Los Altos Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure needed care and services were provided in accordance with the resident's goals of care and professional standards of practice for one resident (Resident 1), when Resident 1's blood pressure (BP, the force of the blood pushing against the walls of the arteries as the heart pumps it through the body) was not checked prior to administering BP medication on 4/5/26, 4/6/26, 4/8/26, 4/11/26 and 4/12/26 and Resident 1's BP was not rechecked on 4/4/26 and 4/7/26 after an episode of low BP reading (A low blood pressure [hypotension] range is defined as any reading below 90/60 mmHg [a unit of measurement]). These failures put Resident 1 at risk for clinical decline and delayed clinical response and support. A review of Resident 1's medical records indicated an admission date of 4/1/26 and discharge date of 4/13/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards for one of one resident (Resident 1) when:1. Licensed nurses did not administer Resident 1's Vancomycin (a powerful prescription antibiotic used to treat serious bacterial infections) as ordered within 60 minutes prior to or after scheduled time and three doses were missed in May 2026;2. Resident 1 received only two doses of Mounjaro (brand named of tirzepatide, a prescription medication taken as a weekly injection to help control blood sugar with type 2 diabetes mellitus [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) since it was ordered on 5/4/2026;3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care to maintain a psychosocial well-being for one of one resident (Resident 1) when Resident 1 with diagnosis of post-traumatic stress syndrome (PTSD - a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or deeply stressful event) had to share a bathroom with male residents. This failure resulted in Resident 1's verbalization of feeling unsafe and had the potential to result in psychosocial distress (the emotional, mental, and social difficulties an individual experiences when overwhelming stress or painful events exceed their ability to cope).

Inspectors wroteBased on interview and record reviews, the facility failed to implement the discharge plan for one out of three residents (Resident 1) when the facility staff (Social Services and/or Case Manager) did not send a referral for home health services (HH, healthcare provided in the client's home) to a Home Health Agency (HHA). The failure had the potential to compromise the health and safety of Resident 1. A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including difficulty in walking, not elsewhere classified and muscle weakness. During a review of Resident 1's document titled, discharged summary/Post Discharge Plan of Care, effective date 11/10/25, indicated in IV. Rehab/Discharge Potential. B. rehab, B2. Comments: Pt (Patient) is independent in bed mobility and transfers. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision to prevent accidents was provided for one resident (Resident 1) out of one sampled Resident. This failure resulted in Resident 1's elopement, minor injuries, and subsequent hospital visit.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure needed care and services were provided when call lights were not answered promptly and urgently. This failure had the potential to put residents at risk for physical, emotional and psychosocial distress. The census during the abbreviated survey was 134.

Inspectors wroteBased on the interview and record review, the facility failed to ensure the half side rails were installed after obtaining the informed consent for one of three sampled residents (1) to help him reposition and stabilize in bed. This failure resulted in Resident 1's falling out of bed within six and half hours after being newly admitted to the facility on [DATE] and was transferred back to an acute hospital for further evaluation and management, and jeopardized Resident 1's health and safety during the short stay in the facility and caused Resident 1 to have a transfer to the acute hospital where he was diagnosed with intraparenchymal hemorrhage of brain (bleeding within the brain's functional tissue).

Inspectors wroteBased on record review, interview, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a discharge Minimum Data Set (MDS) accurately reflected the location to which a resident was discharged for 1 (Resident #141) of 27 sampled residents for whom MDS assessments were reviewed.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of diagnosed mental illness for 1 (Resident #63) of 4 sampled residents reviewed for PASARR requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures when: 1. Certified nursing assistant B (CNA B) and restorative nurse assistant C (RNA C) did not wear N95 (a mask or a respirator worn over the mouth and nose to protect the respiratory system by filtering out dangerous substances [such as dusts, fumes, or bacteria] from inhaled air) properly; and 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC, a form given by the facility to all Medicare beneficiaries before the end of a Medicare covered Part A stay or when all of Part B therapies are ending) was not given in a timely manner to one of two sample residents (Resident 1). This failure resulted in Resident 1 not being able to make an appeal.

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident representative was notified prior to discharge for one (Resident 1) of two sampled residents. This failure had the potential to result in psychosocial distress for Resident 1 when Resident 1's relative (RR) was not able to communicate with Resident 1 before, during and right after Resident 1's discharge to another facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure two of two residents (Resident 1 and 2) received proper care and treatment services when: 1. For Resident 1, there was no physician order and care plan regarding the use of left-hand splint; and 2. For Resident 2's treatment for the nephrostomy sites (an opening in the skin of the back where the tube is inserted to drain urine from the kidney), was not initiated until 4 days after admission and it was not documented in some days. These failures could affect the residents' health and individualized care and services provided while in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four allegations of abuse was reported within 24 hours per Federal and State law when one resident (Resident 1) left the facility AMA (against medical advice) for his safety after he telephoned the police to report an allegation of being touched inappropriately. This failure had the potential to compromise resident's safety and result in further abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate one of four allegations of abuse when Resident 1 reported being touched inappropriately. This failure had the potential to compromise resident's safety and result in further abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards for two of three residents (Resident 1 and 2) when: 1. Resident 1 ' s eye drop medication was not discontinued after the resident ' s refusals and statement it caused eye irritation; 2. Medications were not provided timely for Residents 1 and 2. These failures had the potential to result in health complications.

Inspectors wroteBased on interview and record review, the facility failed to provide services according to professional standards for one of three sampled residents (Resident 1) when a licensed vocational nurses A (LVN A) did not follow the five rights of medications administration (safety check prior to medication administration: right patient, right drug, dosage, right route, right time) and administered the wrong medications to Resident 1. This resulted in Resident 1 getting administered incorrect medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their smoking policy and procedure (P/P) for one of three sampled residents (Residents 1) when Resident 1 had cigarettes and a lighter in her possession, even though she was assessed to not be an independent smoker (her Smoking Safety Screen and smoking care plan indicated she was to be supervised and assisted during smoking); therefore, staff needed to control and manage Resident 1's smoking items. This failure allowed Resident 1 to manage her own smoking items, contrary to the safety measures indicated in the facility's smoking policy and procedure.

Inspectors wroteBased on interview and record review, the facility failed to ensure an inventory of personal effects form was completed upon discharge for one resident (Resident 4). This failure resulted to inaccurate record of personal effects .

Inspectors wroteBased on observation , interview and record review , the facility failed to ensure call lights were properly working and accessible for three of four residents (Resident 1, 2, and 3) when: 1. Resident 1 ' s bed call light did not work . This failure resulted to delay in providing care to Resident 1. 2. Residents' 2 and 3 call lights were not within reach while in bed. These failures could potentially put resident ' s comfort and safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received a medication as ordered. The facility also failed to notify the physician when Resident 1 did not receive this medication. These failures had the potential to compromise Resident 1's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards for two of 24 sampled residents (40 and 94) when: 1. Resident 40 was not properly assessed for Smoking Safety Screen. This failure resulted in Resident 40 sustaining burns to face, neck, and chest after smoking unsupervised while on oxygen on 7/31/21; 2. Resident 94 was not provided adequate supervision while smoking as indicated in his smoking care plan. This failure had the potential to result in serious injury to the residents in the facility.

Inspectors wroteBased on observations, resident and staff interviews, and facility document review, the facility failed to provide food that was palatable. This failure placed the 114 residents eating at the facility at risk of poor food intake further compromising their nutritional status.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when: 1. Resident food refrigerators and microwaves were not properly monitored, and not maintained in a sanitary condition, and multiple expired, moldy, and/or unlabeled foods were stored in the refrigerators; 2. Time/Temperature Control for Safety (TCS) foods (food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation), were not properly monitored for cool down; 3. TCS foods were not properly labeled, and expired items were in the refrigerator; and 4. Multiple food service pans and equipment were stored wet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 8 of 24 residents (84, 98, 112, 7, 116, 384, 53, and 67) received necessary and proper care and services when: 1. Licensed nurses did not follow ordered pain level for pain medications for Resident 84 and Resident 98; 2. Licensed nurses did not initiate change of condition and treatment for Resident 112's abrasions; 3. Residents 7 and 98 did not get any assistance or supervision after delivery of nourishments by the housekeeping supervisor (HKS); 4. Licensed nurses did not follow Resident 116's physician's order for bolus feeding (a larger amount of liquid nutrition is given in a short period of time, usually less than 30 minutes); 5. Licensed nurses did not closely monitor Resident 384 during intravenous (IV, given through veins) fluid hydration; 6. Licensed nurses did not document Resident 53's skin tear; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration, ensure medications were available to administer, medications were given according to the manufacturer's specifications, and ensure controlled medications (those with high potential for abuse and addiction) were fully accounted for when: 1. Licensed vocational nurse W (LVN W) left Resident 85's medications on his overbed table. This failure had the potential for misuse of residents' medications that could affect residents' health and well-being; 2. Two of six nurses failed to identify residents (Residents 22, 368, and 384) during medication pass. This failure had the potential for medication errors. 3. Two out of six nurses failed to inform the residents (Residents 22 and 109) the medications being administered during the medication pass. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 5 of 12 residents (10, 72, 20, 63, and 76) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 10 had received duloxetine (brand name: Cymbalta, antidepressant and nerve pain medication) 60 milligrams (mg, a metric unit of mass) every day since 8/1/21, and Resident 87 had received duloxetine 60 mg every day since 2/7/2020, without gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); and there was no documented clinical rationale by the physician for why an attempted GDR was not indicated; 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Four medications identified in the medication refrigerator did not have the pharmacy label; 2. Temperature monitoring was not consistently documented twice daily on the temperature log sheets for three of four medication refrigerators; and 3. An oral inhaler in active stock was being used beyond the discard (expiration) date. The deficient practices had a potential for medication errors due to medications not being labeled; inadequately monitored medications, which could lead to unsafe and ineffective medications for the residents; and residents to receive medications with unsafe and reduced potency from being used past their discard date.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed for: 1. Eight of eight residents (Residents 51, 100, 47, 75, 468, 98, 77, 223) on renal diets (diets designed for people with kidney disease) when they were served pasta instead of peas; 2. Six of six residents (Residents 9, 27, 45, 469, 103, 378) on puree diets (texture modified diets for people with chewing or swallowing difficulties) when they were served the wrong portion size for bread and zucchini; 3. Five of five residents (Residents 59, 92, 383, 68, 66) on minced and moist diets (texture modified diets for people with chewing or swallowing difficulties) when they were served the wrong portion size for ham, zucchini, and bread; and 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Certified nursing assistant V (CNA V) did not put on gown and gloves when he brought the lunch tray to Resident 61 who was isolated and on contact precautions (intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment); 2. Glucometer (blood sugar testing monitor) was not cleaned and disinfected after resident use; 3. Medication nurse did not wipe down the vial stopper before drawing up medication into the syringe; 4. The treatment nurse (TN) did not perform hand hygiene in between tasks during Resident 3's wound care; 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comfortable and safe temperature level for one of three sampled resident rooms when Resident 218's room temperature was not maintained in the range of 71 to 81 degrees Fahrenheit. This failure had the potential for the resident to have an uncomfortable environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for one of 24 sampled residents (Resident 74). Failure to accurately assess the resident had the potential to compromise the facility's ability to provide resident-centered care planning and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plans were developed and implemented for three of 24 sampled residents (Residents 6, 116, and 74) when: 1. Resident 6's care plan for non-compliance with use of Aspen collar (a device used to support the resident's neck) was not initiated; 2. Resident 116's care plans for dialysis (a procedure when a resident is attached to an artificial kidney that helps clean blood), tube feeding (a flexible tube inserted through nose or belly to provide nutrients), antidepressant (type of medication used to treat depression) and insulin (a hormone used to lower the blood sugar) use were not initiated; and 3. Resident 74's care plan for Nephrostomy (an artificial opening created between the kidney and the skin which allows for the urinary diversion) tube/drainage bag care was not implemented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to prevent pressure ulcer for two of seven sampled residents (Resident 114 and Resident 220) when: 1. Resident 114's heels were not floated while in bed; and 2. Resident 220's heels were not offloaded and not covered with dressing while in bed. These failures had the potential to cause or worsen pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 24 sampled residents (Residents 88 and 117) received necessary respiratory care and services in accordance with professional standards of practice when: 1. Resident 88's oxygen tank was left empty while in use; and 2 .Facility staff did not post an Oxygen in use/No smoking sign on Resident 117's door. These failures had the potential to affect the resident's health and safety.

Inspectors wroteBased on observation, interview and record review the facility had a 6.67% medication error rate when two medication errors out of 30 opportunities were observed during medication pass for one of six residents (Resident 378). Resident 378 received Trospium (a medication used to relax the bladder muscles to improve control of urination) not in accordance with the manufacturer's specifications and did not receive Isosorbide Mononitrate (a medication used to prevent chest pain in patients with a certain heart condition) as scheduled. These failures had the potential to result in compromising the health and safety of the residents.

Inspectors wroteBased on interview and record review, the facility failed to offer, administer, and track pneumococcal vaccine (PV, immunization against bacterial that causes pneumonia, one type of lung infection) for two of 24 sampled residents (Resident 40 and 53). This failure had the potential to cause the health complications for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the activities of daily living (ADL's such as bed mobility, toileting, and transferring) self-care deficit care plan for one of eight sampled residents (Resident 104) when the intervention for two persons assist during bed mobility was not provided. This failure resulted in Resident 104 sustaining a fall from bed on 5/3/19, with contusion (any collection of blood outside of a blood vessel) of right upper extremity, contusion of left knee, and avulsion (losing a toenail) of left index toenail.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comply with national guidelines and facility policy to ensure food procurement, store, prepare and served under sanitary conditions. These failures had the potential to effect food quality and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement it's infection control program to provide a safe and sanitary environment to prevent the development and transmission/spread of infection for 4 of 25 sampled residents when: 1. Failed to sanitize hands after taking a residents blood pressure and before returning to the medication cart 2. Nursing staff failed to observe aseptic (sterile) technique and perform handwashing/hygiene after when performing trache care. 3. Visitor coming from one resident isolation room was walking int he hallways wuith her isolation gown and gloves on. 4. For Resident 104, facility failed to change the suprapubic catheter as needed when bag was soiled (a hollow flexible tube that is used to drain urine from the bladder) as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that maintained or promoted the dignity and respect for two of two residents (Residents 60 and 375) when the door was not closed and the privacy curtains were not drawn to prevent them from being unnecessarily exposed to public view. This deficient practice had the potential to cause psychosocial harm to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure no medications were kept at bedside for one of one resident (Resident 373) without a physician's order, care plan, and prior self administration and interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) assessments done. This failure had the potential for improper administration of medications, could possibly cause adverse drug reactions or side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan for three of three sampled residents (Residents 12, 373 and 383) when: 1. Resident 12's care plan for dementia was not developed upon admission; 2. Resident 373's care plan for pain management was not developed upon admission; and 3. Resident 383's care plan for wound vacuum management was not developed upon admission. A care plan identifies residents' concerns, and outlines the care and services needed to meet their needs.

Inspectors wroteBased on observation, interview, and record interview, the facility failed to develop, implement, and revise the care plan (provide direction for individualized care) for four of 25 sampled residents (Residents 13, 88, 90, and 373) when: 1. For Resident 13, the care plan for actual impairment to skin integrity was not implemented; 2. For Resident 88, the care plan for fluoxetine (medication for depression) was not developed; 3. For Resident 90, the care plan for tube feeding was not revised; 4. For Resdient 373, the care plans for refusing daily weights and missing one scheduled dialysis were not developed. These failures had the potential resident care and services not meeting individual needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician orders according to professional standards of practice for one of 1 sampled residents (54). For Resident 54, physician orders were not followed when registered nurse C (RN C) did not check enteral feeding (tube feeding; nutrition taken through a tube that goes directly into the stomach) residuals (volume of fluid remaining in the stomach) prior to medication administration. These failures had the potential to compromise resident health.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate treatment and services for eight of 25 sampled residents (Residents 90, 13, 78, 45, 49, 54, 58, and 76) when the restorative nursing assistance (RNA, it helps the residents to gain an improved quality of life by increasing their level of strength and mobility) program was not provided as scheduled. This failure had the potential not to meet the goal and address their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the necessary care and treatment was provided for one of one sampled resident (Resident 383) for the administration of parenteral (intravenous [IV] infusion of various solutions to maintain adequate hydration) fluids consistent with the facility's policy and professional standards when the: 1. The physician's orders for total parenteral nutrition (TPN, a way of supplying all the nutritional needs of the body by bypassing the digestive system and giving nutrient solution directly into a vein) was not followed. The TPN and peripherally inserted central catheter (PICC, a long, slender, flexible tube inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access) care plan was not developed. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate care and services for one of two dialysis-dependent residents (Resident 373) when: 1. Renal diet was not ordered as per resident's preference and needs 2. Dialysis was not done as per physician's order 3. Congestive Heart Failure (CHF, failure of the heart to pump adequate amount of blood that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet) protocol was not done every shift per MD order. 4. Licensed nurses lack of knowledge on the resident's appropriate dialysis access care. These failures had the potential to affect Resident 383's care and health outcomes by placing Resident at risk for complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure for two of four sampled residents (Residents 88 and 427) were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) when: 1. For Resident 88, the facility failed to attempt a gradual dose reduction (GDR) for Prozac (medication for depression); 2. For Resident 427, the facility failed to ensure as needed medication (PRN) had a rationale for continued use for Ativan (medication for anxiety) and a non- pharmacological intervention was attempted before giving Ativan. These failures had the potential to negatively affect the residents' physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were labeled and stored appropriately when: 1. One expired medication was found in the medication storage room refrigerator 2. One vial of Novolog insulin was found on station 2 med cart. These findings had the potential to result in the accidental administration of expired medications. 3. Home medications labeled by outside pharmacy with MD order to be taken by Resident 373 were not verified by facility in house pharmacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory tests were done as physician ordered for two of 25 sampled residents (Residents 12 and 94) when: 1. Resident 12's valproic acid level (a test measures the amount of valproic acid in a blood sample; valproic acid is a drug used to prevent seizures) was not done every three months; and 2. Resident 94's hemoglobin and hematocrit (H & H test; hemoglobin is the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues; hematocrit measures the volume of red blood cells compared to the total blood volume), prealbumin (a blood test that used to see if a person is getting enough nutrition; prealbumin is a protein made by the liver, and the body uses prealbumin to make other proteins), and albumin (a blood test used to screen for and help diagnose a liver disorder or kidney disease; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the registered dietitian's (RD) recommendation was communicated and coordinated with the primary care physician for two of 25 sampled residents (Residents 58 and 84) in a timely manner. This failure had the potential in delay in meeting the residents' nutritional needs.