Above 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 Vista Healthcare & Wellness Centre during CMS and state inspections, most recent first.
Inaccurate monitoring parameters were documented for a resident receiving Quetiapine for bipolar disorder and psychosis. The physician order and eMAR referenced antidepressant side effects rather than antipsychotic-specific monitoring, while the care plan listed psychotropic monitoring for adverse reactions such as unsteady gait and tardive dyskinesia. The DON stated the order should have been verified and clarified because Quetiapine requires monitoring different from antidepressant medications.
Care plan not revised for worsening skin condition: A resident with dementia and eczematoid dermatitis had an existing rash that worsened, including bleeding on the left foot, and new MD/dermatology orders were documented for topical clobetasol, hydroxyzine, and Dupixent. The care plan continued to address general rash/allergic reaction concerns but was not updated to reflect the new treatment plan or the resident’s change in condition, and staff stated there was no documented evidence the IDT met or revised the plan.
A resident with bipolar disorder received daily Vraylar, but the behavior-monitoring order was left unclear and nursing staff documented target behavior monitoring using the same vague wording without clarifying the specific behaviors to be tracked. The DON acknowledged the order was unclear and that staff were expected to clarify the missing target behavior when the order was received.
Two residents receiving IV therapy had dressing care deficiencies. One resident with a PICC line for IV antibiotics related to endocarditis had a transparent dressing that was overdue for change based on the ordered 7-day schedule, and staff confirmed it should have been changed earlier. Another resident with a peripheral IV for antibiotic therapy related to bacteremia had a dressing that was not labeled with the date, time, and initials, despite the order and facility policy requiring labeled IV dressings.
A resident with COPD and asthma received PRN nebulizer treatments for SOB, but the MAR lacked the required pre- and post-treatment respiratory assessments and documentation of effectiveness. The resident stated she had to ask for her breathing treatment and that no one checked whether it helped, and the DON confirmed the required respiratory therapy documentation was not being completed and that licensed nurses should have documented the assessments and response to treatment.
Pain Assessment and Medication Orders Not Followed: Two residents did not receive pain management as ordered. One resident with a recent hip fracture and surgery had no documented pain assessments for months, and staff gave Dilaudid doses that did not match the ordered pain scale ranges. Another resident with OA and acute pain reported pain level 10, but the available PRN order for oxycodone-acetaminophen was only for severe pain rated 7-9, and the order was not clarified before administration.
A resident who received hemodialysis did not have a completed post-dialysis assessment documented when returning to the facility. The Dialysis Communication Record was left blank in the post-hemodialysis section, and an LVN stated the assessment was not completed by the dialysis facility and/or the assigned nurse. The DON stated post-dialysis forms should include a completed assessment and monitoring, and the facility policy required a pre- and post-dialysis evaluation by the licensed nurse.
Opened medications were found without required open-date labels in two nursing stations. An opened refrigerated PPD vial in one med room and three opened items in a med cart—budesonide inhalation suspension, Humulin N KwikPen, and Lispro KwikPen—lacked dates showing when they were opened. The ADON, LVN, and DON stated staff were expected to label opened medications and follow manufacturer and pharmacy shortened expiration guidance.
A resident with edema and pulmonary hypertension received Furosemide despite a physician's order to hold the medication if systolic blood pressure was below 110. An LVN administered the medication when the resident's blood pressure was 98/68, citing an undocumented verbal order. Review by the DON confirmed no documentation supported this deviation from the original order, and facility policy requiring adherence to medication parameters and documentation was not followed.
The facility failed to accurately code the MDS for PASRR Level II for four residents, despite having completed evaluations. Residents with mental health diagnoses, including psychosis, schizoaffective disorder, and PTSD, were not properly coded in the MDS, leading to discrepancies in their care plans. The DON and MDS staff were responsible for ensuring accurate coding, but a lack of access to the PASRR portal contributed to the errors.
A resident with a history of pneumonia and severe sepsis was readmitted with a peripheral IV access, but the facility failed to obtain physician's orders for its care, including flushes and dressing changes. The IV site was not assessed or documented as per facility policy, and the dressing was left unchanged for over 20 days. Interviews with staff revealed a lack of clarity and adherence to IV care protocols, resulting in a deficiency in the standard of care provided.
Two residents with muscle wasting and cognitive impairments were not provided with splints as ordered, leading to deficiencies in their care. Despite physician orders for daily application of splints to prevent contractures, observations revealed the absence of splints, and documentation was lacking. Staff interviews confirmed the failure to apply splints consistently, highlighting a breakdown in the facility's restorative nursing program.
A facility failed to limit a PRN psychotropic medication order for a resident to 14 days, as required by policy, affecting a resident with schizophrenia, bipolar disorder, anxiety disorder, major depressive disorder, and unspecified dementia. The resident's Ativan order lacked a stop date and documented rationale for continued use. Staff interviews revealed a lack of adherence to policy, with no reassessment conducted to determine the ongoing need for the medication.
A facility failed to disinfect a glucometer between uses, leading to potential infection risks. An LVN used the same glucometer on two residents without cleaning it, contrary to CDC guidelines and facility policy. Staff interviews confirmed the requirement for disinfection with EPA-approved wipes before and after each use.
Inaccurate Monitoring Parameters for Quetiapine
Penalty
Summary
The facility failed to ensure accurate documentation and monitoring parameters for Quetiapine for one resident who was admitted with diagnoses including psychosis and bipolar disorder. The resident’s physician order dated August 14, 2025, directed Quetiapine Fumarate 25 mg, 0.5 tablet by mouth at bedtime for bipolar disorder, but the order also stated to monitor for side effects of antidepressant medication due to use of Quetiapine every shift, including dry mouth, blurred vision, constipation, urinary retention, hypotension, appetite changes, headache, insomnia, dyspepsia, and weight changes. Review of the resident’s care plan dated August 21, 2025, showed the resident used psychotropic medication (Quetiapine) for behavior management and included monitoring/documenting/reporting adverse reactions such as unsteady gait and tardive dyskinesia. However, the eMAR for August 2025 referenced side effects associated with an antidepressant medication rather than monitoring specific to Quetiapine or antipsychotic medications. During interview, an LVN stated licensed nurses were required to monitor residents receiving psychotropic medications every shift and document the monitoring in the eMAR. The DON stated the resident’s monitoring documentation referenced antidepressant medication monitoring rather than antipsychotic medication monitoring, and that the licensed nurses should have verified the monitoring parameters and clarified the order with the physician.
Care Plan Not Revised for Worsening Skin Condition
Penalty
Summary
The facility failed to ensure Resident 4’s comprehensive care plan was revised to reflect new physician recommendations and a worsening skin condition. Resident 4 was admitted with diagnoses including failure to thrive, dementia, and eczematoid dermatitis, and the history and physical stated the resident did not have the capacity to understand and make decisions. The existing care plan, dated June 2, 2025, addressed potential rashes and allergic reactions with interventions such as avoiding scratching, monitoring for spread and infection, seeking medical attention if skin became bloody or infected, and identifying skin allergies. A physician progress note dated July 1, 2025, documented eczematous dermatitis with orders for clobetasol ointment twice daily for flare, hydroxyzine 25 mg at bedtime, and Dupixent. A SBAR communication form dated July 5, 2025, documented that the resident had an existing rash with treatment to the left foot and that the rash on the left foot was exacerbated with scant bleeding. Review of the care plan showed it was not revised to reflect the physician recommendations or the worsening skin condition. The Treatment Nurse stated that if care plan interventions were not effective, the care plan needed to be revised, and that the July 5 change with bleeding should have been included. The Registered Nurse Supervisor stated the care plan should have been revised after the rash worsened and after the dermatologist recommendations, and that there was no documented evidence the interdisciplinary team met or revised the care plan.
Unclear behavior monitoring order for Vraylar
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for one resident with bipolar disorder when the physician’s order for behavior monitoring during use of Vraylar was not clarified. Resident 4 was admitted with a diagnosis of bipolar disorder, and the physician orders included Vraylar 1.5 mg by mouth daily for bipolar disorder manifested by episodes of manic behavior. A subsequent order directed nursing staff to monitor target behaviors for use of Vraylar due to bipolar disorder, but the order stated “insert behaviors manifested/target behaviors” and did not identify the specific behaviors to be monitored. The MAR showed that nursing staff administered Vraylar daily and documented monitoring of target behavior using the same unclear wording on multiple dates without clarification of the missing target behavior. During interview and record review, the DON acknowledged the order was unclear and stated nursing staff were expected to have clarified the missing target behavior when the order was received.
IV Dressing Care and Labeling Deficiencies
Penalty
Summary
The facility failed to provide necessary care and services to maintain IV access for two residents receiving IV therapy. One resident with a PICC line for IV antibiotics related to endocarditis was observed with a transparent dressing dated July 23, 2025, even though the physician’s order required the dressing and cap to be changed every 7 days. The resident stated he had been receiving IV antibiotic medications for five weeks, and the Registered Nurse Supervisor and Director of Nursing both stated the dressing should have been changed on July 30, 2025. The Infection Preventionist stated PICC line dressings should be changed every 7 days to prevent irritation and possible infection at the IV site. A second resident with a peripheral IV for antibiotic therapy related to bacteremia was observed with a dressing on the left hand that was not labeled with the date, time, and nurse’s initials. The physician’s order required the peripheral IV line and dressing to be changed every 48 hours, and the facility’s policy required IV dressings to be labeled with the date, time, and initials. The Infection Preventionist stated the dressing should have been labeled to prevent infection, and the DON stated it was the facility’s policy to label all IV dressings with date, time, and initials.
Missing Respiratory Assessments and Treatment Effectiveness Documentation
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for one resident who was reviewed for respiratory treatment. The resident had diagnoses including COPD and asthma and was admitted with the capacity to understand and make decisions. On August 4, 2025, the resident was observed coughing and stated she had shortness of breath. She also stated that she had to ask for her breathing treatment and that nobody checked to see if it helped. The resident’s physician orders required Ipratropium-Albuterol nebulizer treatments every 4 hours as needed for shortness of breath, with documentation of respiratory assessments before treatment and after treatment, including pulse, respiratory rate, oxygen saturation, and lung sounds, as well as evaluation of effectiveness. The MAR showed 21 PRN nebulizer treatments were given in July and August 2025, but there was no documentation of the required before and after respiratory assessments or post-treatment effectiveness evaluations. The DON stated the respiratory therapy documentation was not being completed for July and August 2025 and acknowledged that the licensed nurses should have assessed the resident before and after treatment and documented the assessments.
Pain Assessment and Medication Orders Not Followed
Penalty
Summary
Safe, appropriate pain management was not provided for two residents who required pain assessment and medication management. Resident 12 was admitted with a displaced intertrochanteric fracture of the right femur and had surgery to the right hip. The record showed a pain evaluation was indicated, but no pain assessment/evaluation was completed from January 2025 through July 2025. After surgery, Resident 12 had orders for Dilaudid 2 mg, Dilaudid 4 mg, and tramadol for different pain levels, but the medication administration record showed repeated administration of Dilaudid 2 mg for documented pain levels that did not match the ordered pain scale ranges. Resident 12 told staff the pain medication was not as effective as hoped, and the DON stated the pain assessment should have been reviewed at least quarterly and that the orders were not followed. Resident 7 was admitted and readmitted with diagnoses including osteoarthritis of the knee and acute pain due to trauma. The resident had intact cognition with a BIMS score of 14 and a care plan addressing risk for acute and chronic pain. A provider order dated July 31, 2025, directed oxycodone-acetaminophen 10/325 mg every 6 hours as needed for severe pain rated 7-9. During a medication pass observation, Resident 7 reported pain level 10 in the neck and back and received one oxycodone-acetaminophen tablet. The clinical record reviewed at that time did not show a provider order for pain medication prescribed for pain level 10. The DON acknowledged that the oxycodone-acetaminophen order was for pain level 7-9 and did not include pain level 10, and stated the nurse should have clarified the order with the provider when the resident reported pain outside the prescribed parameters. The facility policy stated pain assessments were to be completed upon admission, quarterly, with new onset or exacerbation of pain, or significant change in status, and medications were to be administered as prescribed with clarification obtained when an order seemed unrelated to the resident's current condition.
Incomplete Post-Dialysis Assessment
Penalty
Summary
Appropriate dialysis care/services were not provided for Resident 42 when the post-dialysis evaluation was left incomplete after a hemodialysis treatment. The resident’s Dialysis Communication Record for August 7, 2025 showed the post-hemodialysis assessment section was blank and did not document that the resident was assessed or monitored after returning to the facility. During a concurrent interview and record review, LVN 1 stated the post-hemodialysis assessment was not completed by the dialysis facility and/or assessed by the assigned nurse. The DON stated that post-dialysis forms should include a completed assessment and monitoring of the dialysis treatment, and that any communication from the dialysis clinic must be followed up and documented to show all interventions provided to the resident. The facility’s Dialysis Management policy stated that a pre- and post-dialysis evaluation will be completed by the licensed nurse.
Opened Medications Found Without Required Dates
Penalty
Summary
Medication storage and labeling were not maintained for several drugs and biologicals found in the facility. During observation in Nursing Station 1, an opened refrigerated multi-dose vial of Tuberculin PPD 5 TU per 0.1 ml was found without an open date label. The ADON stated nursing staff were expected to label the opened vial with the date it was opened and that the vial was good for 30 days after opening according to the manufacturer. The ADON also stated the opened, used, and undated PPD vial should have been discarded. The manufacturer's instructions reviewed during the survey indicated that a vial of PPD that has been entered and in use for 30 days should be discarded. During observation in Nursing Station 3, three medications in the medication cart were found opened without open date labels: one budesonide inhalation suspension foil pack with four unused ampules, one prefilled Humulin N KwikPen insulin pen, and one prefilled Lispro KwikPen insulin pen. LVN 2 stated these medications should have been labeled with open dates and reviewed the packaging instructions showing shortened use periods after opening. The ADON and DON stated nurses were expected to write the opened date on medications when opened and that the date was needed to determine when the medication expired and to maintain stability and sterility. The DON also stated the facility did not have a policy regarding medication labeling and that nurses were expected to follow manufacturer instructions and pharmacy expiration guidance.
Failure to Follow Physician's Order for Medication Administration Based on Blood Pressure Parameters
Penalty
Summary
A deficiency occurred when a licensed nurse failed to follow a physician's order regarding the administration of Furosemide for a resident with localized edema and pulmonary hypertension. The physician's order specified that Furosemide should be held if the resident's systolic blood pressure (SBP) was less than 110. Despite this, the medication was administered on a day when the resident's blood pressure was recorded as 98/68, which was below the prescribed threshold. During interviews and record reviews, the nurse stated that a verbal order had been given by the physician to continue the medication despite the low SBP, but there was no documentation in the resident's medical record or progress notes to support this claim. The Director of Nursing confirmed that there was no documentation authorizing the administration of Furosemide outside the original parameters. Facility policy required that medications be administered as prescribed and that vital signs be checked and documented when administration is dependent on such parameters, which was not followed in this instance.
Inaccurate MDS Coding for PASRR Level II
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) to reflect a Preadmission Screening and Resident Review (PASRR) Level II for four residents. This deficiency was identified through record reviews and interviews, revealing that the facility did not have a policy on MDS accuracy and relied on the Resident Assessment Instrument (RAI) manual. The Director of Nursing (DON) acknowledged the absence of a specific policy and stated that the MDS coordinators were responsible for coding section A of the MDS, which includes PASRR Level II information. Resident #14 was admitted with a history of unspecified psychosis and vascular dementia. Despite having a PASRR Level II evaluation completed, the MDS did not reflect this, indicating a failure to accurately code the resident's mental health needs. Similarly, Resident #62, with diagnoses including schizoaffective disorder and bipolar disorder, had a PASRR Level II evaluation, but the MDS did not reflect this. The Social Services Supervisor confirmed the residents were receiving psychiatric services, yet the MDS staff failed to accurately code the necessary information. Resident #80, with diagnoses of anxiety disorder and PTSD, also had a PASRR Level II evaluation, but the MDS did not reflect this. The resident refused psychiatric services, preferring family support, yet the MDS was inaccurately coded. Resident #55, with severe cognitive impairment and multiple mental health diagnoses, had a positive Level I PASRR screening, but the MDS did not reflect the Level II evaluation. Interviews with the DON and MDS Coordinator revealed a lack of access to the PASRR portal until recently, contributing to the inaccuracies in MDS coding.
Failure to Provide and Document IV Site Care
Penalty
Summary
The facility failed to provide and document care for a peripheral intravenous (IV) access site in accordance with accepted nursing standards and facility policy for a resident. The resident, who was readmitted to the facility with a medical history of pneumonia and severe sepsis with septic shock, had a peripheral IV access in the right foot. However, there were no physician's orders for the care or maintenance of the IV site, including flushes or dressing changes. The dressing on the IV site was observed to be over 20 days old, and the resident's care plan did not address the presence of the IV access site or include interventions for its care and monitoring. Interviews with facility staff revealed a lack of clarity and adherence to the facility's policy regarding IV site care. The RN Supervisor stated that the IV access was discontinued only after confirming it was not needed, but there was no documentation or orders for its care prior to removal. LVN #7 and LVN #5 indicated that the site should have been assessed and monitored every shift, with appropriate orders for flushing and dressing changes, but this was not done. The Director of Staff Development and the Director of Nursing also expressed uncertainty about the frequency of dressing changes and the duration a peripheral IV line could remain in place. The Administrator acknowledged that if a resident was admitted with IV access, the nurse should determine its necessity and obtain physician orders for its care. Despite this, the facility did not have such orders for the resident in question, leading to a deficiency in the standard of care provided. The lack of proper documentation and adherence to facility policy resulted in the IV site remaining in place without necessary care or monitoring, highlighting a significant oversight in the facility's care processes.
Failure to Apply Splints as Ordered for Residents
Penalty
Summary
The facility failed to ensure that splints were applied as ordered for two residents, leading to deficiencies in their care. Resident #18, who had a medical history of muscle wasting, atrophy, and cachexia, was observed without the necessary splints on multiple occasions. Despite having orders for a right elbow extension splint and a right resting comfy hand splint to be applied daily, these were not consistently applied, and there was a lack of documentation for the splint care on several days. Interviews with staff revealed that the splints were not applied regularly, and there was no documentation explaining the absence of the splints. Similarly, Resident #46, who had severe cognitive impairment and functional limitations in range of motion, was also observed without the required splints. The resident had orders for left and right elbow extension splints to be applied daily, but these were not consistently in place, and documentation was missing for several days. Staff interviews indicated that the splints were not applied as ordered, and there was no documentation to justify the lack of application. The facility's staff, including RNAs, LVNs, and the Director of Nursing, acknowledged the importance of splints for contracture prevention and the need for adherence to physician orders. However, there was a clear breakdown in the implementation and documentation of the restorative nursing program, leading to the observed deficiencies in care for both residents.
Failure to Limit PRN Psychotropic Medication Order to 14 Days
Penalty
Summary
The facility failed to ensure that an as-needed (PRN) psychotropic medication order for a resident was limited to 14 days unless there was documented rationale for extended use and a specific duration of the order. This deficiency affected a resident with a medical history of schizophrenia, bipolar disorder, anxiety disorder, major depressive disorder, and unspecified dementia. The resident had a PRN order for Ativan, a benzodiazepine, with no stop date or documented rationale for continued use. The facility's policy required that any psychoactive medication ordered on a PRN basis must not exceed 14 days unless the physician documented the reasons for continued usage. Interviews with facility staff, including a Registered Nurse, Licensed Vocational Nurse, Director of Staff Development, Director of Nursing, and the Administrator, revealed a lack of adherence to the facility's policy regarding PRN psychotropic medications. The staff acknowledged that the PRN order should have had a 14-day stop date and that the resident should have been reassessed to determine the ongoing need for the medication. However, the resident's Ativan order did not have a stop date, and there was no documentation of reassessment for the rationale of its ongoing use. The Director of Nursing confirmed that the resident exhibited behaviors warranting the use of the medication, but the necessary procedural steps were not followed, leading to the deficiency.
Failure to Disinfect Glucometer Between Uses
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of a glucometer between uses, which is crucial to prevent the potential spread of infection. Observations revealed that a Licensed Vocational Nurse (LVN) performed blood glucose tests on two residents without cleaning or disinfecting the glucometer between uses. After testing Resident #7, the LVN placed the uncleaned glucometer on the medication cart and proceeded to use the same device on Resident #26 without disinfection. This action was contrary to the facility's policy and the Centers for Disease Control and Prevention (CDC) recommendations, which require cleaning and disinfection of reusable medical equipment between residents. Interviews with various staff members, including the Infection Preventionist, Registered Nurse Supervisor, Director of Staff Development, Director of Nursing, and the Administrator, confirmed that the glucometer should be cleaned before and after each use with an Environmental Protection Agency (EPA)-approved disinfectant. The LVN involved admitted to forgetting to disinfect the glucometer due to nervousness. The facility's policy, revised in 2012, clearly states that reusable items must be cleaned and disinfected or sterilized between residents, aligning with the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard.
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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 Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Villa Health Care Center | 0.2 mi | ★★★★★ | 3 | 0 |
| Mission Care Center | 0.6 mi | ★★★★★ | 4 | 0 |
| Riverwalk Post Acute | 0.8 mi | ★★★★★ | 21 | 0 |
| Citrus Grove Post Acute | 0.9 mi | ★★★★★ | 20 | 0 |
| Extended Care Hospital Of Riverside | 1.2 mi | ★★★★★ | 15 | 0 |
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