Las Alturas Nursing & Transitional Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control practices. The facility failed to ensure Resident #1 had the appropriate isolation and precaution signage posted outside of his door or room due to having a suprapubic catheter (a device inserted into the bladder to drain urine if an individual could not urinate on their own) with an infection in his urine. The facility failed to ensure Resident #1's EBP orders were removed when the facility added Resident #1's Contact Isolation orders on 07/13/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk of needs and accommodation being unmet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 5 residents (Resident #4) reviewed for pain management. The facility failed to identify and provide pain management for Resident #4 for at least 1 month throughout January and February of 2026. These failures could place residents at risk of increased pain and poor quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure kitchen staff served food in a sanitary manner. The facility failed to ensure food was dated and sealed for 9 items in the refrigerator. These failures could place residents at risk of foodborne illnesses. Finding Included: In observation and initial tour of the facility kitchen on 02/08/26 at 10:45 AM the kitchen refrigerator revealed a package of yellow cheese was open and undated. A plastic bag of grey meat substance found undated and open in refrigerator. A clear plastic bag of cooked biscuits was found undated and unsealed in the refrigerator. A bag of salad was found unsealed and undated in the refrigerator. A container of green peppers was found uncovered unprotected from being exposed to air and prevent contamination. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 2 (Resident #139 and Resident #7) of 5 residents reviewed for infection control and transmission-based precautions, policies, and practices. The facility failed to ensure CNA A performed hand hygiene between glove changes after providing personal care to Resident #139. The facility failed to ensure CNA A performed hand hygiene for at least 20 seconds or greater after transferring Resident 139 from the bed to the shower chair. The facility failed to ensure Resident #7 was placed on the proper infection control precautions for the diagnosis of ESBL Resistant. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in comprehensive assessment for 1 (Resident #139) of 8 residents reviewed for care plans. The facility failed to ensure Resident #139's care plan was developed by not including any plan of care for her contractures (permanent, rigid tightening of muscles, tendons, skin, or tissues around a joint, restricting movement and causing deformity) in her hands. This failure could place residents at an increased risk of needs going unmet or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the comprehensive care plan and provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 Residents (Resident #4) reviewed for care plans. The facility failed to update Resident #4's care plan when her BIMS score changed from 08 to a 03 on her annual MDS dated [DATE]. This failure could place residents at risk of not receiving adequate or required care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #139) reviewed for ADL care. The facility failed to ensure Resident #139's hand contractures were cleaned and maintained appropriately This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one (Resident #67) of four residents reviewed for quality of care. 1. The facility failed to ensure the WCN followed doctor's orders (pat dry wound) during wound care for Resident #67. This failure could place residents at risk for not receiving appropriate care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 (Resident #139) of 3 residents reviewed for incontinent care and indwelling urinary catheters. The facility failed to ensure Resident #139's indwelling urinary catheter tubing was secured during personal care to prevent dislodgement and injury. This deficient practice has the potential to result in urinary tract infections and at risk of accidental pulling of the catheter tubing and/or injury.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 7 residents (Resident #6 and Resident #2) reviewed for pharmacy services in that: The facility failed to ensure Resident #6 was administered insulin before breakfast as ordered by the physician. The facility failed to ensure the nurse cart for 400-hall was free from expired insulin pens. The facility failed to ensure expired insulin was not administered to Resident #2 on [DATE]. These failures could place residents at risk for non-therapeutic responses to medications.

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records that were accurately documented for 1 (Resident #13) of 5 residents reviewed for medical records. 1. The facility failed to ensure Resident #13's blood pressure readings were accurately documented for the month of January 2026. This failure could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Agency, in accordance with State Law through established procedures for 1 out of 5 residents (Resident #1) reviewed for reporting of abuse/neglect. The facility failed to report an allegation of abuse of Resident #1 within 2 hours that occurred on 11/14/25 at around 4:00 PM. This failure could place residents at risk for potential abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident environments remained free of hazards for four (602, 608, 610, 616) of 10 resident rooms in the 600 hall reviewed for environmental hazards. The facility failed to keep spray bottles with a yellow cleaning solution locked while not in use. This deficient practice could place residents at risk of an unsafe environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure kitchen equipment was in good condition. The facility failed to ensure kitchen equipment was kept clean. The facility failed to ensure items in the refrigerator were labeled and dated. These failures could place residents at risk for complications from food contamination. Observation of the kitchen and initial tour on 11/19/24 at 8:35 AM revealed 2 non-stick pans on the clean rack that were eroded to the metal on the bottoms and sides. There was a metal spatula in use with sharp jagged edges and the handle was melted with deep crevasses that had brown and black substances in and around them. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to review the resident ' s total program of care, including medications and treatments, at each visit for 1 of 8 residents (Resident #50) reviewed for resident records. The facility failed to ensure the physician's order was accurate and appropriate for Resident #50's levothyroxine order. The levothyroxine was ordered for 1:00 PM, when professional standards and practices for that medication indicated it should be given early in the morning before breakfast. This failure could place residents at risk for incorrect treatment decisions, evaluation, and plans compromising patient safety due to ineffective levels of thyroid hormone.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident # 88) of 6 residents reviewed for pharmacy services. 1. The facility failed to ensure that MA A accurately documented Resident #88's blood pressure when administering or holding Resident #88's blood pressure increasing medication. 2. The facility failed to ensure that MA A did not administer Resident #88's blood pressure increasing medication when Resident #88's blood pressure was outside of administration parameters or when MA A did not document a blood pressure on 12 opportunities. 3. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure drugs and biologicals were stored securely for 1 (Resident #34) of 5 residents reviewed for storage of medications. The facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards. As a result, this failure placed residents at risk of not getting ordered medications, and/or medications could have been diverted or ingested by another resident. Findings Included: Record review of Resident #34's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with an original admission date of 10/14/2019. Diagnoses included Unspecified Dementia, Type 2 Diabetes, Primary Osteoarthritis, Osteoporosis, Stiffness of Joint, and Pain in Right Shoulder. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 (Resident #2 and Resident #3) of 12 residents reviewed for quality of care. 1a. The facility failed to ensure that Resident #2's admission Assessment was accurately and timely documented in PCC on 9/16/23 when she returned to the facility from the hospital after having surgery. 1b. The facility failed to ensure that an incident in which Resident #2 cut her surgical incision drain tubing on 9/16/23 was timely documented. 2a. The facility failed to ensure that Resident #3's Post Fall Review was documented accurately and timely in PCC after she fell on 6/15/24. 2b. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices, that were accurately documented for 2 (Resident #2 and Resident #3) of 12 residents reviewed for clinical records. 1a. The facility failed to ensure that Resident #2's admission Assessment was accurately and timely documented in PCC on 9/16/23 when she returned to the facility from the hospital after having surgery. 1b. The facility failed to ensure that an incident in which Resident #2 cut her surgical incision drain tubing on 9/16/23 was timely documented. 2a. The facility failed to ensure that Resident #3's Post Fall Review was documented accurately and timely in PCC after she fell on 6/15/24. 2b. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one (Resident # 1) of five residents that were reviewed for infection control and transmission-based precautions policies and practices, in that: a. On 10/27/2024, CNA A touched multiple surfaces and did not perform hand hygiene prior to commencing Resident #1's perineal care . These failures could place residents at risk for infection through cross contamination of pathogens.

Inspectors wroteBased on interview, and record review, the facility failed to promptly notify the residents' representatives immediately of a fall that occurred for one (Resident #1) of two residents reviewed for resident rights. The facility failed to immediately notify Resident #1's responsible party (RP) of a fall that occurred on 9/27/24. This failure could place residents who had falls with injury at risk for not receiving appropriate care and interventions.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents, Resident #105 (R #105), reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for R #105, use of anticoagulant medication. This deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.