Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Las Alturas Nursing & Transitional Care during CMS and state inspections, most recent first.
A resident with schizophrenia, dementia, and severe cognitive impairment, who required extensive assistance with ADLs but could verbally express needs, was found in bed with the call light placed on a bedside table out of reach, despite a care plan intervention to keep the call light accessible and remind the resident of its location. An RN and NA reported the resident had been recently repositioned, and the NA believed the call light had been left within reach before leaving to obtain supplies, but the resident was observed without access to it while requesting food and drink. The DON and Administrator confirmed this was inconsistent with facility policy requiring all call lights to be within easy reach of residents.
A resident with stroke-related diagnoses, gout, osteoarthritis, and documented pain needs reported low back pain for about a month and said staff had not given her pain medication. Although the care plan and physician orders included PRN analgesics and comfort measures, an LVN did not recall recent pain complaints and a CNA said she had not asked about pain. The DON stated pain is subjective and acknowledged managers did not specifically ask the resident about pain during rounds.
Kitchen staff failed to maintain sanitary food handling practices when multiple refrigerated food items were found open, undated, unsealed, or uncovered, including cheese, salad, cilantro, biscuits, luncheon meat, and thawing ground beef. Staff and the DM stated food items should be dated, covered, and sealed, and the Dietitian confirmed the DM and cook were responsible for preventing expired food from being served. Surveyors also observed a DA cutting and plating cake with a bare hand and another DA plating food without gloves, despite staff stating gloves were required for ready-to-serve food.
Infection control failures involved two residents in the LTC facility. A CNA was observed changing gloves without performing hand hygiene and later washing hands for only a few seconds after glove removal while caring for a resident with dementia, Alzheimer’s disease, Parkinson’s disease, and DM2. In a separate case, a resident with necrotizing fasciitis, ESBL, an indwelling catheter, an ostomy, open wounds, and IV therapy was managed with EBP, but the ICP and DON stated contact precautions should have been used for the ESBL diagnosis.
Care Plan Missing Contracture Interventions: A resident with dementia and stiffness of an unspecified joint was observed lying in bed with severely contracted hands that she could not move, and no item was placed in her hands. Her comprehensive care plan did not address the hand contractures, and the LVN/MDS Coordinator and DON both acknowledged the contractures should have been included in the care plan so nursing staff would have the needed guidance.
Care Plan Not Updated After Change in BIMS Score: A resident with CVA, dysphagia, and cognitive communication deficit had an annual MDS showing a BIMS score of 03, but the care plan still reflected a prior BIMS score of 08. The SW said he did not reassess the resident even though he did not feel the score was accurate, and the MDS nurse stated the care plan should have been revised when the BIMS score changed. The DON stated the MDS nurse should have ensured the care plans were accurate and up to date.
A resident with dementia and severe hand contractures was observed in bed with no item placed in her hands, and a strong foul odor was noted when her hands were opened. CNA and RN interviews confirmed the odor and indicated the resident's hands were not being cleaned properly; the care plan did not address the hand contractures, and the DON stated CNAs had a daily hygiene task for the resident.
Failure to Follow Ordered Wound Care: A resident with a Stage 3 sacral pressure ulcer, severe cognitive impairment, DM2, HF, and CKD did not receive wound care exactly as ordered when the WCN cleansed the wound but failed to pat it dry. The WCN said she was nervous and forgot, and the DON and ICP confirmed the order should have been followed to remove moisture and support wound healing.
A resident with dementia, Alzheimer's disease, Parkinson's disease, type 2 DM, and neurogenic bladder had an indwelling Foley catheter that was not secured during transfer, showering, and dressing. Two CNAs confirmed the tubing was left unsecured, and the ICP and DON stated it should have been secured with a strap to prevent tugging or dislodgement; the facility policy required tubing to be properly secured during care.
A facility failed to ensure insulin was administered as ordered and that expired insulin was not used. One resident with DM and severe cognitive impairment received insulin lispro after breakfast instead of before meals, and another resident with DM and severe cognitive impairment received Lantus from an opened pen that had expired. An LPN acknowledged she should have checked expiration dates, and the DON stated insulin should be given per MD order and expired insulin should not be stored or administered.
Inaccurate Blood Pressure Documentation: A resident with HTN and chronic kidney disease had BP readings documented in the chart using prior values when the resident refused a BP check. An MA stated she sometimes used the recall button and entered the previous BP instead of documenting the refusal, and the DON confirmed this was not appropriate because BP can change significantly within an hour.
A facility failed to ensure immediate reporting of an alleged abuse incident after a nurse aide in training witnessed a staff member allegedly retaliate against a resident with severe cognitive impairment during care. The incident was not reported until three days later, contrary to policy and regulatory requirements for prompt reporting of abuse allegations.
The facility failed to secure spray bottles containing disinfectant solutions in four rooms within the 600 hall, leaving them accessible to residents with dementia. Observations found these bottles in various locations, such as on the floor and counters, posing potential harm. Staff interviews confirmed the risk of ingestion or contact with the chemical, and the facility's policy lacked procedures for secure storage.
The facility failed to maintain kitchen equipment and food storage practices according to professional standards. Observations revealed eroded non-stick pans, a jagged metal spatula, and unlabeled milk in the refrigerator. Staff interviews confirmed awareness of these issues but a lack of corrective action. The Food Service Supervisor acknowledged the need for proper utensil use and labeling to prevent food contamination.
A resident with acute kidney failure and dysphagia received levothyroxine at 1:00 PM instead of before breakfast, contrary to professional standards. Despite the resident's care plan and interventions, the medication timing was not adjusted when transitioning from G-tube to oral intake. Interviews with staff confirmed the unusual timing, but no symptoms of hypothyroidism were observed.
A resident with dementia and other health conditions was found with unidentified pills and a cream at her bedside, which she did not recognize. Interviews with nursing staff revealed that none admitted to leaving the medications, and all stated that medications should be disposed of properly if refused. The facility's policy prohibits leaving medications with residents, and the administrator and DON confirmed that medications should not be left at the bedside.
A resident with hypertension was repeatedly administered Midodrine outside of prescribed blood pressure parameters due to inadequate documentation and monitoring by facility staff. Despite being aware of the importance of accurate blood pressure readings, medication aides and a licensed vocational nurse failed to consistently document or measure blood pressure before administering the medication, leading to potential risks for the resident.
The facility failed to provide appropriate care and treatment for two residents due to inaccurate and untimely documentation. One resident's admission assessment and incident involving surgical drain tubing were not properly documented, while another resident's post-fall review and neuro checks were inaccurately recorded. These failures could lead to errors in care and treatment.
The facility failed to maintain accurate and timely clinical records for two residents, leading to deficiencies in documentation. One resident's Admission Assessment was inaccurately documented, and an incident involving her surgical drain was not timely recorded. Another resident's Post Fall Review and Neuro Checks were not completed accurately, with incorrect vital signs and delayed progress notes. Staff interviews revealed inconsistencies in documentation practices, potentially affecting resident care.
A CNA in a long-term care facility failed to follow proper hand hygiene protocols, leading to a breach in infection control. The CNA touched multiple surfaces and then performed perineal care on a resident without changing gloves or washing hands. The resident, who had severe cognitive impairment and multiple health conditions, was at risk due to this lapse. The facility's policies and CDC guidelines emphasize the importance of hand hygiene to prevent infection transmission.
A resident with severe cognitive impairment and chronic health conditions experienced a fall in the facility. Despite being assessed and treated by an LVN, the resident's family was not informed until four hours later when they visited. The delay was attributed to the LVN attending to another critically ill resident. The facility's policy requires prompt notification, which was not adhered to in this instance.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was kept within reach as required by the resident’s care plan and facility policy. The resident was an older male with schizophrenia, hypertension, dementia, and cirrhosis, with a BIMS score of 3 indicating severe cognitive impairment, but was able to understand others and verbally make his needs known. His MDS indicated he required maximum assistance with toileting hygiene, showering, and dressing, and moderate assistance with personal hygiene. His care plan included a focus on call light use, cognition, and safety awareness, with an intervention to keep the call light within reach and to remind him of its location. During an observation and interview, the resident was seen in bed with a lot of movement, and his call light was on the bedside table out of his reach. At that time, he verbally requested cookies and juice. RN A stated she was unaware the resident could not reach the call light and acknowledged it should have been left within reach. NA B reported she had repositioned the resident earlier that day and believed she had placed the call light within reach before leaving the room to get supplies, but the resident was ultimately left without access to it. The DON and Administrator both stated it was not acceptable for residents to be unable to reach their call lights and confirmed that facility policy required call lights to be placed within easy reach of residents.
Failure to Provide Pain Management for a Resident Reporting Ongoing Pain
Penalty
Summary
The facility failed to ensure pain management was provided for a resident with diagnoses including cerebral infarction, dysphagia, cognitive communication deficit, gout, osteoarthritis, pain to the right knee, pain to the ankle and joint of the right foot, and effusion of the right knee. The resident’s BIMS score was 15, indicating intact cognition, and the care plan identified risk for pain related to gout and/or osteoarthritis with interventions to administer pain medication as recommended and attempt non-pharmacological comfort measures. Physician orders included Tylenol 325 mg, 2 tablets every 4 hours as needed for fever or pain, and later Tramadol every 6 hours as needed for pain. During observation and interviews, the resident was able to communicate that she had low back pain for about a month and stated she had been trying to tell staff, but no one had given her pain medication. She also indicated that nurses had not given her anything for the pain. An LVN stated the resident could use the call light and answer simple questions, but then said she did not recall the resident complaining of pain over the past 1.5 months and had not given her anything for pain. A CNA stated the resident never told her about pain and that she had not asked the resident about pain. The DON stated pain was subjective and said she believed the resident if she reported pain, but also stated managers did not specifically ask the resident about pain during rounds.
Food Storage and Glove Use Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure kitchen staff served food in a sanitary manner and failed to ensure multiple food items were dated, sealed, or covered in the kitchen refrigerator. During an observation of the kitchen refrigerator, surveyors found a package of yellow cheese open and undated, a plastic bag of grey meat substance open and undated, cooked biscuits in a clear plastic bag that were undated and unsealed, a bag of salad that was unsealed and undated, a container of green peppers uncovered, a bag of white cheese undated and unsealed, a bag of yellow cheese undated and unsealed, a bag of cilantro open and undated, and a package of luncheon meat undated. The DM stated the items left open or undated were thrown away and replaced, and stated the grey meat substance was ground beef left to thaw in the refrigerator and should have been thrown away. During interviews, the O, DA N, DA P, and the DM stated that all staff were responsible for ensuring food items were dated, covered, and closed, and that food left open or undated could become contaminated. The DM stated she did not know who placed the meat in the refrigerator to thaw or how long it had been there. The Dietitian stated it was the responsibility of the DM and cook to make sure food was not expired, and that all staff were responsible for making sure food was covered and sealed after use. The record review showed facility policies requiring food storage, preparation, handling, and sanitation to follow state, federal, and US Food Codes and HACCP guidelines. In a later kitchen observation, DA M was seen cutting and plating cake with a bare hand and stated she forgot to glove her hands because she was in a hurry. In another observation, DA P was seen plating food on trays without gloves and stated she was not aware gloves had to be worn when serving with utensils because she was not touching the food with bare hands. The DM later stated all staff handling food to be prepared and served must put on gloves while handling ready-to-serve food and must never touch food served to residents with bare hands.
Infection Control Failures With Hand Hygiene and Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents reviewed for infection control and transmission-based precautions. For one resident with dementia, Alzheimer’s disease, Parkinson’s disease, and type 2 diabetes, a CNA was observed removing gloves after transferring the resident from the bed to the shower chair and putting on a new pair of gloves without performing hand hygiene. The same CNA was later observed washing her hands for approximately 6 seconds after removing gloves. During interview, the CNA stated she forgot to sanitize her hands after removing her gloves and acknowledged that proper hand hygiene prevents cross-contamination and disease. The facility’s ICP and DON stated staff were supposed to perform hand hygiene between all glove changes and that hands should be washed for at least 20 seconds or more, with the DON stating the facility protocol required 60 seconds. The facility’s hand hygiene policy stated hand hygiene should be performed between glove changes and after removing gloves, and that glove use does not replace hand hygiene. The CDC guidance reviewed in the report stated hands should be rubbed with soap and water for at least 15 seconds. For the second resident, who had necrotizing fasciitis, ESBL resistance, diabetes mellitus, an indwelling catheter, an ostomy, open lesions, IV access, and IV antibiotics, the record showed an order for enhanced barrier precautions every shift when in contact with the suprapubic urinary catheter and/or open wounds. The resident had an EBP sign posted and PPE outside the room, but the ICP stated the resident should have been placed on contact precautions for ESBL. The ICP stated the ESBL diagnosis had been added to the resident’s list, that follow-up labs were not performed after return from the hospital, and that the resident may still have been colonized or a carrier of ESBL. The DON stated the resident should have been placed on contact precautions to prevent spread of infection and cross contamination.
Care Plan Missing Contracture Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #139 that included measurable objectives and timeframes for her identified needs. Resident #139 was a [AGE]-year-old female admitted on 03/11/22 with diagnoses including unspecified dementia and stiffness of unspecified joint. Her quarterly MDS assessment showed a BIMS score could not be obtained because she was rarely or never understood, and she was dependent on staff for all functional abilities. During an observation on 02/08/26, Resident #139 was lying in bed with her hands severely contracted and unable to move them, and no item was placed in her hands. Record review of the comprehensive care plan dated 02/10/26 showed the contractures in her hands were not addressed. In interview, the LVN who was also the MDS Coordinator stated it was her responsibility to ensure nursing-related items were added to residents' care plans and acknowledged the contractures should have been included. The DON also stated the contractures should have been care planned and that the IDT discussed what belonged in the care plan, with the MDS coordinator entering it.
Care Plan Not Updated After Change in BIMS Score
Penalty
Summary
The facility failed to update Resident #4’s comprehensive care plan after her BIMS score changed from 08 to 03 on her annual MDS. Resident #4 was a [AGE] year-old female with an original admission date of 11/08/2022 and a current admission date of 12/21/2023. Her pertinent diagnoses included cerebral infarction, dysphagia, and cognitive communication deficit. The annual MDS dated [DATE] showed a BIMS score of 03, indicating severely impaired cognition, and also noted no evidence of an acute change in mental status and no pain or hurting in the last 5 days. Record review showed the care plan dated 01/11/2024 identified impaired cognitive function or thought processes based on a BIMS score of 08 and included interventions related to communication, confusion, disease process, and notification of the doctor for changes in cognition. A separate BIMS assessment dated [DATE] showed a score of 15, indicating intact cognition. During interviews, the SW stated he completed the BIMS assessment portion of the MDS, did not feel the score of 03 was accurate, and did not reassess Resident #4. The MDS nurse stated the care plan should have been revised when the BIMS score changed and was not sure why it had not been revised. The DON stated the SW did the BIMS assessments and updated the BIMS on the care plan, and that the MDS nurse should have checked to ensure the care plans were accurate and up to date. The facility’s care plan policy stated the care plan should be updated quarterly, annually, and with significant changes in conditions.
Failure to Maintain Hygiene for Contractured Hands
Penalty
Summary
The facility failed to ensure Resident #139, a female resident with unspecified dementia and stiffness of an unspecified joint, received necessary ADL care to maintain good nutrition, grooming, and personal and oral hygiene. Her quarterly MDS indicated a BIMS score could not be obtained because she was rarely or never understood. Her comprehensive care plan did not address the contractures in her hands. During observation, she was lying in bed with severely contracted hands that she was unable to move, and no item was placed in her hands. When her hands were briefly opened, a strong foul odor was detected coming from them. CNA D and RN E both independently confirmed the odor from Resident #139's hands. CNA D stated that CNAs sometimes placed a cloth in the resident's hands, that the resident did not like her hands opened because it hurt, and that she had not cleaned the resident's hands. CNA D also stated the CNAs who bathed the resident were supposed to clean her hands. RN E stated she had not seen a hand roll in the resident's hands, had not seen a physician's order for one, and smelled a foul, pungent odor coming from the resident's hands, which she believed indicated they were not being cleaned properly. The DON stated there should not be a strong, foul odor coming from the resident's hands and that the odor indicated the hands were not being cleaned properly. The DON also stated CNAs had a daily task to perform hygiene care on the resident, and that not caring for her contractures appropriately could lead to worsening of her condition and possibly infection.
Failure to Follow Ordered Wound Care
Penalty
Summary
The facility failed to ensure wound care was provided according to the physician’s order for a resident with a Stage 3 pressure ulcer to the sacrum. The resident was a female with diagnoses including acute respiratory failure with hypoxia, heart failure, type 2 diabetes, and chronic kidney disease, and her quarterly MDS reflected a BIMS score of 3, indicating severe cognitive impairment. Her physician order directed staff to cleanse the sacrum with wound cleanser, pat dry, apply a collagen sheet, and secure with a super absorbent dressing every day and every shift for wound healing. During observation of wound care, the WCN cleansed the resident’s sacral wound with wound cleanser but did not pat the wound dry as ordered. In interview, the WCN stated she was nervous and forgot to pat dry the wound, and acknowledged the wound should be completely dry to prevent maceration and maintain skin integrity. The DON stated the WCN should have pat dried the wound per the doctor’s order, and the ICP stated the wound should have been pat dried to remove moisture and avoid maceration or slowed healing.
Unsecured Foley Tubing During Resident Care
Penalty
Summary
Resident #139, a [AGE]-year-old female with dementia, Alzheimer's disease, Parkinson's disease, type 2 diabetes, and neurogenic bladder, required an indwelling urinary catheter with catheter care every shift and as indicated. Her care plan also directed staff to provide a catheter secure band or tape as indicated and to offer or provide a privacy bag or cover for the drainage bag as indicated. During observation on 02/10/26, two CNAs transferred the resident from bed to a shower chair, provided shower care, and dressed her without anchoring the Foley catheter tubing. Interviews with both CNAs confirmed the tubing was not secured during care and should have been secured to prevent pulling or dislodgement. The ICP and DON also stated the Foley should have been secured with a strap to prevent tugging, dislodging, and possible injury or trauma. The facility policy stated that residents with tubing should have the device and/or tubing properly secured and handled with caution during care encounters.
Insulin Given Outside Ordered Times and Expired Insulin Found in Nurse Cart
Penalty
Summary
The facility failed to ensure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for two residents reviewed for pharmacy services. One resident had Type 2 diabetes mellitus, severe cognitive impairment with a BIMS score of 3, and an active order for insulin lispro 5 units subcutaneously before meals. During medication administration observation, RN E gave the insulin at 9:40 AM after the resident had already eaten breakfast, and later stated the dose should have been given before breakfast as ordered by the physician. The facility also failed to ensure the 400-hall nurse cart was free from expired insulin pens and failed to ensure expired insulin was not administered to another resident. That resident also had Type 2 diabetes mellitus, severe cognitive impairment with a BIMS score of 3, and an active order for Lantus insulin 10 units subcutaneously once daily. The February 2026 MAR showed LVN F administered the Lantus at 7:00 AM, and during a later observation of the nurse cart, an opened Lantus pen labeled for that resident was found in the top drawer with an open date indicating it had expired 28 days after opening. In interview, LVN F stated she administered the resident’s Lantus from the pen in her cart and acknowledged she was supposed to check expiration dates before administering medications. The DON stated insulin should be administered as ordered, expired insulin should not be stored in nurse carts, and insulin opened on the documented date would have expired on the later date identified in the report. The facility policy stated nurses are responsible to read and follow precautionary instructions on prescription labels and administer medications as ordered by the physician, and the diabetes management policy stated anti-diabetic agents should be administered per physician order.
Inaccurate Blood Pressure Documentation
Penalty
Summary
The facility failed to maintain clinical records that were accurately documented for Resident #13, a [AGE]-year-old female admitted on 05/13/23 with hypertensive heart disease and chronic kidney disease. Her care plan directed staff to administer medications as ordered, monitor vital signs as indicated, and report abnormal findings to the MD. Her MD orders included daily vital signs and Amlodipine Besylate 5 mg by mouth daily for HTN, with instructions to hold the medication if systolic blood pressure was less than 100. Review of Resident #13's January 2026 blood pressure log showed multiple entries with repeated readings documented at different times on the same day. During interview, MA C stated she sometimes used the recall button in the system and, when Resident #13 refused a blood pressure check, she would use the previous blood pressure reading that had been taken. MA C stated she should have documented that Resident #13 was refusing the blood pressure check instead of using the prior reading. The DON stated MA C should not have used previous blood pressure readings and noted that a resident's blood pressure could change drastically within an hour of the last reading.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or exploitation were reported immediately, but not later than two hours after the allegation was made, as required by state and federal regulations. Specifically, a nurse aide in training (NAIT) witnessed what he believed to be an incident of physical and mental abuse involving a resident and a certified nurse aide (CNA) during a transfer for bathing. The NAIT observed the resident, who had a history of combative behavior and severe cognitive impairment, strike a CNA, after which the CNA allegedly retaliated by hitting the resident on the arm. The NAIT did not report the incident immediately, instead waiting three days before informing the charge nurse. The resident involved was a female with a diagnosis of cerebral infarction and a severely impaired cognitive status, as indicated by a BIMS score of 3. Her care plan noted a tendency for combative behaviors, including hitting and biting during care. Interviews with the CNAs involved revealed that both denied hitting the resident, stating that the resident had struck one of them during the transfer, but no staff member struck the resident in return. The resident herself denied ever being physically abused by staff, though she acknowledged sometimes becoming aggressive during bathing due to discomfort. Upon learning of the allegation three days after the incident, the administrator reported the event to the appropriate authorities within the required two-hour window. The facility's policy mandates immediate reporting of all alleged or suspected abuse, but the delay in initial reporting by the NAIT constituted a failure to comply with these requirements. The delay in reporting could have placed residents at risk for potential abuse, as the alleged incident was not promptly investigated or addressed.
Failure to Secure Cleaning Solutions in Resident Areas
Penalty
Summary
The facility failed to ensure that resident environments were free from hazards, specifically in four rooms within the 600 hall. Observations revealed that spray bottles containing a yellow cleaning solution labeled as disinfectant, cleaner, and deodorizer were left out in the open in various locations such as on the floor next to the toilet, on the counter next to the bathroom sink, and in front of a resident's bed. These bottles were accessible to residents, all of whom had a diagnosis of dementia and were not interviewable at the time of observation. Interviews with facility staff, including an LVN, the housekeeping supervisor, and the DON, confirmed that the spray bottles were used for disinfecting purposes and acknowledged the potential harm if ingested or if the chemical came into contact with eyes or skin. The administrator was unaware of the presence of these bottles in the bathrooms, and it was noted that the facility's policy on cleaning and disinfection did not include procedures for storing disinfecting products securely.
Deficiencies in Kitchen Equipment and Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The inspection revealed that two non-stick pans on the clean rack were eroded to the metal, and a metal spatula in use had sharp jagged edges with a melted handle containing brown and black substances. Additionally, a plastic spatula with jagged edges and a serving scoop with a reddish substance were found in the clean drawer with other utensils. Furthermore, two glasses of milk in the refrigerator were unlabeled and undated. Interviews with the Registered Dietitian (RD) and other staff members highlighted awareness of the issues but a lack of action to address them. The RD acknowledged that the eroded non-stick pans needed replacement and that using them could lead to bits of coating contaminating the food, potentially making residents sick. The RD also noted the risk of illness from consuming unlabeled and undated milk. The staff member interviewed admitted to intending to discard the eroded pans but had not done so, and was unaware of the requirement to use plastic or nylon utensils with non-stick pans. The Food Service Supervisor (FSS) confirmed that all kitchen staff were responsible for removing broken utensils and pans from service. She acknowledged the presence of new non-stick pans and the requirement to use appropriate utensils to prevent coating flaking. The FSS also recognized the potential hazards posed by the jagged metal spatula and the importance of labeling and dating all items in storage to prevent the use of outdated food. The facility's policies on food preparation and storage were reviewed, but the kitchen equipment policy was not provided.
Inappropriate Timing of Levothyroxine Administration
Penalty
Summary
The facility failed to ensure that a resident's physician reviewed the resident's total program of care, including medications and treatments, at each required visit. Specifically, the physician's order for levothyroxine was not accurate or appropriate for the resident's needs. The medication was ordered to be administered at 1:00 PM, contrary to professional standards that recommend it be given early in the morning before breakfast to ensure proper absorption. The resident involved was an elderly female with acute kidney failure and dysphagia, who had a BIMS score indicating no cognitive impairment. Her care plan included interventions for her feeding tube and chronic health conditions, including a thyroid disorder. Despite these interventions, the resident's levothyroxine was consistently administered at 1:00 PM, both in March and November, which was not in line with best practices for the medication's absorption. Interviews with facility staff, including a medication aide and the DON, revealed that the resident had been receiving levothyroxine after lunch since her admission. The DON acknowledged that the timing was unusual and not in line with best practices, but noted that the resident had not shown symptoms of hypothyroidism. The MD confirmed that levothyroxine should be taken before the first meal of the day for optimal absorption, but had not adjusted the timing of the medication when the resident transitioned from G-tube feeding to oral intake.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely and labeled in accordance with professional standards, as evidenced by the case of a resident who was found with two large, white, oblong pills on a napkin and a souffle cup with a thick, white paste on her bedside table. The resident, who has a history of unspecified dementia, type 2 diabetes, primary osteoarthritis, osteoporosis, stiffness of joint, and pain in the right shoulder, was observed rubbing her arm and shoulder and complaining of pain. She stated that she did not know what the pills were or where they came from, and mentioned that the nurse was supposed to bring her a cream for her pain, which she never received. Interviews with the nursing staff revealed that none of them admitted to leaving the medications at the resident's bedside, and they all stated that if a resident refused medication, it should be disposed of properly. The facility's Medication Administration Policy clearly states that medications should not be left with residents to self-administer and should be disposed of appropriately if refused. The administrator and the Director of Nursing confirmed that medications should never be left at the bedside, as this could lead to another resident ingesting them. The lack of proper medication storage and labeling placed residents at risk of not receiving their prescribed medications or having medications diverted or ingested by others.
Inadequate Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of Resident #88, specifically in the administration and documentation of blood pressure medication. The resident, a cognitively intact male with a history of hypertension and other chronic conditions, was prescribed Midodrine HCl to manage hypotension. However, the facility staff, including medication aides and a licensed vocational nurse, repeatedly administered the medication outside of the prescribed blood pressure parameters or failed to document the blood pressure readings accurately. The report highlights multiple instances where medication aides (MAs) and a licensed vocational nurse (LVN) administered Midodrine to Resident #88 despite blood pressure readings being outside the specified parameters. On several occasions, the same blood pressure readings were documented for different times, suggesting a lack of proper measurement or documentation. Interviews with the staff revealed that they were aware of the importance of checking and documenting blood pressure accurately but admitted to using previous readings or failing to document new readings before administering the medication. The facility's policy on medication administration requires that vital signs be checked and documented before administering medications with specific parameters. Despite this, the staff did not consistently follow these guidelines, leading to the potential risk of adverse effects for the resident. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the deficiencies and the importance of accurate documentation and adherence to medication parameters to prevent harm to residents.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For Resident #2, the facility did not accurately and timely document the Admission Assessment in the PCC when she returned from the hospital after surgery. Additionally, an incident where Resident #2 cut her surgical incision drain tubing was not documented in a timely manner. The discrepancies in documentation included outdated vital signs, incorrect assessments of mobility and cognitive status, and failure to address the surgical incision in the care plan. For Resident #3, the facility failed to document the Post Fall Review accurately and timely in the PCC after she experienced a fall. The Neuro Checks following the fall were also inaccurately documented, with vital signs recorded from dates that did not correspond to the assessment times. Furthermore, progress notes and Change in Condition Evaluations were not documented in a timely manner, and there were inconsistencies in the documentation of pain assessments and medication changes. These documentation failures could affect residents whose records are maintained by the facility and place them at risk for errors in care and treatment. The report highlights the lack of timely and accurate documentation, which is crucial for ensuring appropriate care and treatment for residents with complex medical needs.
Deficiencies in Clinical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and timely clinical records for two residents, leading to deficiencies in documentation. For the first resident, the facility did not accurately document the Admission Assessment upon her return from the hospital after surgery. The assessment contained several inaccuracies, such as incorrect documentation of vital signs, cognitive status, and medication use. Additionally, an incident where the resident cut her surgical incision drain tubing was not documented in a timely manner, which could have impacted her care and treatment. The second resident's records also showed significant documentation failures. After a fall, the Post Fall Review and Neuro Checks were not completed accurately or timely. Vital signs were recorded incorrectly, with dates and times that did not correspond to the actual assessments. Furthermore, progress notes and Change in Condition Evaluations were not documented promptly, which included instances of pain and bleeding that were not addressed in a timely manner. These documentation lapses could have led to errors in the resident's care and treatment. Interviews with facility staff revealed inconsistencies in the documentation process and a lack of adherence to protocols for documenting changes in condition and vital signs. Staff members acknowledged the importance of immediate documentation and notification of changes in residents' conditions, but the report highlights that these practices were not consistently followed. The deficiencies in documentation could affect the quality of care provided to residents and increase the risk of errors in treatment.
Infection Control Breach Due to Inadequate Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to proper hand hygiene protocols. During an observation, the CNA was seen touching multiple surfaces and then proceeding to perform perineal care on a resident without changing gloves or performing hand hygiene. This lapse in protocol occurred despite the CNA initially washing her hands and applying clean gloves upon entering the resident's room. The resident involved was an elderly female with severe cognitive impairment and multiple health conditions, including Alzheimer's, heart disease, acute kidney failure, diabetes, pleural effusion, muscle weakness, and hypertension. The resident was also noted to be incontinent and dependent on staff for activities of daily living. The comprehensive care plan for the resident emphasized the importance of maintaining skin integrity through proper perineal care, highlighting the potential risk of infection due to the CNA's failure to follow hand hygiene procedures. Interviews with the CNA and the Director of Nursing (DON) revealed that the CNA was aware of the proper procedures but had forgotten to change gloves and perform hand hygiene due to nervousness. The DON confirmed that the facility's policy required hand hygiene before moving from contaminated to clean procedures and acknowledged the potential risk of introducing infectious microorganisms to the resident. The facility's hand hygiene policy and CDC guidelines were reviewed, which outlined the necessity of hand hygiene in preventing the transmission of infections.
Delayed Notification of Resident's Fall
Penalty
Summary
The facility failed to promptly notify the responsible party of a resident's fall, which occurred on 9/27/24. The resident, an elderly female with severe cognitive impairment and multiple chronic health conditions, was found on the floor by a CNA after attempting to get out of bed. The resident sustained a small cut to the eyebrow and swelling to the left knee. Despite the assessment and treatment by LVN A, the resident's family was not informed of the incident until approximately four hours later when they visited the facility. During interviews, the ADM and LVN A acknowledged the delay in notifying the family. LVN A explained that the delay was due to attending to another resident who was critically ill and nearing the end of life. The ADM stated that there was no specific timeframe for notifying the family as long as it was done on the same day. The DON confirmed that LVN A prioritized the needs of the residents based on their conditions, and the family was not notified immediately because the resident was stable. The facility's Fall Prevention policy requires that the physician and resident's representative be notified of any fall. However, in this case, the notification was delayed, leading to the family learning about the fall during a visit. The family expressed dissatisfaction with the delay, despite understanding the busy circumstances faced by the staff. The facility conducted in-service training on various topics, including effective communication and reporting changes in condition, following the incident.
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What surveyors actually found near you
We read the 31 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Laredo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laredo Medical Center | 0.4 mi | ★★★★★ | 1 | 0 |
| Laredo Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 8 | 0 |
| Laredo West Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 21 | 0 |
| Laredo South Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 1 | 0 |
| La Frontera Nursing & Rehabilitation | 2.3 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.