonitis due to inhalation, and diabetes mellitus, was moderately cognitively impaired and required substantial to maximal assistance with activities of daily living. The weight loss was documented in the resident's records, but there was no evidence that the physician was informed of this significant change. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the weight loss met the facility's criteria for a significant change, which should have triggered physician notification and an interdisciplinary review. The facility's policy required staff intervention and care plan revision for such changes, but documentation and staff statements indicated that the physician was not made aware, and the resident was not reassessed in response to the weight loss.
Unclean Bed Rail Found in Resident's Room
Penalty
Summary
A deficiency was identified when a resident's environment was found to be unclean during a survey. Specifically, a thick, dried, brown-colored pasty substance was observed on the top and inner side surfaces of the right side bed rail in the resident's bedroom. This observation was made during a concurrent interview and inspection with a CNA, who acknowledged the bed rail was dirty and indicated an intention to clean it. The resident involved was dependent on staff for all activities of daily living and had a gastrostomy tube, as well as a history of delayed childhood milestones. The facility's policy on infection prevention and control, dated April 2025, states that all personnel are trained on infection prevention and control procedures upon hire and periodically thereafter. The DON confirmed the importance of maintaining a clean environment for residents' health and well-being. The failure to maintain cleanliness in the resident's immediate environment constituted a breach of the facility's obligation to provide a safe, clean, and comfortable living space.
Failure to Complete Timely Resident Assessment
Penalty
Summary
A deficiency was identified when the facility failed to assess a resident completely and in a timely manner upon admission and at required intervals, specifically at least every 12 months. The report notes that the necessary comprehensive assessment was not conducted as mandated, which constitutes noncompliance with assessment requirements.
Inaccurate MDS Coding for Resident Weight Loss
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was accurately coded to reflect a significant weight loss. The resident, who had diagnoses including unspecified protein-calorie malnutrition, dysphagia, and pneumonitis due to inhalation, experienced a weight loss of 7.2 pounds, equating to a 5.9 percent decrease over 14 days. This weight loss was documented in the resident's nutrition assessment and care plan. However, the MDS assessment incorrectly indicated that there was no weight loss in the last one to six months. The MDS coordinator, responsible for completing the assessment, misinterpreted the calculation method after consulting with the facility's MDS consultant, leading to the inaccurate entry. The Director of Nursing confirmed that the MDS was coded incorrectly. The facility's policy requires that any healthcare professional completing the MDS must certify the accuracy of the assessment, but this was not adhered to in this instance, resulting in incorrect data being transmitted to CMS.
Failure to Develop Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who experienced significant weight loss shortly after admission. The resident, who had diagnoses including unspecified-calorie malnutrition, dysphagia, and pneumonitis due to inhalation of food and vomit, lost 7.2 pounds (5.9 percent of body weight) within 14 days. The Minimum Data Set indicated the resident had moderately impaired cognition, and the nutrition assessment by the Registered Dietitian confirmed the recent weight loss. Despite these findings, there was no evidence that a care plan addressing the resident's nutritional needs and weight loss was developed. Facility policy required that any weight change of 5 percent or more since the last assessment should prompt immediate written notification to the dietitian and physician, and involve a multidisciplinary team including nursing staff, the dietitian, the consultant pharmacist, and the resident or their legal surrogate. However, the records and interviews indicated that this process was not followed for the resident in question, resulting in a lack of timely and coordinated care planning to address the resident's nutritional status.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper labeling and storage protocols for medications and biologicals within the facility. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Complete Antibiotic Surveillance Documentation
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship for one of three sampled residents by not completing an Infection Surveillance Outcome form for a resident who was prescribed multiple antibiotics. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, skin cancer, and recent scalp surgery, and was cognitively intact and able to make decisions. Upon review, it was found that the resident was receiving Vancomycin and Meropenem for a brain abscess, as well as Erythromycin ointment and Bacitracin Zinc ointment for other conditions. However, the Infection Preventionist did not review or document the use of Vancomycin and Meropenem on the required surveillance form. Interviews with facility staff confirmed that the Infection Preventionist was responsible for completing the Infection Surveillance Outcome form for all residents on antibiotics, and that this process was not followed for the resident in question. The facility's policy required that all antibiotic usage and outcomes be documented and reviewed as part of the Antibiotic Stewardship Program, but this was not done for the antibiotics prescribed to the resident. This lapse was identified through interviews and record reviews conducted by surveyors.
Failure to Administer Pneumococcal Vaccine After Resident Consent
Penalty
Summary
A resident with diagnoses including chronic obstructive pulmonary disease (COPD), skin cancer, and recent scalp surgery was admitted to the facility and was found to be cognitively intact and able to make her own medical decisions. The resident provided written consent to receive the pneumococcal vaccine (PVC 20) on 7/26/2025. However, a review of the immunization record and medication administration record (MAR) for July and August 2025 showed that the vaccine was not administered, resulting in a delay of 25 days since the resident's request and consent. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that facility policy requires the PVC 20 vaccine to be ordered and administered within 72 hours of obtaining resident consent. In this case, the IP did not place the order for the vaccine, and the resident did not receive the immunization as required by facility policy. The facility's policy and procedure on pneumococcal vaccination states that all residents will be offered the vaccine unless medically contraindicated, already given, or refused, but this protocol was not followed for the resident in question.
Insufficient In-Service Training for Restorative Nursing Assistant
Penalty
Summary
The facility failed to ensure that a Restorative Nursing Assistant (RNA) received the required 12 hours of in-service training, including education in dementia care and abuse prevention. During an interview and record review with the Interim Director of Staff Development (IDSD), it was found that the RNA did not receive any training prior to working on the floor. The employee file lacked documentation of the mandatory in-service training, and the in-service binder showed only 1 hour of dementia training and 9 hours of abuse prevention training for the relevant period, both of which were insufficient according to facility policy. The facility's policy requires all staff to participate in initial orientation and annual in-service training, with specific requirements for dementia and abuse prevention education. The IDSD confirmed that the RNA's training was incomplete and acknowledged that the lack of adequate training could impact the ability to care for elderly residents, particularly those with dementia or at risk of abuse. The deficiency was identified through review of training records and staff interviews, which confirmed the absence of required documentation and insufficient training hours.
Failure to Develop Care Plan for Resident's Central Venous Catheter
Penalty
Summary
The facility failed to develop a care plan for a resident's Central Venous Catheter (CVC), which is crucial for administering fluids, blood, and medications. This oversight was identified during a review of the resident's records, which showed that the resident was readmitted with multiple diagnoses, including chronic obstructive pulmonary disease, diabetes mellitus, dementia, muscle weakness, and pressure ulcers. The resident was noted to have severely impaired cognition and was dependent on staff for various activities of daily living. Despite these complex medical needs, there was no care plan in place for the CVC, as confirmed by the Director of Nursing during an interview and record review. The facility's policy and procedures, reviewed in November 2024, require that care plans incorporate goals and objectives to achieve the resident's highest level of independence. These goals and objectives should be derived from the resident's comprehensive assessment. However, the absence of a care plan for the CVC indicates a failure to adhere to these policies, potentially affecting the delivery of care and services to the resident.
Failure to Document Central Venous Catheter Care
Penalty
Summary
The facility failed to ensure proper documentation of care for a resident with a Central Venous Catheter (CVC). The resident, who was readmitted with multiple diagnoses including COPD, diabetes mellitus, dementia, muscle weakness, and pressure ulcers, had an intravenous central line on the left upper chest. The facility's IV Administration Record (IVAR) for December 2024 showed missing entries for monitoring the central line site for signs of infection and infiltration from 12/21/24 to 12/31/24, and for measuring the external catheter length and changing the transparent dressing on 12/25/24. During an interview, the Director of Nursing (DON) confirmed the absence of documentation for the central line care on the specified dates. The DON speculated that the registered nurses might have performed the care but failed to document it due to a possible issue with the order entry system, which may not have displayed the tasks. The facility's policy and procedures emphasize the importance of care plans incorporating goals and objectives for residents' highest level of independence, but the lack of documentation made it impossible to verify if the care was completed as required.
Failure to Notify Physician and NOK of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and the next of kin (NOK) of a significant change in condition for a resident who experienced a notable weight loss. The resident, admitted with diagnoses including dementia and chronic kidney disease, had a weight of 126 pounds on October 8, 2024, which decreased to 118 pounds by November 4, 2024, indicating a significant weight loss of eight pounds in one month. Despite the care plan's directive to inform the physician about significant weight changes, the facility did not notify the resident's physician or NOK in a timely manner. The facility's policy requires prompt notification of the resident, their attending physician, and their representative of any significant changes in condition. However, documentation showed that the physician was only informed on November 8, 2024, and there was no evidence that the NOK was notified. Interviews with staff revealed discrepancies in the communication process, with one licensed vocational nurse admitting to entering incorrect information regarding family notification. The facility's policy emphasizes timely communication, which was not adhered to in this case.
Failure to Document Urine Sample Collection
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident who had a physician's order to collect a urine sample for urinalysis, culture, and sensitivity. The order was given after the resident's next of kin notified the facility of the resident's complaint of pain upon urination. Despite the physician's order, the urine sample was not collected, and there was no documentation in the resident's medical record indicating the failure to collect the sample or the notification of the resident's primary physician. The resident, who was admitted with diagnoses including dementia and chronic kidney disease, was cognitively impaired and required assistance with various activities of daily living. The facility's policy and procedure on charting and documentation required that all services provided, changes in the resident's condition, and notifications to family or physicians be documented in the medical record. However, the director of nursing confirmed that the urine sample was not collected due to difficulty in obtaining it, and the medical record director verified that the laboratory had no record of receiving the sample. This resulted in an inaccurate representation of the resident's medical record.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, leading to potential health risks for residents. During an observation, it was found that dishware was not sanitized with an adequate amount of chlorine sanitizer, as the concentration was below the recommended level of 50 parts per million (ppm). Dietary staff did not notice the low levels of chlorine in the container and continued washing dishes, which could lead to cross-contamination and foodborne illness. The facility's policy required immediate corrective action if sanitizer concentrations were too low, but this was not adhered to during the incident. Additionally, the ice machine in the kitchen was not maintained in a clean manner, with grey and black residue found in the ice storage bin. The Dietary Supervisor confirmed the presence of residue and acknowledged the importance of keeping the ice machine clean to prevent cross-contamination. The Registered Dietitian and Director of Maintenance also confirmed that the ice machine should be free from buildup to prevent contamination, but the machine had not been cleaned as frequently as required by the facility's policy. Furthermore, the facility did not monitor the thaw dates of individual juice cartons and deli meats, leading to potential consumption of expired products. Juice cartons were stored without thaw dates, and a package of ham was labeled with dates exceeding the facility's policy for food storage. The Dietary Supervisor admitted that staff did not label the deli meat correctly, which could result in spoilage and health risks for residents. The facility's policy required proper dating and rotation of food items to ensure safety, but this was not followed in these instances.
Inaccurate MDS Coding for Restorative Nursing Program
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, specifically in the section relating to the Restorative Nursing Program. This deficiency was identified for one resident who was admitted with conditions including neuralgia, neuritis, muscle weakness, and a right-hand contracture. The resident's care plan included the use of a cock-up splint and passive range of motion exercises, which were not accurately reflected in the MDS. The resident's care plan, developed in July 2023, indicated the need for an exercise program due to limitations in range of motion and a right-hand contracture. The plan included goals to increase endurance and regain strength, with interventions such as applying a cock-up splint and providing passive range of motion exercises. However, the Quarterly MDS did not indicate that the resident received restorative nursing services, despite records showing that the resident received these services for 18 days in July 2024. Interviews with staff, including the Restorative Nurse Aide and the MDS Coordinator, confirmed that the MDS was completed incorrectly. The MDS Coordinator acknowledged that the MDS did not reflect the resident's receipt of RNA services or the use of a splint. The Director of Nursing also stated that the MDS should accurately reflect the care the resident is receiving, and incorrect coding could lead to an inaccurate assessment of care.
Failure to Administer and Document Chest Physiotherapy
Penalty
Summary
The facility failed to provide chest physiotherapy to a resident, identified as Resident 42, on two specific dates, despite a physician's order. Resident 42 was admitted with multiple diagnoses, including Parkinson's disease, aspiration pneumonia, dysphagia, a Stage IV pressure ulcer, and Alzheimer's disease. The resident's care plan, developed in July 2024, aimed to reduce the frequency of acute exacerbations through various interventions, including adherence to prescribed regimens and regular respiratory assessments. However, the facility did not document the administration of chest physiotherapy on 8/10/2024 and 8/12/2024, as required by the physician's order dated 8/9/2024. The physician's order specified that Resident 42 was to receive chest wall manipulation five times a day for 30 days to aid lung function due to aspiration pneumonia. While the respiratory therapy daily note on 8/9/2024 indicated that the treatment was administered and well-tolerated, there was no documentation for the specified dates in question. Interviews with the registered nurse and the Director of Nursing confirmed that the absence of documentation implied the treatment was not performed, which could potentially compromise the resident's respiratory status. The facility's policy and procedure for respiratory therapy care and documentation required thorough and accurate records of all services provided, including the type and duration of therapy and the resident's response. The policy also mandated that all services, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. The lack of documentation for the chest physiotherapy on the specified dates indicates a failure to adhere to these policies, resulting in a deficiency in the care provided to Resident 42.
Failure to Accurately Account for Controlled Medication
Penalty
Summary
The facility failed to accurately account for a dose of lorazepam, a controlled medication, for a resident. During an observation and interview with an LVN, it was discovered that there was a discrepancy between the Controlled Drug Record and the medication card. The Controlled Drug Record indicated there were 16 doses left, but the medication card contained only 15 doses. The LVN admitted to administering the missing dose to the resident but failed to document it in the Controlled Drug Record at the time of administration. The facility's policy on Controlled Substances requires that an individual resident controlled substance record be maintained, which includes the time of administration and the signature of the nurse administering the medication. The LVN acknowledged the requirement to sign off on controlled medications immediately after administration to prevent potential over-administration. This oversight increased the risk of medication diversion and the possibility of the resident receiving an incorrect dosage, which could lead to serious health complications.
Delay in Dental Services for Dentures
Penalty
Summary
The facility failed to follow up on requested dental services for dentures for a resident, resulting in a delay in evaluation and increased risk for weight loss and muscle mass loss. The resident, who was initially admitted with diagnoses including anxiety, dorsalgia, and COPD, had intact cognition and was able to communicate needs. The resident's Minimum Data Set indicated obvious broken natural teeth, and a nutritional assessment noted a request for dentures. A physician order for a dental consult for dentures was made, but the resident only saw a dental hygienist who could not address denture-related questions. The Social Services Director, responsible for coordinating appointments, was unaware of the resident's request for dentures or any related issues. The resident had a scheduled dental appointment, but the Director of Nursing was unsure why there was a delay in the dental examination. The facility's policy stated that residents have the right to select dentists and that social services should assist with appointments and transportation. Despite this, the resident experienced a delay in receiving necessary dental care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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What surveyors actually found near you
We read the 6,994 citations issued within 25 miles in the last 12 months — including the 36 immediate-jeopardy cases — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| California Post Acute | 0 mi | ★★★★★ | 9 | 0 |
| Grand Park Convalescent Hospital | 0.1 mi | ★★★★★ | 1 | 0 |
| Olympia Convalescent Hospital | 0.3 mi | ★★★★★ | 4 | 1 |
| Alvarado Care Center | 0.3 mi | ★★★★★ | 30 | 1 |
| Alden Terrace Convalescent Hospital | 0.4 mi | ★★★★★ | 14 | 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.