Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Alta Gardens Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to coordinate contracted transportation for a resident on hemodialysis, resulting in the resident independently navigating public transit and walking back while weak and anxious, without the facility’s knowledge. Staff did not perform or document a change-of-condition assessment, notify the MD, or provide same-day psychosocial follow-up despite the resident reporting fear, crying, and anxiety, and PRN anxiolytics were not available until days later. The same resident’s midodrine was administered significantly late without MD notification. Another resident with a scalp lesion had a dermatology appointment rescheduled when transportation failed, with no evidence that all alternative transport options were exhausted beforehand. For two residents receiving dialysis, nurses did not document departure and return times for multiple outpatient treatments, contrary to facility P&P, leaving gaps in tracking residents’ whereabouts and clinical status around appointments.
The facility failed to protect a resident from physical abuse when two residents encountered each other in a hallway and one, who had severe cognitive impairment, became frustrated that the other resident in a wheelchair did not move quickly enough. The cognitively intact resident reported being struck in the face, and staff witnesses, including an RN and a Social Services Assistant, observed the aggressive resident yelling and then slapping the other resident’s head/face. Documentation noted redness on the affected resident’s face and forehead, and the incident was substantiated as physical abuse under the facility’s abuse prohibition policy.
The facility failed to provide necessary care and services for IV access maintenance for six residents, including inadequate documentation of PICC and midline catheter measurements, unlabeled dressings, and lack of care plans. These deficiencies could delay the identification of catheter-related complications.
The facility failed to follow dietary guidelines and menu plans, serving residents incorrect items such as yellow cake instead of carrot cake and vanilla pudding instead of chocolate ice cream. A resident on a renal diet did not receive the appropriate diet or double protein portion. The CDM acknowledged these issues, noting that the menu was not updated to reflect substitutions, and residents were not informed of changes.
A facility failed to implement the care plan intervention of placing floor mats on both sides of the bed for a resident with severe cognitive impairment and high fall risk. The mats were found leaning against the wall instead of on the floor, as confirmed by an LVN. The DON and Interim Administrator were informed of this oversight.
The facility failed to manage gastrostomy tubes (GT) appropriately for three residents. A resident's enteral feeding formula and water bag were not labeled correctly, and a CNA resumed GT feeding without verifying placement. Another resident's GT placement was not checked before medication administration, and an abdominal binder was not used as required. Additionally, a third resident's head of the bed was not elevated properly during feeding, increasing the risk of aspiration.
The facility failed to provide safe respiratory care for two residents. One resident did not receive oxygen as per the physician's order, leading to low oxygen saturation levels. Another resident's sterile water for humidification was not labeled with an opened date, violating facility policy. Staff acknowledged these deficiencies.
A resident who underwent orthopedic surgery did not receive appropriate pain management as per physician's orders. The facility failed to administer hydrocodone-acetaminophen for moderate pain and inconsistently provided non-pharmacological interventions before administering morphine. Interviews confirmed these deficiencies, highlighting a lack of adherence to the facility's pain management policy.
A resident requiring dialysis care did not receive appropriate services as the facility failed to hold hypertension medications on dialysis days, assess the AV shunt post-treatment, and document fluid intake. The facility also did not notify the physician of new recommendations or significant status changes, as confirmed by staff interviews and medical record reviews.
The facility failed to provide accurate pharmaceutical services for two residents, leading to potential medication errors. A resident's medications were ordered for oral administration instead of via GT, and a nurse did not administer a complete dose. Another resident's sodium chloride was unavailable, and its administration was undocumented. These lapses posed health risks due to potential complications or delays in interventions.
The facility failed to monitor two residents for signs of bleeding related to anticoagulant use. One resident was on enoxaparin, and another on apixaban, both without documented monitoring for adverse effects. Staff confirmed the lack of monitoring, and the Interim Administrator and DON acknowledged the findings.
The facility failed to monitor antipsychotic medication use for three residents, leading to potential adverse effects. One resident was not accurately monitored for orthostatic hypotension related to Seroquel, and their informed consent was incomplete. Another resident's informed consent for Risperdal lacked necessary details, and they were not monitored for orthostatic hypotension. A third resident was also not monitored for orthostatic hypotension as ordered. Staff acknowledged these deficiencies.
The facility's medication error rate was 11.54%, exceeding the acceptable threshold. Errors included a nurse failing to administer zinc due to unavailability, and two nurses administering polyethylene glycol 3350 without verifying residents' bowel movement history, contrary to physician orders. These oversights led to improper medication administration.
The facility failed to ensure kitchen staff had the necessary skills for safe operations in the Food and Nutrition Services Department. Dietary Aide 1 incorrectly demonstrated the procedure for testing sanitizing solution concentration, and both Dietary Aides 1 and 2 were unable to accurately describe the manual dishwashing process. These failures could lead to foodborne illnesses among residents.
The facility failed to ensure food safety and sanitation in the kitchen by not labeling and dating food items in the freezer and improperly storing maintenance tools. Unlabeled and undated food items, such as veggie vegan patties, French toast, and hamburger buns, were found, violating the facility's policy. Additionally, brooms were improperly stored on the ground outside the kitchen, contrary to the USDA Food Code 2022. These issues posed a risk of foodborne illnesses to residents.
The facility failed to educate staff on safe food handling for food brought in by family members, leading to potential food safety risks. Staff, including CNAs and LVNs, were not trained on proper reheating practices, and there was no designated microwave for family use. The DSD admitted to not providing necessary education, and the Interim Administrator and DON acknowledged these deficiencies.
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies. The infection surveillance tool did not include all residents with infections, only those prescribed antibiotics. Additionally, staff did not consistently use proper PPE when caring for residents with infections, and medical equipment was not maintained in a sanitary condition. These failures posed a risk for the transmission of infections within the facility.
The facility failed to maintain complete advance directives in the medical records for two residents, risking their healthcare decisions not being honored. For one resident, only part of the directive was uploaded, missing key healthcare instructions. For another, no directive was found, and there was no documentation of attempts to obtain it. The DON and Interim Administrator acknowledged these deficiencies.
A facility failed to provide a resident or their representative with written information about the bed hold policy during a hospital transfer. Despite the facility's policy requiring notification at the time of transfer, there was no documentation in the medical records. Staff interviews confirmed the absence of the required notification, and the Interim Administrator and DON acknowledged the deficiency.
The facility failed to properly store garbage in one of six dumpsters, which was observed propped open on two consecutive days. This was against the FDA Food Code 2022, which mandates that outdoor refuse receptacles be covered with tight-fitting lids. The Maintenance Assistant confirmed the deficiency and acknowledged the importance of keeping lids closed for infection control.
The facility failed to remove expired medications from Medication Cart B, as observed during an inspection with an RN. Fourteen packets of Vitamin A & D ointment, expired since October 2023, were found in the cart. The facility's policy requires immediate removal and disposal of outdated medications, which was not followed in this instance.
The facility failed to maintain infection control practices in the laundry room, risking disease transmission. Personal items, including food and drink, were found on laundry detergent boxes, and a fragrance mist spray was on the clean area counter. Staff confirmed these findings, acknowledging that such items should not be present to maintain infection prevention.
A resident at risk for falls did not have a floor mat as specified in their care plan, despite being identified as needing substantial assistance and having a history of falls. Staff familiar with the resident confirmed the absence of the floor mat, which was a required intervention to minimize injury risk.
Dialysis Transportation, Assessment, and Documentation Failures
Penalty
Summary
The deficiency involves multiple failures to coordinate and document transportation and clinical care for residents receiving dialysis and specialty appointments. For one resident with ESRD on hemodialysis, the facility’s transportation arrangements to and from the dialysis clinic were not properly coordinated. On one dialysis day, the contracted transportation left because the resident’s treatment was not yet complete, and the resident was not picked up from the clinic. The resident, who had muscle weakness, difficulty walking, and an ileostomy, reported walking to a nearby restaurant, emptying his ostomy bag, taking two public buses, stopping at a bank, and then walking the remaining distance back to the facility, including crossing major intersections. Staff interviews confirmed ongoing transportation issues for this resident, including prior occasions when transportation left the resident at the clinic and a family member had to pick him up. The facility also failed to assess, document, and notify the physician when this resident returned to the facility approximately seven to eight hours after dialysis. There was no documentation of the resident’s clinical condition, no change-of-condition assessment, no progress notes, and no monitoring despite the resident reporting fear, anxiety, and crying related to being followed by a man and involving the police while returning by public transit. Nursing staff acknowledged that the resident’s symptoms of being tired, weak, fearful, and crying constituted a change of condition and that the physician was not notified. The DON and DSD verified there was no assessment upon arrival, no physician notification of the incident, and no documentation of the resident’s status at the time of return. The facility further failed to provide timely psychosocial support and timely medication management for this resident. The resident’s PRN lorazepam for anxiety had been discontinued the day before the incident and was not available on the day the resident reported fear, anxiety, and crying; it was reordered the following day and first administered two days after the incident. There was no documented social services follow-up with the resident on the day of the incident, and the SSD confirmed she had not spoken with the resident until the following day. Additionally, the resident’s midodrine, ordered three times daily with meals for hypotension, was administered significantly late on one dialysis day, outside the facility’s one-hour window, and the physician was not notified of the late administration. Another resident experienced a failure in transportation coordination for a dermatology appointment. This resident had a documented brown scalp lesion and a dermatology consultation scheduled, which was rescheduled to a later date. Nursing notes showed the appointment was moved, and social services notes later documented that transportation did not arrive for the rescheduled appointment, requiring another rescheduling and arrangement of private transportation. Staff interviews indicated that alternative transportation options such as private ride-share and CNA accompaniment were available, but there was no evidence that all transportation methods were exhausted before rescheduling the earlier appointment, despite having time to arrange alternatives. The facility also failed to document departure and arrival times for two residents who regularly left the facility for outpatient dialysis. For one resident, progress notes for multiple dialysis dates lacked documentation of either departure time, arrival time, or both. For the second resident, treatment records showed multiple dialysis sessions, but corresponding progress notes were missing departure and/or arrival times on numerous dates. The DSD stated that nurses were responsible for documenting residents’ departure and arrival times in progress notes, and the DON confirmed that this documentation was missing for the identified dates.
Failure to Prevent Resident-to-Resident Physical Abuse in Hallway
Penalty
Summary
The facility failed to protect a resident’s right to be free from physical abuse by another resident, in violation of its Abuse Prohibition Policy and Procedure. The policy, dated 2/23/21, prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. On the date of the incident, a cognitively intact resident (Resident 105), who used a wheelchair, was in the Station 2 hallway when another resident (Resident 3), who had severe cognitive impairment, attempted to pass. Resident 3 yelled for Resident 105 to get out of the way and, when Resident 105 did not move quickly enough, Resident 3 swung his hand and struck Resident 105 in the face. The altercation was witnessed by staff and corroborated by interviews and documentation. An RN reported hearing Resident 3 yell "get out of my way" and observed both residents in the hallway, with Resident 3 unable to pass because Resident 105 was blocking his way; the RN stated that Resident 3 then swung his hand and slapped Resident 105’s head. The Social Services Assistant, who heard yelling from his office, also reported seeing Resident 3 slap Resident 105’s face. Resident 105 reported that he was sitting in his wheelchair in the hallway, that the other resident was going in the opposite direction, and that he could not move out of the way fast enough before being hit in the face, which he described as a closed-fist strike. An eINTERACT Change in Condition Evaluation documented that Resident 105 had redness on the face and forehead following the slap. The Administrator later confirmed that the facility substantiated the physical abuse based on the witnessed incident and the observed redness on Resident 105’s face.
Deficiencies in IV Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for the administration and maintenance of IV accesses for six residents. For Resident 83, the facility did not document the initial PICC line external catheter measurements or confirm baseline measurements of the PICC line external catheters and arm circumferences before administering IV antibiotics. Additionally, the PICC dressing was not labeled with the date, and a care plan was not developed for the use of the PICC line. Resident 60's care was compromised as the facility did not accurately document the monitoring of the right arm midline, and a care plan was not developed for its use. The external catheter length measurements were found to be inaccurate, and the documentation of monitoring was for the wrong arm. Resident 716's midline dressing was not changed as required, and Resident 110's PIV site was not labeled with the date and initials of the staff. For Resident 816, the PIV site was not labeled with the date and the nurse's initials, and Resident 818's midline external catheter and arm circumference measurements were not performed and documented upon admission. These failures had the potential to delay the identification of catheter-related complications for the residents, as confirmed by interviews with the facility's RN, DON, and Interim Administrator.
Failure to Follow Dietary Guidelines and Menu Plans
Penalty
Summary
The facility failed to adhere to the dietary requirements and menu plans for its residents, leading to several deficiencies. Residents were served yellow cake instead of the carrot cake with cream cheese frosting as indicated on the menu. Additionally, two residents were not provided with chocolate ice cream as per the menu, and a resident on a renal diet did not receive the appropriate renal diet or the double portion of protein as ordered. These discrepancies were confirmed through observations and interviews with the Certified Dietary Manager (CDM) and other staff members, who acknowledged the substitutions and the lack of notification to residents about these changes. The facility's policies and procedures require that menus be served as written unless a substitution is necessary due to preference, unavailability, or special meals, and that any substitutions be documented and communicated. However, the CDM admitted that the menu was not updated to reflect the substitutions, and residents were not informed of the changes. The facility's failure to follow its own dietary guidelines and communicate effectively with residents about menu changes resulted in the potential for residents not receiving adequate nutrition and appropriate servings to meet their individual needs.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement the care plan intervention of placing bilateral floor mats on both sides of the bed for Resident 4, who was at high risk for falls and had severe cognitive impairment. On observation, the floor mats were found leaning against the wall instead of being placed on the floor as required by the care plan. This oversight was confirmed by LVN 4, who acknowledged the necessity of the floor mats to prevent potential falls. The Director of Nursing and Interim Administrator were informed of these findings, which highlighted the facility's failure to adhere to the care plan designed to mitigate fall risks for Resident 4.
Deficiencies in Gastrostomy Tube Management
Penalty
Summary
The facility failed to provide appropriate care and services related to the management of gastrostomy tubes (GT) for three residents. For Resident 55, the facility did not ensure that the enteral feeding formula and water bag were properly labeled with the date, time, and contents. Additionally, a CNA resumed the GT feeding after providing incontinent care without verifying the GT placement, which is a task that should be performed by licensed nurses to prevent potential dislodgment. For Resident 58, the facility did not ensure that the licensed vocational nurse (LVN) checked the GT placement via auscultation before administering medications through the GT. Furthermore, the resident's care plan required the use of an abdominal binder to prevent the resident from pulling out the GT, but the resident was observed not wearing the binder during medication administration, despite having a history of dislodging the GT. Resident 74 was observed receiving enteral feeding with the head of the bed (HOB) elevated less than the required 30 degrees, which is necessary to prevent aspiration. The LVN confirmed the improper elevation of the HOB, acknowledging that it should have been elevated to at least 30 degrees during feeding. These deficiencies posed risks for complications related to the use of GTs for the residents involved.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide safe respiratory care for two residents, Resident 816 and Resident 55, as observed during a survey. For Resident 816, the facility did not administer oxygen according to the physician's order. The resident was observed receiving oxygen at three liters per minute, despite a physician's order for six liters per minute to maintain an oxygen saturation level greater than 92%. The resident expressed difficulty breathing, and the oxygen saturation level was recorded at 92%, below the desired range of 95-97%. The Licensed Vocational Nurse (LVN) acknowledged the discrepancy and increased the oxygen flow to six liters per minute, which improved the resident's oxygen saturation level to 95-96%. The Director of Nursing (DON) confirmed that staff should adhere to the physician's orders for oxygen administration. For Resident 55, the facility failed to label the sterile water used for the humidifier with an opened date, as required by the facility's policy and procedure for respiratory equipment care. The resident was observed receiving oxygen via nasal cannula with a bottle of sterile water for humidification that lacked an opened date. The LVN verified the observation and acknowledged that the sterile water should have been dated when opened. The Interim Administrator and DON were informed of these findings and acknowledged the deficiencies.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for Resident 818, who was admitted following an orthopedic surgical procedure and was experiencing severe pain. The facility did not administer pain medication as per the physician's order, which specified morphine for severe pain and hydrocodone-acetaminophen for moderate pain. The medical records showed that the resident was consistently administered morphine for pain levels that were sometimes outside the prescribed parameters, and the hydrocodone-acetaminophen was not administered at all. Additionally, the facility did not consistently provide or document non-pharmacological interventions (NPI) prior to administering narcotic pain medication, as required by the facility's pain management policy. The medical records lacked evidence that NPIs were offered before administering morphine on multiple occasions. The facility's documentation also failed to include a legend explaining the codes used for NPIs, leading to further confusion and lack of clarity in the resident's care. Interviews with Resident 818, RN 1, and the Director of Nursing (DON) confirmed these findings. Resident 818 reported experiencing agonizing pain and taking morphine every four hours. RN 1 and the DON verified that the morphine was administered outside the pain scale parameters and that NPIs were not consistently provided before administering pain medication. This lack of adherence to the pain management protocol potentially compromised the effective management of the resident's pain.
Deficiency in Dialysis Care for a Resident
Penalty
Summary
The facility failed to provide necessary dialysis care and services for Resident 21, who required hemodialysis. The facility did not adhere to the physician's orders to hold hypertension medications on dialysis days, as hydralazine Hcl and nifedipine ER were administered on those days without notifying the physician. This oversight was confirmed by RN 1, who verified that the medications were not held as ordered and that there was no documentation of physician notification. Additionally, the facility did not assess Resident 21's AV shunt after dialysis treatment on specific dates, as required by the facility's policy and procedure. LVN 11 confirmed the absence of documented evidence for the assessment of the AV shunt on 1/8/25. Furthermore, the facility failed to document the total daily fluid intake for Resident 21, which was crucial given the fluid restriction orders and recommendations from the dialysis center to monitor for signs of fluid overload. The facility also did not notify the physician of new recommendations from the dialysis center or significant status changes in Resident 21's condition. This included recommendations to limit fluid intake and monitor for fluid overload, as well as the inability to remove interdialytic weight gain due to low blood pressure. The DON acknowledged these findings, indicating a lapse in communication and documentation regarding Resident 21's dialysis care.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure accurate pharmaceutical services for two residents, leading to potential medication administration errors. For Resident 58, the physician's orders inaccurately specified oral administration for medications that should have been given via a gastrostomy tube (GT). This discrepancy was not clarified by the licensed nurses responsible for entering and executing the physician's orders. During a medication administration observation, a licensed nurse failed to administer the complete dose of a multivitamin to Resident 58, as a significant residue was left in the medication cup after administration via GT. Additionally, the facility did not ensure proper documentation and availability of medication for Resident 50. A licensed nurse was unable to administer a scheduled dose of sodium chloride because it was not available in the medication cart and failed to check the central supply or contact the pharmacy promptly. Although the nurse later obtained and administered the medication, there was no documentation in the resident's medical administration record (MAR) or progress notes to reflect this action or the reason for the initial delay. These deficiencies in medication administration and documentation posed risks to the residents' health conditions, as they could lead to complications or delays in necessary interventions. The facility's policies and procedures for medication administration were not followed, resulting in these lapses in care.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to properly monitor two residents, Resident 60 and Resident 110, for signs and symptoms of bleeding related to their use of anticoagulant medications. Resident 110 was prescribed enoxaparin to prevent clotting, with a care plan in place to monitor for potential adverse reactions such as bruising, skin tears, and bleeding. However, there was no documented evidence that Resident 110 was monitored for these signs, as confirmed by LVN 7 during an interview. The Interim Administrator and DON acknowledged the lack of monitoring documentation. Similarly, Resident 60 was prescribed apixaban for the treatment and prevention of blood clots. The physician's orders did not include monitoring for side effects, and the Medication Administration Record (MAR) for February 2025 showed no documentation of monitoring for bleeding signs. Resident 60's care plan also included monitoring for adverse reactions, but this was not carried out as verified by RN 1. The Interim Administrator and DON were informed of these findings and acknowledged the deficiency.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to properly monitor the use of antipsychotic medications for three residents, leading to potential adverse effects and incorrect data for prescribers. For one resident, the facility did not accurately monitor orthostatic hypotension as ordered by the physician for the use of Seroquel. The resident's informed consent for Seroquel was also incomplete, lacking the indication for its use and a stop date. Interviews with nursing staff confirmed that the orthostatic blood pressure readings were inaccurately recorded, posing a risk for unrecognized low blood pressure. Another resident's informed consent for Risperdal was missing documentation of frequency and behavior manifestations. The facility also failed to monitor this resident for orthostatic hypotension related to Risperdal use. The physician did not document justification for the continued daily use and the absence of a stop date for the PRN Risperdal. The facility's pharmacist had recommended ensuring physician documentation for the continued use of Risperdal, but this was not followed up in a timely manner. A third resident was not monitored for orthostatic hypotension as ordered by the physician for Seroquel use. The facility's staff acknowledged that the orthostatic blood pressure readings were not conducted as required, which could lead to unrecognized side effects from the medication. The Director of Nursing confirmed these findings and acknowledged the lapses in monitoring and documentation.
Medication Error Rate Exceeds 5% Due to Administration Oversights
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 11.54%. During medication administration observations, three licensed nurses were found to have made errors. One nurse, LVN 1, did not administer zinc to a resident as ordered due to the medication's unavailability in the medication cart. The nurse did not check the central supply or contact the pharmacy in a timely manner to obtain the medication, resulting in the resident missing a dose that was prescribed for wound healing. Another nurse, LVN 2, administered polyethylene glycol 3350 to a resident without verifying the resident's bowel movement history and stool consistency, as required by the physician's order. The resident had a recent bowel movement and loose stools, which should have contraindicated the administration of the laxative. This oversight occurred because the nurse did not review the resident's medical record before administering the medication. Similarly, LVN 10 administered polyethylene glycol 3350 to another resident without checking if the resident had a bowel movement within the last 72 hours. The resident had a bowel movement less than 72 hours prior, which should have prevented the administration of the laxative. The nurse failed to verify the resident's bowel movement history before proceeding with the medication administration.
Inadequate Kitchen Staff Training in Sanitation Procedures
Penalty
Summary
The facility failed to ensure that the kitchen staff possessed the necessary skills to safely perform daily operations in the Food and Nutrition Services Department. Specifically, Dietary Aide 1 was unable to correctly demonstrate the procedure for testing the chemical concentration of the sanitizing solution used on food contact surfaces. During an observation, Dietary Aide 1 used a quaternary test strip incorrectly by dipping it for only four seconds instead of the required ten seconds, as per the guidelines. This incorrect procedure was confirmed by both the Dietary Aide and the Certified Dietary Manager (CDM), who acknowledged the error. Additionally, both Dietary Aides 1 and 2 were unable to accurately describe the manual dishwashing process. Dietary Aide 2 incorrectly stated that dishes were washed at 110 degrees Fahrenheit and sanitized at 171 degrees Fahrenheit for 30 seconds, which did not align with the facility's documented procedures. Dietary Aide 1 also provided an incorrect description of the dishwashing process, stating that dishes were sanitized for only three to five seconds. These failures in following proper sanitation procedures had the potential to lead to foodborne illnesses among the residents who consumed food prepared in the facility's kitchen.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation requirements in the kitchen, as evidenced by improper labeling and dating of food items in the freezer. During an initial tour of the kitchen, it was observed that an opened bag of veggie vegan patties, a package of French toast, and a bag of hamburger buns were all unlabeled and undated. The Certified Dietary Manager (CDM) confirmed these findings, which were in violation of the facility's policy and procedure titled 'Food Receiving and Storage,' which mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated. Additionally, the facility did not properly store maintenance tools, which could compromise sanitation. According to the USDA Food Code 2022, maintenance tools such as brooms and mops should be stored in an orderly manner to facilitate cleaning. However, during an observation and interview, it was noted that three brooms were stored on the ground outside of the kitchen, contrary to the CDM's statement that cleaning materials should be kept hanging on the wall. These deficiencies had the potential to cause foodborne illnesses among the medically vulnerable resident population consuming food prepared in the kitchen.
Lack of Staff Education on Safe Food Handling for Outside Food
Penalty
Summary
The facility failed to ensure that staff received education on safe food handling practices for food brought in by family members and visitors. This deficiency was identified through interviews and observations, revealing that staff members, including CNAs and LVNs, were not adequately trained in handling and reheating food safely. The facility's policy required family members to inform nursing staff when bringing food, but there was no consistent practice or education provided to staff on how to manage these situations safely. The DSD admitted to not providing the necessary education, and the past in-service training lacked a clear lesson plan. During the survey, it was observed that food brought in by family members was not labeled, and there was no designated microwave for family use, contrary to what the IP stated. Family members and staff were unsure about safe reheating temperatures, and there was no resident refrigerator due to infection control concerns. The Interim Administrator and DON acknowledged these findings, indicating a systemic issue in ensuring food safety for residents consuming food from outside sources.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies. The infection surveillance tool used by the facility did not include all residents with infections, only those prescribed antibiotics. This oversight was acknowledged by the Infection Preventionist (IP) and the Director of Nursing (DON), who admitted that residents with signs and symptoms of infection but not on antibiotics were not tracked, potentially missing critical data on infection spread within the facility. Additionally, the facility did not ensure proper use of personal protective equipment (PPE) for staff entering the rooms of residents with infections. In one instance, a Certified Nursing Assistant (CNA) failed to wear a face shield or goggles while caring for a resident with COVID-19, despite facility policy requiring such precautions. This lapse was confirmed by the IP and acknowledged by the Interim Administrator and DON. Similarly, a Licensed Vocational Nurse (LVN) did not don a gown while administering medication to a resident under enhanced barrier precautions, contrary to the facility's infection control policies. Furthermore, the facility did not maintain sanitary conditions for medical equipment, as evidenced by a resident's nasal cannula tubing touching the ground and being placed under a trash can. This was observed and verified by an LVN, who recognized the infection control risk and corrected the situation. These failures collectively posed a risk for the transmission of disease-causing microorganisms and infections within the facility.
Failure to Maintain Complete Advance Directives in Medical Records
Penalty
Summary
The facility failed to obtain and maintain complete copies of advance directives in the medical records for two residents, which could potentially lead to their healthcare decisions not being honored. For Resident 18, only one page of the advance directive was uploaded into the electronic medical record, missing the crucial healthcare directives. This was confirmed during an interview with the SSA and SSD, who acknowledged that the complete document should be available to ensure the resident's wishes are respected if they lose decision-making capacity. For Resident 60, although the POLST indicated the presence of an advance directive, no copy was found in the medical record, and there was no documentation of attempts to obtain it. The SSA confirmed the inaccuracy of the POLST information. The DON explained that the admissions personnel and social services department are responsible for ensuring advance directives are obtained and documented, but this was not done for Resident 60. The Interim Administrator and DON acknowledged these findings during an interview.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written information regarding its bed hold policy to a resident or the resident's representative at the time of transfer to an acute care hospital. This deficiency was identified during a review of the facility's policies and procedures, medical records, and interviews with staff. The facility's policy, revised in October 2022, mandates that residents and their representatives receive written notice of the bed hold policy both in advance of any transfer and at the time of transfer, or within 24 hours if the transfer is an emergency. In the case of a resident who was transferred to the hospital, there was no documentation in the medical records indicating that the bed hold notification was provided. Interviews with LVN 2 and RN 2 confirmed the absence of written documentation regarding the bed hold policy. The Interim Administrator and DON were informed of these findings and acknowledged the lack of compliance with the facility's policy.
Improper Garbage Storage in Facility Dumpster
Penalty
Summary
The facility failed to ensure proper storage of garbage in one of six dumpsters located outside the facility. Observations on two consecutive days revealed that one dumpster was propped open, contrary to the FDA Food Code 2022, which requires receptacles for refuse to be covered with tight-fitting lids or doors when kept outside. This deficiency was confirmed by the Maintenance Assistant, who acknowledged responsibility for maintaining the dumpsters and stated that the lids should be closed for infection control purposes.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure the removal of expired medications from one of its medication carts, specifically Medication Cart B. During an inspection conducted by RN 1, it was observed that 14 packets of Vitamin A & D ointment, which had expired in October 2023, were still present in the cart. The facility's policy and procedure, effective since April 2008, mandates that outdated medications be immediately removed from stock and disposed of according to established procedures. RN 1 confirmed the presence of the expired medications and acknowledged that they should have been removed and discarded.
Infection Control Breach in Laundry Room
Penalty
Summary
The facility failed to maintain proper infection control practices in the laundry room, which could potentially lead to the transmission of communicable diseases to residents. During an inspection, a black fabric bag containing a bottle of Gatorade, a can of soda, and a paper bag with food items was found on top of unopened boxes of laundry detergents. Additionally, a bottle of Sunshine Mimosa Fine Fragrance mist spray was observed on the counter in the clean area. Laundry Staff 1 confirmed these findings and acknowledged that personal belongings, including food and drink, should not be present in the laundry room to maintain infection prevention. The Housekeeping and Laundry Supervisor and the Infection Preventionist (IP) were informed of these findings and acknowledged that staff were expected to adhere to the facility's infection control practices in the laundry room area.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide a floor mat for Resident 2, as specified in the resident's care plan, to prevent or minimize injury in the event of a fall. This deficiency was identified through observation, interviews, and a review of medical records and facility policies. Resident 2, who was at risk for falls due to confusion, attempts to self-transfer, and requiring substantial assistance with activities of daily living, was observed without a floor mat beside her bed. Despite the care plan intervention to place a floor mat on the right side of the bed, both CNA 1 and LVN 1, who were familiar with Resident 2, confirmed that a floor mat had never been used in her room. Resident 2 had a history of falls, as indicated by a Change of Condition Evaluation dated 5/14/24, which documented an episode resulting in a skin tear to the right hand. The care plan, initiated on 7/3/23, specifically addressed the resident's fall risk and included the use of a floor mat as an intervention. However, during an interview and medical record review with RN 1, it was verified that the care plan's intervention to place a floor mat was not implemented. This oversight had the potential to place Resident 2 at risk for serious injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 3,227 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Garden Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Park Care Center | 0.4 mi | — | 3 | 0 |
| The Grove Post Acute | 0.6 mi | — | 3 | 0 |
| Pacific Haven Subacute And Healthcare Center | 0.7 mi | — | 3 | 0 |
| Citrus Post-acute | 0.9 mi | — | 3 | 0 |
| Chapman Care Center | 1.2 mi | — | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Alta Gardens Care Center.
100% money-back within 48 hours.
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.