Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Las Alturas De Penitas during CMS and state inspections, most recent first.
Incomplete OOH-DNR Documentation: A resident with severe cognitive impairment, dementia, HTN, CAD, and dysphagia had DNR status documented, but the OOH-DNR form was not fully completed. The form was signed by the qualified relative, yet the attending physician did not sign the required section and the document lacked the physician's dated signature, printed name, and license number; the DON stated the form was still valid based on the witness signature date.
A resident with severe cognitive impairment and a documented schizophrenia diagnosis had an inaccurate PASRR Level 1 that indicated no mental illness. RN F said there was no PASRR Level II completed and she was trying to contact the LMHA to determine whether the resident had been receiving services before admission. The DON stated MDS was responsible for completing PASRRs and that residents needed to be evaluated so their proper diagnoses could be addressed.
A resident with tracheostomy status, severe cognitive impairment, and continuous O2 orders via trach was found with the O2 tubing disconnected from the trach mask, the concentrator set at 4 LPM instead of the ordered 5 LPM, and the humidifier bottle dated past the ordered change day. The LVN stated she was unaware the tubing was off, had difficulty keeping it connected, and found the concentrator would not stay at the ordered setting; the DON confirmed nurses were responsible for ensuring proper connection, correct O2 settings, and scheduled humidifier bottle changes.
Failure to label and remove expired food from resident refrigerators. Two residents had personal refrigerators containing unlabeled, undated, or expired items, including yogurt, probiotic drinks, and candy brought in by family. The DON said CMAs checked temperatures while managers were supposed to check for expired food and labeling each morning, but specific room assignments were not identified and new management staff were still being trained.
A resident with dementia, CKD stage 3, anemia, and bradycardia had an order for a continuous IV infusion of 0.9% Sodium Chloride at 50 ml/hr for hydration over two days. An RN reported starting the IV and later removing it after the resident pulled it out, without reinserting it. Despite this, an LPN documented on the eMAR that the IV Sodium Chloride was administered during the night shift, although video footage showed the LPN entering and exiting the room without an IV bag and the LPN later stated she had assumed the IV order was already completed. The DON confirmed the order required the IV to run continuously until finished and that each shift’s charge nurse was to check the IV and sign the eMAR only after verifying it, and stated the medication should not have been signed off because it was not being infused.
A resident with dementia, Alzheimer's disease, and hypoxemia was observed receiving oxygen at 2.5 lpm via nasal cannula, contrary to the physician's order for 2 lpm. An LVN confirmed the incorrect setting and acknowledged responsibility for ensuring the correct flow rate, while the DON reiterated staff responsibility to follow physician orders. Facility policy required adherence to ordered oxygen flow rates.
Two residents experienced lapses in infection prevention when an LVN performed hand hygiene for less than the required 20 seconds after medication administration, and a Foley catheter bag was found lying on the floor instead of being properly secured. Staff interviews confirmed awareness of correct procedures, but observations revealed non-compliance with facility and CDC guidelines.
A resident with cognitive and mood disturbances inappropriately touched two other residents in separate incidents. Despite being placed on 1:1 observation after the first incident, the facility failed to implement ongoing monitoring or update the resident's care plan, leading to a second incident. Staff interviews revealed a lack of communication and awareness regarding the resident's behaviors and necessary interventions.
The facility failed to report two incidents of resident-to-resident abuse within the required two-hour timeframe. A male resident with intact cognition was observed inappropriately touching two other residents with severely impaired cognition. The incidents were reported to the state agency several hours after they occurred, contrary to the facility's policy and state law requirements.
A facility failed to update a care plan for a resident with a history of inappropriate behaviors, despite incidents involving two other residents. The resident, with diagnoses including dementia and mood disturbance, was involved in inappropriate touching incidents. Staff interviews revealed that care plans should be updated with any changes, but this was not done, potentially risking the care and safety of other residents.
A resident requiring two-person assistance for transfers was improperly transferred by a single CNA, contrary to the care plan. The CNA was unaware of the two-person requirement, relying on weekly checks of electronic records. Staff interviews confirmed the care plan's accessibility and the importance of adherence to prevent injuries.
Incomplete OOH-DNR Documentation
Penalty
Summary
The facility failed to ensure a resident had a properly completed advance directive for Resident #5, whose electronic face sheet listed Advance Directives: DNR. Resident #5 had diagnoses including unspecified dementia with behavioral disturbance, hypertension, atherosclerotic heart disease with angina, and dysphagia. The quarterly MDS reflected a BIMS score of 0, indicating severe cognitive impairment, and the quarterly care plan noted that the resident's family/representative completed documentation for DNR status and that the code status would be reviewed quarterly and as needed. Record review of the resident's OOH-DNR form dated 12/08/22 showed the form was signed by the qualified relative in section C, but the attending physician did not sign section E, and the form did not include the physician's dated signature, printed name, or license number. Section F, which required all persons who signed above to acknowledge the document was properly completed, was also not signed by the physician. During interview, Social Services stated DNR forms must be filled out completely and said forms may not be valid if the physician's dated signature and license number were missing. The DON stated the form was valid and said they went with the date of the witness signature when the physician's signature was not dated.
Inaccurate PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that all PASRR Level 1 residents with mental illness had an accurate PASRR Level 1 screening for Resident #93. Resident #93 was admitted on 04/10/26 with diagnoses including essential hypertension, mild neurocognitive disorder due to a known physiological condition without behavioral disturbance, chronic kidney disease stage 4, and other seizures. The admission MDS reflected a BIMS score of 05, indicating severe cognitive impairment, and also listed an active diagnosis of schizophrenia under Section I. The PASRR dated 04/14/26 showed Section C0100, Evidence of Mental Illness, marked as 0, indicating the resident did not have a mental illness. During interview, RN F stated the PASRR indicated no mental illness even though the resident had a schizophrenia diagnosis, and she was trying to contact the Local Mental Health Authority to determine whether he had been receiving services before admission. She also stated there was no PASRR Level II completed. The DON stated that MDS was responsible for completing resident PASRRs and that residents needed to be evaluated so their proper diagnoses could be addressed.
Respiratory Care Not Provided as Ordered for Resident with Tracheostomy
Penalty
Summary
Resident #69, a severely cognitively impaired female with a history of traumatic brain injury, tracheostomy status, hydrocephalus, muscle wasting and atrophy, cognitive communication deficit, and bed confinement, was ordered continuous oxygen therapy via tracheostomy at 5 LPM to maintain SpO2 at 93-99%. Her care plan directed staff to give humidified oxygen as prescribed, change oxygen and trach tubing, humidification, and filter as ordered or indicated, and provide oxygen as ordered by the physician. The active orders also required the humidifier bottle to be changed weekly and as needed on Sundays. During observation, Resident #69 was lying in bed with no respiratory distress noted, but her oxygen tubing was not connected to the trach mask. Her humidifier bottle was dated 05/18/26. When the LVN was informed, she stated she had not been aware the tubing was off and attempted to reconnect it. After several attempts, the tubing was attached and the resident's oxygen saturation was checked at 97%. The LVN then checked the oxygen concentrator and found the flow meter was set at 4 LPM instead of the ordered 5 LPM, and stated the concentrator did not appear to be working properly because the flow would not stay at 5 LPM. The LVN stated the resident was checked every 2 hours or sooner and that she had last checked the resident at the start of her shift. She also stated the resident could not use the call light and needed frequent checks. The DON stated nurses were responsible for ensuring the oxygen tubing was connected properly, following the physician's oxygen settings, and checking that the concentrator was working properly. The DON confirmed the night shift nurse on Sunday was responsible for changing the oxygen tubing and humidifier bottle. The night shift nurse stated he had changed the tubing but forgot to get the humidifier bottle when gathering supplies, and acknowledged the bottle should have been changed to prevent bacteria buildup and infection.
Failure to Label and Remove Expired Food from Resident Refrigerators
Penalty
Summary
The facility failed to follow its food storage policy for resident refrigerators by not ensuring that foods brought in by family or other visitors were labeled, dated, and not expired. During observation, Resident #13’s personal refrigerator contained 3 small individual cups of yogurt with no expiration date and a plastic zip top bag of candy pieces that was not labeled or dated. Resident #13, who had diagnoses including vascular dementia without behavioral disturbance, type 2 diabetes mellitus with hyperglycemia, lack of coordination, and hyperkalemia, was alert and said her family had brought the items in, but she could not remember when. Resident #43’s personal refrigerator was also observed to contain 4 small probiotic drink bottles with no expiration date and 1 individual cup of yogurt that was expired. Resident #43 had diagnoses including systolic congestive heart failure, type 2 diabetes mellitus without complications, generalized muscle weakness, and essential hypertension, and her BIMS score was 13. Staff interviews showed CMA staff checked refrigerator temperatures, while managers were supposed to check for expired food, labeling, and cleanliness each morning; however, the DON and ADM could not identify which manager was assigned to check these two rooms, and the ADM stated new management staff were being trained and specific rooms had not been assigned.
Failure to Accurately Administer and Document Ordered IV Sodium Chloride
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate administration and documentation of an IV order for Sodium Chloride 0.9% for a resident with dementia, chronic kidney disease stage 3, anemia, and bradycardia. The resident’s care plan identified risk for infection related to compromised medical condition, with an intervention to administer medications and/or antibiotics per MD orders. The physician’s order summary showed an order for Sodium Chloride 0.9% at 50 ml/hr IV every shift for hydration for 2 days, one liter total, with a start date of 03/25/26 and end date of 03/27/26. RN B reported that on 03/25/26 during the 2 p.m. to 10 p.m. shift, he started the IV at the beginning of his shift and removed it before clocking out after the resident had removed her IV, and he did not reinsert it. The March 2026 eMAR reflected that the Sodium Chloride 0.9% had been signed off as administered on 03/26/26 by LVN A during the 10 p.m. to 6 a.m. shift. In an initial interview, LVN A stated she entered the resident’s room at 3:00 a.m. to administer an IV bag of Sodium Chloride 0.9% and returned at 3:00 a.m. to remove it, and that she signed it as administered on the eMAR. However, review of surveillance footage showed LVN A entering the resident’s room at 3:38 a.m. without an IV bag and exiting at 3:39 a.m. In a later telephone interview, LVN A stated the order was for one liter of Sodium Chloride 0.9% to run continuously until finished, that each shift’s charge nurse was supposed to check the IV, and that when she entered the room around 3:30 a.m. she did not see the IV running and assumed the order had been completed. She acknowledged she was not sure if she had signed it off and that her earlier account to the surveyor was incorrect. The DON confirmed the order was for one bag of Sodium Chloride 0.9% to run continuously until completed and that each shift’s charge nurse was to check the IV and sign the eMAR once checked, and stated that LVN A should not have signed off the Sodium Chloride order because it was not being infused. The facility’s Medication Administration policy required medications to be administered as ordered by the physician.
Failure to Administer Oxygen at Ordered Flow Rate
Penalty
Summary
A deficiency occurred when a resident with dementia, Alzheimer's disease, and hypoxemia was not provided respiratory care in accordance with physician orders. The resident was admitted with an order for oxygen therapy at 2 liters per minute (lpm) via nasal cannula as needed for shortness of breath and comfort. However, during an observation, the resident was found receiving oxygen at 2.5 lpm instead of the ordered 2 lpm. The resident was asleep and not in distress at the time of observation. A licensed vocational nurse (LVN) confirmed the oxygen concentrator was set at 2.5 lpm and acknowledged the physician's order was for 2 lpm. The LVN stated it was her responsibility to ensure the correct oxygen setting and had checked on the resident multiple times during her shift. The Director of Nursing (DON) also confirmed the order and stated nursing staff were responsible for ensuring the oxygen setting matched the physician's order. Facility policy required that oxygen be administered according to physician orders, including the specified flow rate.
Infection Control Deficiencies: Hand Hygiene and Foley Catheter Management
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by two specific incidents involving two residents. In the first incident, a resident with a history of pressure ulcer, chronic obstructive pulmonary disease, and a feeding tube due to dysphagia received medication administration from an LVN who performed hand hygiene for only approximately 13 seconds after the procedure. This duration was less than the facility's policy and CDC guidelines, which require at least 20 seconds of handwashing to prevent the spread of infection. The LVN acknowledged the correct procedure during an interview but did not adhere to it during the observed event. In the second incident, a resident with neuromuscular dysfunction of the bladder and an indwelling Foley catheter was observed with the catheter bag lying on the floor. Staff interviews confirmed that the catheter bag should have been attached to the bed frame to prevent contamination and reduce the risk of infection. Both a CNA and an LVN stated that the improper placement of the Foley bag could lead to infection and posed a safety hazard. The ADON and DON also confirmed that the Foley bag should not touch the floor and that proper hand hygiene is essential for infection control. Record reviews indicated that the facility had policies in place for hand hygiene and infection prevention, including adherence to CDC guidelines and proper handling of medical devices and tubing. Despite these policies, the observed actions of staff did not align with established procedures, resulting in deficiencies related to infection prevention and control for the two residents involved.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and exploitation, as evidenced by incidents involving inappropriate touching by one resident towards two others. Resident #26, a male with a history of cognitive and mood disturbances, was involved in two separate incidents of inappropriate touching. The first incident occurred when Resident #26 was observed touching Resident #25 in the groin area over his clothing. The second incident involved Resident #26 touching Resident #24 in the breast area. Both incidents were witnessed by facility staff, yet the facility did not implement adequate interventions to prevent further occurrences. Resident #26 had a history of cognitive impairment and behavioral disturbances, yet his care plan did not reflect interventions following the first incident with Resident #25. Despite being placed on 1:1 observation for 72 hours after the first incident, there were no follow-up orders or ongoing monitoring for inappropriate behaviors. The facility's failure to update Resident #26's care plan and implement effective monitoring measures contributed to the recurrence of inappropriate behavior with Resident #24. Interviews with facility staff revealed a lack of communication and awareness regarding Resident #26's behaviors and the necessary interventions. Staff members, including CNAs and LVNs, were not informed of the incidents or instructed to monitor Resident #26 for inappropriate behaviors. The Director of Nursing, who started working at the facility after the first incident, was unaware of the interventions in place and did not ensure that appropriate measures were taken to prevent further incidents. This lack of communication and oversight resulted in the facility's failure to protect residents from abuse and neglect.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report incidents of resident-to-resident abuse to the state agency within the required time frame, as mandated by state law. Specifically, two separate incidents involving inappropriate touching by one resident towards two other residents were not reported within the two-hour window. The first incident involved a male resident with intact cognition, who was observed inappropriately touching another male resident with severely impaired cognition. This incident was reported to the state agency approximately five hours and forty-five minutes after it occurred. The second incident involved the same male resident inappropriately touching a female resident with severely impaired cognition. This incident was reported four and a half hours after it occurred. The facility's policy on abuse guidance requires that all alleged or suspected violations be promptly reported to the appropriate state agencies. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that they were aware of the requirement to report such incidents within two hours. However, the incidents were not reported within this timeframe, potentially placing residents at increased risk for abuse. The DON acknowledged the importance of timely reporting and noted that the facility could face citations for failing to report allegations immediately.
Failure to Update Care Plan for Resident with Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #26, which was consistent with the resident's rights and included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. This deficiency was identified during a review of Resident #26's care plan, which did not reflect necessary interventions for monitoring inappropriate behaviors after two separate incidents involving inappropriate touching of other residents. Resident #26, a male with diagnoses including cerebral infarction, cognitive communication deficit, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, was involved in two incidents of inappropriate behavior. The first incident occurred with Resident #25, who has severe cognitive impairment and other mental health conditions, and the second incident involved Resident #24, a female with severe cognitive impairment and physical disabilities. Despite these incidents, the care plan for Resident #26 was not updated to include specific interventions to address these behaviors. Interviews with facility staff, including RN X, the ADON, and the DON, revealed that care plans should be updated with any changes in a resident's condition or after significant incidents. However, Resident #26's care plan was not updated following the incidents, and specific interventions for his behaviors were not documented. This oversight could place residents at risk of not receiving necessary care or services tailored to their specific needs.
Failure to Follow Transfer Protocols for Resident
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance during transfers, as required by their care plan. Specifically, a Certified Nursing Assistant (CNA) did not follow the care plan for a resident who required assistance from two staff members for transfers due to poor physical functioning. During an observed transfer from bed to wheelchair, the CNA attempted to transfer the resident alone, resulting in the resident's legs shaking while pivoting. The CNA admitted to not knowing the resident required a two-person assist and relied on checking the electronic medical records weekly to determine the level of assistance needed for residents. Interviews with other staff members, including another CNA, Licensed Vocational Nurses (LVNs), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that the plan of care was accessible to all staff through the Point Click Care system. They emphasized the importance of following the care plan to prevent injuries to residents and staff. The facility's policy on resident handling and transfers mandates that lifting and transferring be performed according to the individualized plan of care to ensure safety and minimize risk of injury.
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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 Penitas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Nursing & Rehabilitation Center | 8.6 mi | ★★★★★ | 9 | 0 |
| Mission Valley Nursing And Transitional Care | 8.7 mi | ★★★★★ | 14 | 3 |
| Village Healthcare And Rehabilitation | 11.3 mi | ★★★★★ | 2 | 0 |
| Briarcliff Nursing And Rehabilitation Center | 11.4 mi | ★★★★★ | 14 | 0 |
| Windsor Nursing And Rehabilitation Center Of Mcall | 13.3 mi | ★★★★★ | 5 | 0 |
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