Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Los Altos Post-acute during CMS and state inspections, most recent first.
A resident with impaired mobility and muscle weakness had a documented post-discharge plan and PA and CM notes indicating that HH with PT/OT would continue after discharge, and the discharge summary specified home health services. However, the resident was discharged home without HH, and the family reported no HH visits and no returned calls from facility staff. Record review showed no HH referral was sent, while interviews with SS, CM, ADON, DON, and the Administrator revealed unclear and overlapping responsibilities between SS and CM for initiating HH referrals, resulting in the failure to arrange the ordered post-discharge services.
A resident with gait abnormalities, unsteadiness, and moderate cognitive impairment eloped and sustained minor injuries after leaving the facility unnoticed. The resident’s care plan addressed fall risk but did not include elopement assessment, wandering monitoring, or Wanderguard use despite cognitive deficits. On the morning of the incident, the oncoming RN found the resident already missing and acknowledged not conducting joint rounds with the outgoing nurse to verify all residents were present. The resident was later brought to a hospital ED by a bystander after an unwitnessed fall. Observations showed no CCTV at entrance/exit doors, three residents on the porch without staff supervision, and no receptionist coverage overnight, despite facility policies requiring prompt reporting of missing residents and individualized supervision to prevent accidents.
Call lights in multiple rooms were not answered promptly while staff, including RNs and the DON, were present in the hallway and nurse station. Staff interviews confirmed that all personnel are responsible for responding to call lights, even during shift report, as outlined in facility policy.
A resident with a history of intracerebral hemorrhage and on blood thinners fell from bed shortly after admission due to the facility's failure to install side rails, despite having obtained informed consent. The resident, at moderate fall risk, was transferred to a hospital with an intraparenchymal hemorrhage. Staff interviews revealed a lack of awareness about the consent, leading to the oversight.
A facility failed to accurately code the discharge MDS for a resident, incorrectly indicating a discharge to a hospital instead of home. This error was confirmed through record reviews and staff interviews, with the MDS Coordinator acknowledging the mistake. The DON and ED emphasized the expectation for accurate MDS coding.
A resident was admitted with diagnoses of dementia and major depressive disorder, but their Level I PASARR did not reflect these conditions, resulting in an inaccurate negative outcome. Facility staff, including the MDS Coordinator, DON, and ED, confirmed the oversight and the need for resubmission of the PASARR.
The facility failed to implement proper infection control measures during a COVID-19 outbreak. Staff members were observed not wearing N95 masks properly and not following contact precautions. A resident with multiple health conditions was involved, and the facility's infection prevention policies were not adhered to.
A facility failed to provide a timely Notice of Medicare Non-Coverage (NOMNC) to a resident, preventing an appeal. The NOMNC was signed by case managers the evening before coverage ended, but there was no confirmation of receipt by the resident or responsible party. Interviews with staff confirmed the notice was not given three days prior as required, and the Director of Nursing was unaware of the NOMNC.
A resident with severe mental impairment was discharged without notifying their designated representative, as required by the facility's policy. The facility staff, including the Social Services Director and Administrator, confirmed the oversight, acknowledging that the case manager should have communicated with the resident's relative before proceeding with the discharge.
Two residents in the facility did not receive proper care and treatment. One resident had a left-hand splint without a physician order or care plan, despite having a wrist fracture. Staff were unaware of the fracture and the need for the splint. Another resident with a nephrostomy tube did not receive timely treatment for the nephrostomy sites, and the treatment was not consistently documented. These deficiencies were due to non-compliance with facility policies on care management and documentation.
A resident left a facility AMA after alleging inappropriate touching by two CNAs and calling the police. The facility failed to report the abuse allegation within the required 24-hour timeframe, as mandated by Federal and State law. Interviews revealed a lack of communication and action, with the ADM and ADSD acknowledging the failure to adhere to reporting policies.
A resident reported inappropriate touching by two CNAs and left the facility against medical advice for safety concerns. The facility failed to investigate the allegation as required by policy, and the CNAs were not suspended or counseled. The Administrator, new to the role, did not recall the report, and the incident was not documented or investigated according to federal and state law.
Failure to Implement Ordered Home Health Services at Discharge
Penalty
Summary
The deficiency involves the facility’s failure to implement a resident’s post-discharge plan of care by not arranging ordered home health (HH) services. The resident was admitted with diagnoses including difficulty in walking and muscle weakness. The discharge summary/Post Discharge Plan of Care dated 11/10/25 documented that the resident was independent in bed mobility and transfers, required supervision for ambulation with a front-wheeled walker, was independent with wheelchair use, and was to continue with home health services. A physician assistant note dated 11/12/25 indicated time spent to discharge the patient, review medications, and order PT/OT and needed equipment, with medications ordered to an outpatient pharmacy. The case manager’s note on 11/12/25 stated the patient would be discharging home with HH, including rehab PT/OT. Despite these documented plans, the facility’s discharged resident list showed the resident was discharged home with no home health services. A family member reported that at the time of discharge they were told they would be contacted about HH services, but no HH visit occurred after discharge. The family member also stated they attempted to call facility staff but did not receive a call back. Review of the clinical record by the ADON confirmed that home health was marked on the discharge summary/Post Discharge Plan of Care, but there was no documentation of any HH referral. Interviews with facility staff revealed confusion and lack of follow-through regarding responsibility for initiating the HH referral. The social services staff member stated she did not know about the HH referral and indicated the case manager knew more about HH referrals. The case manager stated that normally HH is set up before discharge based on rehab recommendations and that referrals are faxed or emailed, but acknowledged she did not send a referral for HH and stated that usually social services handles HH referrals. The ADON, DON, and Administrator each confirmed that HH was indicated in the discharge documentation and that either social services or the case manager was responsible for HH referrals, but their statements reflected vague and overlapping duties. This confusion resulted in no referral being sent to a home health agency and the resident being discharged home without any home care services, contrary to the documented post-discharge plan of care.
Failure to Supervise Cognitively Impaired Resident Resulting in Elopement and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and an environment free from accident hazards, resulting in an elopement and injuries for one resident. The resident was admitted with diagnoses including unsteadiness on feet, abnormalities of gait and mobility, and a cognitive communication deficit. An MDS assessment showed a BIMS score of 8, indicating moderate cognitive impairment. Despite these conditions and an existing care plan for risk of falls and injuries related to multiple medical issues, the care plan prior to the incident did not include interventions for monitoring wandering, use of a Wanderguard, or a personalized safety monitoring plan. There was no elopement assessment or elopement care plan in the clinical record before the resident left the facility. On the morning of the incident, the RN in charge reported that the resident was already missing when his shift began and acknowledged he should have conducted rounds with the outgoing nurse during shift report to ensure all residents were accounted for. The resident was later brought to a hospital emergency department by a bystander after reporting a misstep and unwitnessed fall, with documented head injury and an abrasion to the left hand. A complaint filed with the Department indicated the resident left the facility without informing anyone, stating he felt he was going to be killed, and that he had memory loss and impaired cognition per chart. Observations at the facility showed there was no CCTV at entrance/exit doors and three residents were on the porch without staff supervision. The receptionist confirmed there was no receptionist coverage during nighttime hours. These conditions occurred despite facility policies stating that staff must promptly report missing residents and that resident supervision and individualized, resident-centered safety interventions are core components of the facility’s safety system.
Failure to Respond Promptly to Resident Call Lights
Penalty
Summary
Surveyors observed that call lights in several resident rooms were not answered promptly, despite staff being present in the hallway and at the nurse station. Specifically, a call light for one room remained on while two licensed nurses were conducting a shift report nearby. Interviews with nursing staff and the Director of Nursing confirmed that staff are expected to respond to call lights even during report, and that the facility's policy requires all staff who see or hear an activated call light to respond. The failure to answer call lights in a timely manner was directly observed and acknowledged by staff and leadership during the survey. No specific resident medical history or condition at the time of the deficiency was provided in the report.
Failure to Install Side Rails Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that half side rails were installed for a newly admitted resident, despite having obtained informed consent from the resident's wife, who is the legal decision maker. This oversight occurred for a resident who was admitted with a history of nontraumatic intracerebral hemorrhage and was on blood thinners, which increased his risk of bleeding. The resident was at moderate risk for falls upon admission, as indicated by a fall risk assessment score of 35. Within six and a half hours of admission, the resident experienced an unwitnessed fall from his bed, which was not equipped with the requested side rails. The fall resulted in the resident being transferred to an acute hospital, where he was diagnosed with an intraparenchymal hemorrhage. The resident's condition was further complicated by his recent stroke, which left him with left-side weakness and poor safety awareness, making him more susceptible to falls. Interviews with facility staff revealed that the registered nurse responsible for the resident's care was unaware that informed consent for side rails had been obtained, leading to the failure to install them. The assistant director of nursing confirmed that the side rails should have been installed promptly after obtaining consent. The facility's policy on fall prevention and response emphasizes assessing each resident for fall risk factors and providing care according to their individualized level of risk, which was not adhered to in this case.
Inaccurate MDS Coding for Resident Discharge Location
Penalty
Summary
The facility failed to ensure that the discharge Minimum Data Set (MDS) accurately reflected the location to which a resident was discharged. Specifically, for one resident, the MDS was incorrectly coded to indicate that the resident was discharged to a short-term general hospital, whereas the resident was actually discharged home. This discrepancy was identified through a review of the resident's admission record, progress notes, and the facility's Notice of Transfer or Discharge, all of which confirmed that the resident was discharged home. Interviews with facility staff, including the MDS Coordinator, Director of Nursing (DON), and Executive Director (ED), revealed that the incorrect coding was acknowledged, and it was expected that MDS assessments should be coded accurately. The MDS Coordinator admitted the error, and both the DON and ED expressed their expectations for accurate coding of MDS assessments. The facility's policy and the CMS Long-Term Care Facility RAI 3.0 User's Manual were referenced, emphasizing the importance of accurate coding to reflect the resident's discharge status.
Inaccurate PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of diagnosed mental illness for a resident. The resident was admitted to the facility with a medical history that included diagnoses of dementia and major depressive disorder. However, the Level I PASARR completed at the time of admission did not reflect these diagnoses, resulting in a negative PASARR outcome, indicating no mental illness, intellectual disability, developmental disorder, or dementia. Interviews with facility staff, including the MDS Coordinator, Director of Nursing, and Executive Director, confirmed that the resident's Level I PASARR was inaccurate and should have been resubmitted to reflect the resident's mental health diagnoses. The MDS Coordinator acknowledged the importance of accurate Level I PASARRs in determining the need for a Level II Evaluation and stated that the resident's PASARR should have been corrected. The Director of Nursing and Executive Director also confirmed the oversight and the need for resubmission of the PASARR.
Infection Control Lapses During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection control measures, as observed during a survey. Certified Nursing Assistant B (CNA B) and Restorative Nurse Assistant C (RNA C) were seen not wearing their N95 masks properly while conversing with a resident who was not wearing a mask. This occurred during a COVID-19 outbreak in the facility, which had affected 42 patients and 11 staff members. Both CNA B and RNA C acknowledged the improper use of masks, with RNA C citing asthma as a reason for pulling down her mask. Additionally, Certified Nursing Assistant D (CNA D) did not adhere to contact precautions when entering Resident 3's room. CNA D donned gloves before the gown, did not wear eye protection, and failed to perform hand hygiene after leaving the room. Resident 3 had multiple health conditions, including HIV, MRSA, and CRE, and was on contact isolation precautions. The infection preventionist confirmed the lack of face shields in the isolation cart and acknowledged the oversight. The facility's policies on infection prevention and PPE usage were not followed, as evidenced by the actions of CNA D. The sequence for donning PPE was not adhered to, and CNA D did not remove PPE or perform hand hygiene before leaving Resident 3's room. These lapses in protocol were confirmed by interviews with staff and a review of the facility's infection prevention policies.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) in a timely manner to a resident, resulting in the resident's inability to make an appeal. The NOMNC, which is required to be given to all Medicare beneficiaries before the end of a Medicare-covered Part A stay or when all Part B therapies are ending, was not delivered appropriately. The resident's relative received a voicemail from the facility on the day before the coverage was set to end, which did not allow sufficient time for an appeal. The NOMNC was signed by two case managers on the evening of the day before the coverage ended, but there was no confirmation that the resident or their responsible party understood or received the information. Interviews with facility staff, including the Social Services Director, Administrator, and Director of Nursing, confirmed the NOMNC was not provided three days prior to the end of Medicare coverage as required. The facility's policy and procedure on transfer and discharge, as well as federal regulations, mandate that such notices be given at least two days before the proposed end of services. The Director of Nursing was unaware of the NOMNC, and there was no signature from the resident or responsible party on the document, indicating a lapse in communication and procedure adherence.
Failure to Notify Resident's Representative Before Discharge
Penalty
Summary
The facility failed to notify the resident's representative prior to the discharge of a resident, which was a requirement as per the facility's policy and procedure. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating severe impairment, was determined by a medical doctor to lack the mental capacity to make healthcare decisions. The resident's Advance Health Care Directive designated a relative as the agent to make healthcare decisions. However, the facility did not communicate the discharge to this relative, resulting in the relative being unaware of the discharge until after it had occurred. Interviews with facility staff, including a Licensed Vocational Nurse, the Social Services Director, the Administrator, and the Director of Nursing, confirmed that the facility did not follow its policy of notifying the resident's representative. The Social Services Director and the Administrator acknowledged that the case manager should have communicated with the resident's relative before proceeding with the discharge. The facility's policy required that the transfer/discharge notice be provided to the resident and their representative, including the effective date of the discharge, which was not adhered to in this case.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate care and treatment for two residents, leading to deficiencies in their care. For the first resident, there was no physician order or care plan regarding the use of a left-hand splint, despite the resident having a nondisplaced fracture of the trapezium. The resident was readmitted to the facility with a splint in place, but staff, including the Director of Nursing (DON) and Case Manager (CM), were unaware of the fracture and the need for a splint. Interviews with staff revealed a lack of knowledge about the indication for the splint, and the facility's policies on admission orders and care plans were not followed. The second resident was admitted with a nephrostomy tube but did not receive treatment for the nephrostomy sites until four days after admission. The treatment was not consistently documented on several occasions, as confirmed by the Nurse Supervisor (NS) during a review of the Treatment Administration Record (TAR). The resident was later readmitted to the hospital with a UTI associated with the nephrostomy catheter. Interviews with nursing staff, including the Licensed Vocational Nurse (LVN) and Registered Nurse (RN), indicated that the admitting nurse should have obtained a treatment order for nephrostomy care and documented the treatments once completed. The facility's failure to ensure proper care and treatment for these residents was a result of not adhering to established policies and procedures. The lack of physician orders and care plans for the first resident's splint and the delayed and undocumented treatment for the second resident's nephrostomy sites highlight deficiencies in the facility's care management and documentation practices.
Failure to Report Abuse Allegation Timely
Penalty
Summary
The facility failed to report an allegation of abuse within the required 24-hour timeframe as mandated by Federal and State law. A resident, who had undergone major spinal surgery and was self-responsible, left the facility against medical advice after alleging inappropriate touching by two CNAs. The resident called the police to report the incident, which he perceived as sexual assault, and subsequently left the facility for his safety. Despite the resident's report to law enforcement, the facility did not document the reason for the resident's departure or report the allegation to the necessary authorities within the stipulated time. Interviews with facility staff revealed a lack of communication and action regarding the abuse allegation. The Assistant Director of Staff Development (ADSD) reported the incident to the Administrator (ADM), who was new to the position and did not recall being informed. The ADSD was instructed to interview the resident, but the resident had already left the facility. The ADM later acknowledged that the police had been contacted and reported no investigation was needed. Both the ADSD and ADM admitted that the facility failed to adhere to their policy, which requires immediate reporting of suspected abuse to the administrator and other officials, including the State Survey Agency and Adult Protective Services, within 24 hours of the allegation being made.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident who reported being touched inappropriately by two certified nursing assistants (CNAs). The resident, who was self-responsible and had been admitted for a spinal fusion surgery, left the facility against medical advice after the incident, citing concerns for his safety. The resident reported the incident to the police, but the facility did not document the reason for the resident's departure or conduct an investigation into the allegations as required by federal and state law. Interviews with facility staff revealed that the Assistant Director of Staff Development (ADSD) was aware of the resident's report to the police and had informed the Administrator, who was the Abuse Coordinator. However, the Administrator, who was new to the position, did not recall the report and did not ensure an investigation was conducted. The CNAs involved were not suspended or counseled, and they later resigned for unrelated reasons. The facility's policy required that suspected abuse be investigated and reported, but this was not followed in this case.
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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 Los Altos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Healthcare Center | 0.9 mi | ★★★★★ | 3 | 0 |
| Villa Siena | 1.2 mi | ★★★★★ | 0 | 0 |
| Health Care Ctr At The Forum At Rancho San Antonio | 1.2 mi | ★★★★★ | 23 | 0 |
| Camino Ridge Post-acute | 1.3 mi | ★★★★★ | 2 | 0 |
| Sunnyvale Post-acute Center | 1.7 mi | ★★★★★ | 3 | 0 |
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