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 The Terraces At Los Altos Health Facility during CMS and state inspections, most recent first.
A resident with multiple health issues, including a pathological fracture and lymphoma, experienced an unwitnessed fall in their bedroom. The facility's interdisciplinary team did not update the resident's fall risk care plan after the incident, despite the facility's policy requiring care plan revisions following significant changes in a resident's condition. The Director of Nursing confirmed the oversight.
A medication administration error occurred when an LVN administered an RSV vaccine to a resident who did not have a prescription for it. The error originated from the DON entering the order for the wrong resident, and the LVN did not verify the medication with another staff member. The resident had Alzheimer's disease, dysphagia, and major depressive disorder.
The facility failed to administer medications as ordered and did not inform the physician about missed doses for a resident with multiple diagnoses, including atrial fibrillation and congestive heart failure. The DON confirmed the medication was not available and that there was no documentation indicating the physician was informed about the missed doses.
The facility failed to offer alternatives, explain risks and benefits, or obtain informed consent before using side rails for 25 residents. This led to one resident's hand getting caught between the mattress and side rail, causing injury. Interviews revealed that the facility did not consider side rails as restraints and did not follow their own policy requiring informed consent and documentation of risks and benefits.
The facility failed to maintain sanitary conditions in the kitchen, with staff not wearing hair restraints, improper storage of a red bucket, inadequate hand hygiene by a dietary aide, and white residue or scale buildup on three ice machines. These issues could lead to food contamination and the spread of food-borne illnesses.
A resident with full mental capacity reported that a night shift nurse was rough while cleaning her, causing her to scream. The facility's administrator and executive director were informed but did not report the allegation to the Department of Public Health, contrary to the facility's policy requiring immediate reporting of abuse allegations.
The facility failed to follow a physician's order for weekly weights for a resident admitted with pneumonia and muscle weakness. The resident's weights were not documented for over two weeks, contrary to the facility's policy and the physician's order.
A resident developed a pressure ulcer due to improper placement of a medical device. The resident's boot was placed incorrectly, with the liner removed, causing the plastic part to rub against the skin and resulting in a blister. The resident's care plan aimed to minimize skin integrity issues.
The facility failed to administer a prescribed antifungal cream to a resident with psoriasis and did not ensure proper accounting of oxycodone in a medication cart. A nurse did not see the medication in the MAR, and discrepancies were found in the controlled substance binder for oxycodone tablets.
The facility failed to ensure that two residents were free from unnecessary psychotropic medications by not monitoring hours of sleep or side effects for trazodone. The DON confirmed the lack of monitoring during interviews and record reviews.
The facility failed to implement infection prevention strategies when a nurse did not change gloves or perform hand hygiene during a dressing change for a resident, and a urinary catheter bag was observed on the floor in another resident's room. The facility's policies were not followed in both instances.
The facility failed to ensure that an 85-year-old resident was offered and/or received influenza and pneumococcal vaccinations. The resident's clinical record showed no documentation of these vaccinations in 2023 or 2024, which was confirmed by the DSD during interviews. This failure was contrary to the facility's policy and CDC recommendations.
Failure to Update Fall Risk Care Plan After Resident Fall
Penalty
Summary
The facility's interdisciplinary team failed to review and revise the fall risk care plan for a resident after a fall incident. The resident, who was admitted with diagnoses including a pathological fracture, unspecified B-cell lymphoma, severe obesity, and neoplastic-related fatigue, experienced an unwitnessed fall in her bedroom. Despite the fall occurring, the care plan, which was last revised prior to the incident, was not updated to prevent further falls. During interviews and record reviews, the Director of Nursing confirmed that the resident was a fall risk and acknowledged that the fall risk care plan was not updated following the fall. The facility's policy and procedure on care plans and falls indicated that care plans should be revised when there is a significant change in the resident's condition and that staff should identify interventions to prevent subsequent falls. However, these protocols were not followed in this instance.
Medication Administration Error
Penalty
Summary
The facility failed to ensure the correct administration of medication when a licensed vocational nurse (LVN) administered a medication to the wrong resident. This incident involved a resident who was admitted with Alzheimer's disease, dysphagia, and major depressive disorder. The director of nursing (DON) mistakenly entered an order for the RSV vaccine into the resident's records, which was intended for another resident. Consequently, the vaccine was administered to the resident without a prescription. During interviews, the DON acknowledged the error, and the LVN confirmed that the medication was administered without verification from another staff member. The facility's policy and procedure for administering medications, dated April 2019, requires medications to be administered safely, timely, and as prescribed.
Failure to Administer Medication and Notify Physician
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards of practice for one resident when medications were not administered as ordered by the physician and the physician was not informed regarding missed doses of medication. Resident 1, who had multiple diagnoses including a fractured shaft of the right fibula, atrial fibrillation, congestive heart failure, hypertensive heart disease with heart failure, and the presence of a cardiac pacemaker, did not receive her scheduled doses of sotolol on several occasions. The Director of Nursing (DON) confirmed that the medication was not available and that the licensed nurses should have followed up with the pharmacy to ensure the medication was available. Additionally, the DON confirmed that there was no documentation indicating that the physician was informed about the missed doses of sotolol on the specified dates. The facility's policies on Medication Ordering and Receiving From Pharmacy Provider and Medication Administration - General Guidelines were reviewed. These policies indicated that medications should be received from the provider pharmacy on a timely basis and that the MAR must be appropriately documented if a dose of regularly scheduled medication is withheld. Furthermore, if two consecutive doses of a vital medication are withheld, the physician must be notified. The failure to follow these policies had the potential to compromise Resident 1's health and well-being.
Failure to Obtain Informed Consent and Consider Alternatives for Side Rail Use
Penalty
Summary
The facility failed to offer and/or attempt alternatives, explain risks and benefits, or obtain informed consent prior to the use of side rails for 25 residents. This deficiency was observed during multiple room inspections where residents were found with bilateral side rails without proper documentation or consent. The facility's policy requires that alternatives be considered, risks and benefits explained, and informed consent obtained before using bed rails, but these steps were not followed for any of the residents observed. For example, Resident 137 was found in bed with bilateral side rails, and the review of their physician order and side rail evaluation indicated that no alternatives were offered, risks and benefits were not explained, and informed consent was not obtained. Similar deficiencies were noted for Residents 80, 16, 23, 179, 180, 181, 182, 14, 4, 138, 10, 18, 130, 11, 2, 12, 7, 6, 129, 131, 133, 136, 132, and 30. In the case of Resident 30, the failure to follow proper procedures resulted in the resident's left hand getting caught between the mattress and the side rail, causing redness and mild numbness. Interviews with the Director of Nursing (DON) and the Director of Staff Development (DSD) revealed that the facility did not consider side rails as restraints and therefore did not obtain informed consent or document the risks and benefits. The DON admitted that the facility did not have consents for side rails for all residents and did not attempt any alternatives. The facility's policy, dated November 2016, clearly states that alternatives should be considered, and informed consent should be obtained, but these procedures were not followed, leading to the observed deficiencies.
Sanitary Conditions Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. Kitchen staff were repeatedly seen without hair restraints, including the dishwasher and the director of dining services, despite the facility's policy requiring hair restraints. Additionally, a red bucket was improperly stored on the floor by the dishwasher, contrary to the facility's policy that it should be placed on a lower shelf. Furthermore, a dietary aide did not perform proper hand hygiene after picking up an item from the floor, only changing one glove and not washing or sanitizing her hands as required by the facility's guidelines. Three ice machines in different areas of the facility were found to have white residue or scale buildup. The director of building and grounds acknowledged the need for more cleaning and confirmed that the presence of scaling was not acceptable. These observations indicate a failure to adhere to professional standards for food storage, preparation, and service, potentially leading to food contamination and the spread of food-borne illnesses among residents.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the proper authorities as required by their abuse policy. Resident 23, who had full mental capacity, reported that a night shift nurse was rough while cleaning her, causing her to scream. This incident was reported to the facility's administrator and executive director by the surveyor, but the facility did not report the allegation to the Department of Public Health, citing no suspicions of abuse. The facility's policy mandates that any allegations of abuse be reported immediately, but not later than 24 hours after the allegation. Despite this, the administrator confirmed that the allegation was not reported because they did not suspect abuse. This failure to report left the abuse allegation unaddressed by the required agencies, contrary to the facility's own policy and state regulations.
Failure to Follow Physician's Order for Weekly Weights
Penalty
Summary
The facility failed to follow a physician's order for weekly weights for Resident 180, who was admitted with diagnoses including pneumonia and muscle weakness. The physician's order, dated 3/13/24, specified that weekly weights were to be taken. However, the Resident Vital Sign Report indicated no documentation of weights since 3/18/24. During an interview and concurrent record review with the admissions nurse on 4/9/24, it was confirmed that no weights were taken between 3/18/24 and 4/4/24. The facility's policy, revised in 3/2022, stated that residents are to be weighed upon admission and at intervals established by the interdisciplinary team, which was not followed in this case.
Improper Placement of Medical Device Leads to Pressure Ulcer
Penalty
Summary
The facility failed to prevent a pressure ulcer from developing for one resident when a medical device was not placed properly. Resident 12, admitted with a fractured left foot, had a physician's order to keep a boot on at all times. However, a wound assessment on 3/9/24 identified a facility-acquired pressure injury on the resident's left heel. Interviews with a registered nurse revealed that the boot was placed incorrectly, with the liner removed, causing the plastic part of the boot to rub against the resident's skin and resulting in a blister. The resident's care plan included a goal to minimize the risk of skin integrity issues throughout their stay at the facility.
Medication Administration and Accounting Deficiencies
Penalty
Summary
The facility failed to administer all physician-ordered medications to a resident diagnosed with psoriasis. During a medication administration observation, a licensed vocational nurse did not administer Miconazole nitrate 2% topical cream as prescribed. The nurse acknowledged that she did not see the medication in the medication administration record (MAR) but saw it in the orders, leading to the medication not being given as required by the physician's order dated 3/18/24 for twice-daily application at 9 am and 9 pm. Additionally, the facility failed to ensure proper accounting of the controlled medication oxycodone in one of the medication carts. During an inspection, discrepancies were found in the count of oxycodone tablets and half tablets for a resident. The controlled substance binder indicated different counts than what was physically present in the pill pack. The director of nursing and a registered nurse confirmed that a half tablet was given but signed off as a whole tablet, leading to inaccuracies in the controlled substance records.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 130 and Resident 131, were free from unnecessary psychotropic medications. For Resident 130, who was admitted with Alzheimer's disease and hypertension, there was an order for trazodone 50 mg every bedtime for insomnia. However, there was no monitoring for hours of sleep or side effects related to trazodone. During an interview and record review, the Director of Nursing (DON) confirmed the lack of monitoring for Resident 130. Similarly, Resident 131, who was admitted with acute respiratory failure and atrial fibrillation, had an order for trazodone 50 mg at bedtime for sleep. There was also no monitoring for hours of sleep or side effects for this resident. The DON confirmed the absence of monitoring during an interview and record review. The facility's policy on psychotropic medication use, dated July 2022, indicated that psychotropic medication management should include adequate monitoring for efficacy and adverse consequences, which was not followed in these cases.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility failed to implement infection prevention strategies in two instances. First, during a wound dressing change for Resident 12, a registered nurse (RN D) did not change gloves or perform hand hygiene after removing a soiled dressing, before cleaning the wound, and before cleaning another wound. RN D confirmed she only used one pair of gloves throughout the procedure. The facility's policy indicated that hand hygiene should be performed after removing a soiled dressing. Second, in Resident 130's room, the urinary catheter bag was observed on the floor. RN D acknowledged that it was not acceptable for the bag to be on the floor. The facility's policy stated that the catheter/tubing and drainage bag should be kept off the floor.
Failure to Administer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that an 85-year-old resident, referred to as Resident 7, was offered and/or received influenza and pneumococcal vaccinations. Resident 7's clinical record indicated she was admitted to the facility on an unspecified date and had received an influenza vaccination on 11/13/21. However, there was no documentation that she was offered or received an influenza vaccination in 2023 or 2024, nor was there any record of her being offered or receiving a pneumococcal vaccination. This was confirmed by the Director of Staff Development (DSD) during interviews, who acknowledged the absence of such documentation for Resident 7. The facility's policy, dated 3/2022, required that residents be assessed for eligibility to receive the pneumococcal vaccine series upon admission and be offered the vaccine within thirty days unless medically contraindicated or already vaccinated. The policy also mandated adherence to the CDC's recommendations for pneumococcal vaccinations for adults aged 65 years or older. Additionally, the CDC recommends annual influenza vaccinations for everyone six months and older. The facility's failure to follow these guidelines for Resident 7 was identified during the review of her clinical records and confirmed through staff interviews.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Villa Siena | 2.1 mi | ★★★★★ | 0 | 0 |
| Camino Ridge Post-acute | 2.5 mi | ★★★★★ | 2 | 0 |
| Mountain View Healthcare Center | 2.8 mi | ★★★★★ | 3 | 0 |
| Los Altos Post-acute | 3 mi | ★★★★★ | 2 | 0 |
| Health Care Ctr At The Forum At Rancho San Antonio | 4.1 mi | ★★★★★ | 23 | 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.