Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alden Terrace Convalescent Hospital during CMS and state inspections, most recent first.
A resident alleged being hit on the shoulder by another resident, resulting in pain and limited arm movement. Although the incident was witnessed by an OT and assessed by nursing staff, the facility did not report the abuse allegation to the state survey agency within the required two-hour timeframe, as mandated by facility policy.
A resident with epilepsy experienced a seizure, and the facility failed to monitor the resident during the night shift as ordered by the NP. The resident's care plan required monitoring for seizure activity and vital signs, but no documentation or vital signs were recorded during the night shift, contrary to facility policy.
A facility failed to accurately document seizure activity for a resident with epilepsy and diabetes. The MAR incorrectly showed a seizure during a night shift due to an LVN's documentation error, despite confirmation from the LVN and an RN supervisor that no seizure occurred. This resulted in an incomplete and inaccurate medical record, violating the facility's documentation policy.
The facility failed to maintain the dignity of two residents by referring to them as 'feeders' due to their need for feeding assistance. Staff, including an LVN, RNA, and CNA, used this term as part of the RNA feeding program, despite acknowledging it as disrespectful. Both residents required substantial assistance with daily activities, including eating, and were observed being fed while being labeled as 'feeders.' The facility's policy emphasized treating residents with respect and addressing them by their proper names, which was not followed in these cases.
The facility failed to maintain updated advance directives for three residents, resulting in incomplete acknowledgment forms lacking necessary signatures from representatives. These residents, with conditions such as dementia and COPD, had impaired cognition and required assistance with daily activities. The Social Services Director acknowledged the process but did not ensure compliance with facility policy.
The facility failed to maintain safe food storage and sanitation practices, with expired mixed fruits in the refrigerator, stained cups stored as clean, and improper use of kitchen towels. These actions risked cross-contamination and foodborne illness for residents.
A resident's urinary catheter was not anchored as per physician's orders, risking discomfort and dislodgement. Despite the resident's medical conditions requiring careful catheter management, observations showed the catheter unsecured for several days. Staff acknowledged the oversight, which contradicted facility policy and CDC guidelines.
A facility failed to label a resident's nasal cannula with the date, time, and initials, as required by their oxygen administration policy. The resident, with conditions such as dementia and peripheral vascular disease, had orders for oxygen at 2 lpm for shortness of breath. An LVN confirmed the tubing was unlabeled, and the DON stated it should be changed weekly and labeled to prevent infection.
The facility failed to maintain sanitary conditions in the dumpster area, with one dumpster overfilled and uncovered, and trash littering the surrounding area. This was observed during an interview with the Dietary Supervisor, who acknowledged the need for proper trash management. The Maintenance Supervisor confirmed daily cleaning routines, emphasizing the importance of covering trash to prevent pest attraction. Facility policy and FDA guidelines require dumpsters to be closed and free of litter.
A resident's urinal was improperly placed on an oxygen concentrator, touching the oxygen tubing, which violated the facility's infection control policy. This was confirmed by a family member and an LVN, who acknowledged the infection control risk. The resident had a history of dementia and required oxygen for shortness of breath.
A facility failed to notify a resident's designated healthcare decision maker before discharging the resident to a friend's home. Despite attempts to contact the decision maker, the facility proceeded with the discharge based on information from another family member. The primary physician was not informed about the inability to reach the decision maker, contrary to the facility's policy.
A facility failed to provide correct information in a Notice of Proposed Transfer and Discharge for a resident, listing the wrong agency for discharge appeals and omitting the reason for discharge. The resident, with diagnoses including diabetes and vascular dementia, was cognitively intact and required supervision for daily activities. The Care Plan indicated discharge due to improved health, but this was not reflected in the Notice.
A facility failed to isolate a resident suspected of having scabies and did not ensure staff wore PPE, leading to potential infection spread. The resident, showing symptoms, was not isolated from roommates, and staff did not use PPE during care. The Infection Preventionist Nurse confirmed the oversight, and the Director of Nursing acknowledged the care plan was not implemented, violating the facility's scabies prevention policy.
A resident with scabies was not isolated as per the care plan, leading to a deficiency in care. Despite orders for isolation when Elimite was applied, the resident was placed with roommates, and staff did not use PPE. The resident showed signs of scabies, but the facility's policy did not require isolation for prophylactic treatment, resulting in a failure to implement the care plan.
A resident with a history of diabetes and other health issues developed fluid-filled blisters on their left arm, which were not properly assessed or documented by the facility's staff. Despite signs of infection, the wound care specialist was not informed of the resident's diabetes or the presence of drainage. The care plan was delayed, and the resident was eventually hospitalized for cellulitis and sepsis, highlighting deficiencies in documentation and communication.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow and implement its abuse policy for one of three sampled residents after an allegation of abuse was made. On 3/15/25, a resident reported that another resident hit her on the left shoulder, resulting in pain and limited movement of her left arm. The incident was witnessed by an occupational therapist, who intervened and informed the second resident to use the resident's name instead of tapping her. The registered nurse supervisor was notified and assessed the resident, finding no bruising or discoloration, but the resident continued to complain of pain. The nurse practitioner was notified, and orders for pain management and an x-ray were given, with the x-ray result being negative. Despite the resident's allegation of being hit and subsequent pain, the facility did not report the allegation of abuse to the state survey agency within two hours as required by their policy. Interviews with staff, including the assistant director of staff development, confirmed that the facility's policy mandates reporting any abuse allegations to the administrator and the state agency within two hours of awareness. However, the director of nursing and administrator stated they did not report the incident because the occupational therapist witnessed the event and determined that no abuse occurred. The facility's policy on abuse and mistreatment requires reporting all alleged and substantiated violations to the state agency and taking necessary corrective actions based on the investigation results. In this case, the failure to report the allegation in a timely manner constituted a deficiency in following established abuse reporting protocols, regardless of the staff's assessment of the situation.
Failure to Monitor Resident After Seizure
Penalty
Summary
The facility failed to monitor a resident who experienced a change in condition, specifically a seizure, in accordance with professional standards of practice. The resident, who had a history of epilepsy and diabetes mellitus, experienced a petit mal seizure lasting approximately 30 seconds. Following the seizure, the resident's nurse practitioner was notified and gave orders to continue monitoring the resident. However, during the night shift, the facility did not take the resident's vital signs or document any monitoring activities, which was a deviation from the facility's policy on managing changes in condition. The resident's care plan, initiated on the day of the seizure, included goals and interventions to observe for seizure activity and notify the physician as needed. Despite this, the director of staff development confirmed that no vital signs were taken, and no nursing documentation was completed during the night shift. The facility's policy required documentation of vital signs each shift and reassessment of the resident's condition as needed, which was not adhered to in this instance.
Inaccurate Documentation of Seizure Activity
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident, specifically regarding the monitoring and documentation of seizure activity. The resident, who had a history of epilepsy and diabetes mellitus, was supposed to be monitored for seizures every shift, with the results documented in the Medication Administration Record (MAR). On a specific date, the MAR incorrectly indicated that the resident experienced a seizure during the night shift, as a result of a documentation error by a licensed vocational nurse (LVN). Upon review, both the LVN and a registered nurse supervisor confirmed that the resident did not have a seizure on the night in question. The LVN admitted to mistakenly entering the wrong information in the MAR, which should have indicated no seizure activity. This error led to an incomplete and inaccurate medical record for the resident, contrary to the facility's policy that requires documentation to be objective, complete, and accurate.
Residents Referred to as 'Feeders' Compromises Dignity
Penalty
Summary
The facility failed to ensure that staff did not refer to residents requiring assistance with feeding as 'feeders,' which compromised the dignity and respect of the residents involved. Specifically, two residents, identified as Residents 101 and 114, were referred to as 'feeders' by various staff members, including a Licensed Vocational Nurse (LVN), a Restorative Nursing Assistant (RNA), and a Certified Nursing Assistant (CNA). This terminology was used because these residents were part of the RNA feeding program, which grouped residents needing feeding assistance together. The use of the term 'feeder' was acknowledged by staff as disrespectful, and it was noted that residents should be treated with respect and dignity. Resident 114 was admitted with diagnoses including adult failure to thrive, chronic obstructive pulmonary disease, hypertension, and muscle weakness, and required substantial assistance with daily activities, including eating. Similarly, Resident 101, who had diagnoses of hypertension and depression, also required maximal assistance with eating and other daily activities. Observations during meal times confirmed that these residents were assisted with feeding while being referred to as 'feeders.' The facility's policy on dignity emphasized treating residents with respect and addressing them by their proper names, which was not adhered to in these instances.
Failure to Maintain Updated Advance Directives
Penalty
Summary
The facility failed to ensure that the advance directives for three residents were complete and updated, which is a violation of the residents' rights to have their medical treatment wishes honored. Specifically, the facility did not maintain an accurate and current copy of the residents' advance directives in their clinical records. This deficiency was identified for three out of four sampled residents, who had various medical conditions including dementia, chronic obstructive pulmonary disease, hypertension, and muscle weakness. The Minimum Data Set (MDS) assessments indicated that these residents had impaired cognition and required assistance with activities of daily living. During an interview, the Social Services Director (SSD) explained the process for obtaining signatures on advance directive acknowledgment forms, which involves the resident's representative and the resident's physician. However, the review revealed that the acknowledgment forms for the three residents lacked the necessary signatures from their representatives. The facility's policy requires that the SSD or designee inquire about the existence of any written advance directives upon admission, but this was not adequately followed, leading to the deficiency.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Thirteen small containers of previously prepared mixed fruits were found in the walk-in refrigerator with an expired use-by date. The cook acknowledged that the fruits were prepared for a previous date and should have been discarded to prevent serving expired food to residents. The Dietary Supervisor confirmed that food should be labeled and dated, and expired items should be discarded according to the facility's policy. Additionally, clean resident cups stored on racks were observed with red color stains, which were identified as thickened cranberry juice stains. The Registered Dietitian stated that the cups should have been rewashed and not placed on racks for air drying, as they could cross-contaminate resident beverages. The Dishwasher admitted that the cup was missed during the checking process, which goes against the facility's policy and procedures for dishwashing and sanitizing equipment and surfaces. Furthermore, wet kitchen wiping cloths were improperly stored on kitchen counters and reused to clean food contact surfaces and equipment. Dietary Aides were observed using the same cloths to clean different surfaces without returning them to a sanitizer solution, as required by the facility's policy. The Registered Dietitian confirmed that kitchen towels should be stored in a sanitizer solution when not in use to prevent cross-contamination, aligning with the U.S. Food and Drug Administration Food Code requirements.
Failure to Anchor Urinary Catheter
Penalty
Summary
The facility failed to properly anchor a urinary catheter for a resident, as per the physician's order, which could lead to discomfort and potential dislodgement. The resident, who was readmitted with conditions including benign prostatic hyperplasia, obstructive and reflux uropathy, and urinary retention, had a physician's order to secure the urinary catheter tubing daily to minimize dislodgement. However, during an observation, it was noted that the catheter was not anchored to the resident's leg, and the resident confirmed it had not been secured for the past two or three days. Further observations and interviews revealed that the catheter was not anchored, and the treatment nurse acknowledged the absence of an anchor, stating it should be in place to prevent dislodgement or tugging. The Director of Nursing also confirmed that the catheter should be anchored to prevent pain and ensure it remains in place. The facility's policy and CDC guidelines emphasize the importance of securing catheters to prevent complications, but these were not followed in this instance.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not labeling the nasal cannula with the date, time, and initials as per the facility's policy on oxygen administration. This oversight was observed during a survey, where the nasal cannula attached to the resident's oxygen concentrator was found undated and exposed to air. The resident, who had been readmitted to the facility with diagnoses including dementia, cerebral aneurysm, and peripheral vascular disease, had physician orders for oxygen administration at 2 liters per minute via nasal cannula as needed for shortness of breath. During interviews, a Licensed Vocational Nurse (LVN) confirmed that the oxygen tubing was not labeled and could not specify when it was attached to the concentrator. The Director of Nursing (DON) stated that oxygen tubing should be changed weekly and labeled to prevent infection. The facility's policy indicated that oxygen equipment should be dated and stored in a clean bag when not in use. The failure to label the nasal cannula had the potential to cause complications associated with oxygen therapy, including infection.
Improper Trash Disposal and Sanitation
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster areas in a sanitary manner. During an observation and interview with the Dietary Supervisor, it was noted that one of the two garbage dumpsters outside the kitchen was overfilled with cardboard boxes and left uncovered. Additionally, the surrounding floor area was littered with various trash items, including plastic utensils, gloves, plastic bags, disposable lunch trays, plates, and a resident meal ticket. This situation was identified as having the potential to attract pests. The Dietary Supervisor acknowledged that the cardboard boxes should be flattened to fit in the dumpster, allowing the lids to close properly. The Maintenance Supervisor confirmed that the housekeeping staff is responsible for cleaning the trash on the floor daily at 2 pm and emphasized the importance of keeping the trash covered to prevent pests. The facility's policy, as well as the FDA Food Code, both require that outside dumpsters be kept closed and free of surrounding litter to prevent access by insects and rodents.
Improper Placement of Urinal on Oxygen Concentrator
Penalty
Summary
The facility failed to implement its infection control policy and procedures by allowing a urinal to be improperly placed on an oxygen concentrator, which was in contact with the oxygen tubing for a resident. This practice was observed during a survey and was confirmed by both a family member and a Licensed Vocational Nurse (LVN). The LVN acknowledged that the urinal should not have been touching the oxygen tubing or the concentrator, as it posed an infection control issue that could lead to respiratory infections. The resident involved had a medical history that included dementia, cerebral aneurysm, occlusion and stenosis of the carotid artery, and peripheral vascular disease. The resident required oxygen administration at 2 liters per minute via nasal cannula as needed for shortness of breath. The facility's infection control policy, reviewed earlier in the year, emphasized maintaining a safe and sanitary environment to prevent disease transmission, which was not adhered to in this instance.
Failure to Notify Healthcare Decision Maker Before Resident Discharge
Penalty
Summary
The facility failed to notify the designated healthcare decision maker for a resident regarding the resident's discharge plan. The resident, who had designated a family member as their healthcare decision maker through a Power of Attorney for Healthcare, was discharged to a friend's home without the facility obtaining consent from the designated decision maker. Despite several attempts to contact the family member, the facility did not succeed in reaching them and proceeded with the discharge based on information from another family member who claimed the designated decision maker did not want to be involved. Additionally, the facility did not inform the resident's primary physician that they were unable to contact the designated healthcare decision maker before proceeding with the discharge. The facility's policy and procedures require notifying the responsible party and providing discharge instructions, which were not adequately followed in this case. The Director of Nursing acknowledged the failure to document the notification to the primary physician about the inability to reach the designated decision maker.
Deficiency in Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide the correct information in the Notice of Proposed Transfer and Discharge for a resident, resulting in a deficiency. The Notice, issued on 9/9/24, contained the incorrect address and telephone number of the agency responsible for handling discharge appeals, listing the state survey agency instead. Additionally, the Notice did not specify the reason for the resident's discharge, which is a requirement. This oversight was confirmed during a review of the Notice with the Medical Record Director, who acknowledged the error and emphasized the importance of providing the correct agency information for appeal purposes. The resident involved was originally admitted to the facility on 3/12/24 and readmitted later with diagnoses including diabetes, difficulty walking, and vascular dementia. The Minimum Data Set indicated that the resident was cognitively intact and required supervision for various daily activities. The Care Plan initiated on 9/9/24 included a physician's order for discharge home, stating that the resident no longer needed the facility's services. However, the Notice failed to reflect this reason for discharge. Interviews with the Director of Nursing confirmed that the resident's health had improved, justifying the discharge, but this was not communicated in the Notice as required by policy.
Failure to Implement Scabies Isolation and PPE Protocols
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment, leading to the potential spread of scabies among residents and staff. Resident 1, who was suspected of having scabies, was not placed in isolation on the date when symptoms were first observed. Despite the presence of rashes and itching, Resident 1 was not isolated from roommates, and no contact precaution signage or PPE cart was available outside the room. Staff members, including CNAs and LVNs, confirmed that they did not wear PPE when providing care to Resident 1, and they were not asked to monitor themselves for symptoms of scabies. The facility's Infection Preventionist Nurse (IPN) acknowledged that Resident 1 showed signs and symptoms of scabies and confirmed that the resident was not isolated during the treatment with Elimite cream. The IPN admitted that the facility's policy, which required isolation precautions for suspected scabies cases, was not followed. Additionally, there was no log or list maintained to monitor staff who were exposed to Resident 1, and the IPN recognized that staff vigilance was lacking. The Director of Nursing (DON) confirmed that Resident 1's care plan, which included contact isolation precautions, was not implemented. The facility's policy and procedures for scabies prevention and control, which required immediate isolation of symptomatic residents and staff education, were not adhered to. This oversight in implementing the care plan and infection control measures contributed to the potential spread of scabies within the facility.
Failure to Implement Care Plan for Resident with Scabies
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with scabies, a parasitic infestation. The resident was admitted with conditions including benign prostatic hyperplasia and cognitive impairments, requiring maximal assistance for activities of daily living. Despite the physician's order to isolate the resident from roommates when Elimite, a medication for scabies, was applied, the care plan was not followed. The resident was not placed on contact isolation, and staff did not use personal protective equipment when providing care. Observations and interviews revealed that the resident had multiple rashes and was scratching due to discomfort, yet no contact precaution signage or PPE cart was present outside the resident's room. The resident was placed in a room with two roommates, contrary to the care plan's instructions. The Infection Preventionist Nurse confirmed that the resident showed signs of scabies and should have been isolated, but the facility's policy did not require isolation for prophylactic treatment, leading to a failure in implementing the care plan. The Director of Nursing acknowledged that the care plan was not implemented, and the Infection Preventionist Nurse admitted to not maintaining a log to monitor staff exposure to the resident. The facility's policy required the care plan to be implemented upon admission and throughout the assessment process, but this was not adhered to, resulting in a deficiency in care for the resident.
Failure to Document and Communicate Wound Condition Leads to Hospitalization
Penalty
Summary
The facility failed to properly assess and document a resident's wound, leading to inadequate treatment and care. Multiple nurses documented the resident's condition using identical language, indicating a lack of thorough assessment and individual evaluation. The resident, who had a history of diabetes, chronic kidney disease, and dementia, developed fluid-filled blisters on the left upper extremity. Despite the presence of brown drainage and signs of infection, the facility did not inform the wound care specialist of the resident's diabetes diagnosis or the drainage, which could have influenced the treatment plan. The resident's care plan for the blister and risk of infection was not initiated until after the resident had been transferred to a hospital, indicating a delay in addressing the change in condition. Interviews with staff revealed inconsistencies in the assessment and documentation of the wound, with some staff noting significant blistering and drainage, while others did not report these observations. The lack of comprehensive documentation and communication among staff and with the wound care specialist contributed to the resident's condition worsening, resulting in hospitalization for cellulitis and sepsis. The facility's failure to document the wound's characteristics, such as size, drainage, and signs of infection, hindered effective communication with medical professionals and delayed appropriate interventions. The resident was eventually transferred to a hospital where they were diagnosed with severe sepsis and cellulitis, requiring antibiotic treatment and consideration for surgical debridement. The deficiency highlights the need for accurate and timely documentation and communication in managing residents' health conditions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alvarado Care Center | 0.1 mi | — | 25 | 0 |
| Olympia Convalescent Hospital | 0.1 mi | — | 1 | 1 |
| California Post Acute | 0.4 mi | — | 7 | 0 |
| Alta View Post Acute | 0.4 mi | — | 4 | 0 |
| Grand Park Convalescent Hospital | 0.5 mi | — | 1 | 0 |
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