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 Alta Vista Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with a history of stroke-related hemiplegia, T2DM, and lack of coordination, and documented as moderately cognitively impaired, was started on Trazodone 25 mg at bedtime for insomnia based on a physician order. The medication was administered before the resident’s legal representative signed the psychoactive medication informed consent form, and when the form was later signed, the section indicating whether consent was granted was not completed. During interview, the DON confirmed that the consent for Trazodone was not properly completed prior to administration, despite facility policy requiring review of psychotropic orders and efforts to obtain and document prior informed consents on admission.
A resident with a history of stroke-related hemiplegia, type 2 DM, and lack of coordination, and who was moderately cognitively impaired and required moderate ADL assistance, received Trazodone 25 mg at bedtime for insomnia based on a physician order. The medication was administered before an informed consent for psychoactive medication was signed by the resident’s legal representative, and when the consent was later completed it indicated that the representative did not consent to the Trazodone. During interview, the DON stated that medications were not supposed to be given without a consent form, and facility policy required review of psychotropic orders and efforts to obtain and document prior informed consents on admission.
Surveyors found a wound care treatment cart left unlocked and unattended in a hallway, containing medications and wound care supplies. An RN responsible for the cart acknowledged she was expected to lock it when walking away and that an unsecured cart could allow a resident to access medications not prescribed for them. The DON confirmed that she, the ADON, and other staff were responsible for ensuring medication carts remained locked when not in use, consistent with the facility’s medication storage policy requiring medication supplies to be secured and accessible only to authorized personnel.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen administration. A resident with respiratory failure was observed receiving oxygen at a lower rate than prescribed, and the care plan did not include oxygen therapy. Another resident with vascular dementia received oxygen at a higher rate than ordered, with an outdated care plan. A third resident with severe cognitive impairment received oxygen at a lower rate than prescribed due to an adjustment error. These discrepancies highlight lapses in following established procedures for oxygen administration.
The facility failed to update care plans for two residents receiving oxygen therapy, despite their medical needs. One resident with severe aortic stenosis and another with cognitive impairment were both observed using oxygen, but their care plans lacked necessary updates. Interviews revealed that MDS nurses were responsible for care plan updates, and the oversight was acknowledged by the DON.
A resident's care plan was not updated to reflect a new oxygen order, leading to discrepancies in the oxygen settings administered. The resident, with multiple health conditions, had a physician's order for oxygen at 2L/min, but the care plan still indicated 4L/min. Observations showed the oxygenator set at 3L/min, and staff interviews revealed a lack of timely monitoring and updating of the care plan.
A nurse in an LTC facility failed to check gastric residuals before administering medication via G-tube to a resident with severe cognitive impairment and a feeding tube. Despite being trained and evaluated on this procedure, the nurse did not follow the facility's protocol, which requires checking residuals before medication administration. This oversight was identified during an observation and confirmed through interviews with the nurse and the DON.
A resident's mini refrigerator contained unlabeled and undated food items, contrary to the facility's policy requiring all outside food to be labeled and dated by the charge nurse. The resident, with severe cognitive impairment and multiple health conditions, had food brought by his daughter that was not properly managed, posing a risk of foodborne illnesses. Staff interviews revealed a breakdown in the process, as the Business Office Coordinator noticed the issue but failed to address it.
A facility failed to report an alleged neglect incident involving a resident within the required 24-hour timeframe. The incident involved two CNAs, one of whom alleged abuse by the other. The resident, who had mild cognitive impairment, denied any abuse. The DON did not report the allegation, and the administrator reported it only after returning from vacation.
Failure to Obtain Informed Consent Before Administering Psychoactive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was fully informed in advance and that consent was obtained prior to administering a psychoactive medication. Resident #1 was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and lack of coordination. An admission MDS assessment documented that the resident was moderately cognitively impaired, required moderate assistance with most ADLs, and received antipsychotic and antidepressant medications for seven days during the assessment period. The consolidated physician orders showed an order dated 03/08/26 for Trazodone 25 mg by mouth at bedtime for insomnia, unspecified. Record review showed that the informed consent for psychoactive medication form for Trazodone was signed by Resident #1’s legal representative on 03/10/26, and the section indicating whether the representative consented to the medication was not completed. The medication had already been administered to the resident on 03/09/26, before the consent form was signed and completed. During an interview, the DON acknowledged that the informed consents for Trazodone were not completed and did not show if the medication was consented to by the responsible party, and stated that informed consents should have been completed prior to administering the medication. The facility’s policy on Chemical Restraints and Psychotropic Medication Management stated that on admission, the admitting nurse will review transfer orders for psychotropic medications and make all efforts to obtain history and prior informed consents, documenting any information obtained in the clinical record.
Psychotropic Medication Administered Without Informed Consent
Penalty
Summary
Surveyors identified a deficiency related to the use of a psychotropic medication without proper informed consent. Resident #1, admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and lack of coordination, had an admission MDS showing moderate cognitive impairment and a need for moderate assistance with most ADLs. The MDS also reflected that the resident received antipsychotic and antidepressant medications for seven days during the assessment period. The consolidated physician orders showed an order dated 03/08/26 for Trazodone 25 mg by mouth at bedtime for unspecified insomnia. Record review showed that the informed consent for psychoactive medication for Trazodone was signed by the resident’s legal representative on 03/10/26, and the form indicated that the legal representative did not consent to the medication. Despite this, Trazodone had already been administered to the resident on 03/09/26, prior to obtaining a signed consent. During an interview, the DON acknowledged that medication was not supposed to be given without a consent form because it could cause an adverse effect to the resident. The facility’s policy on Chemical Restraints and Psychotropic Medication Management stated that on admission the admitting nurse would review transfer orders for psychotropic medications and make all efforts to obtain history and prior informed consents, documenting any information in the clinical record, but this process did not prevent administration of Trazodone before consent was obtained.
Unlocked and Unattended Wound Care Medication Cart
Penalty
Summary
Surveyors observed that a wound treatment cart on the 300 hallway was left unlocked and unattended by an RN at 6:03 p.m. The cart contained medications needed for residents’ wound care and wound care supplies. When the surveyor notified the RN that the cart was unlocked, the RN locked it and acknowledged she was responsible for the treatment cart and was expected to lock it whenever she walked away. She stated that if the cart was left unlocked, a resident could open a drawer and take a medication that was not prescribed for them. In a subsequent interview, the DON stated that numerous staff, including herself and the ADON, were responsible for ensuring medication carts were locked and that her expectation was that staff lock the cart when walking away from it. The DON stated that if the cart was left unlocked, a resident or visitor could grab medication from the cart and it could harm them. Review of the facility’s “Medication Storage” policy showed that medications and biologicals must be stored properly and that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended only by persons with authorized access. The observed unlocked and unattended wound care cart was not in accordance with this policy or with accepted professional principles for medication storage and security.
Deficiencies in Oxygen Administration for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen administration. Resident #225, a male with multiple health conditions including respiratory failure and severe aortic stenosis, was observed receiving oxygen at a rate lower than the prescribed 4 liters per minute (LPM). The resident was found with oxygen set between 2.5 and 3 LPM, which was confirmed by LVN B, who admitted not checking the oxygen rate at the start of her shift. The resident's care plan did not include oxygen therapy, and the Director of Nursing (DON) acknowledged that the charge nurse was responsible for checking oxygen settings every shift. Resident #18, a female with respiratory failure and vascular dementia, was observed receiving oxygen at 3 LPM instead of the prescribed 2 LPM. The discrepancy was noted by a staff member who had not checked the oxygen setting since the start of his shift. The resident's care plan was outdated, and the DON confirmed that the care plan did not reflect the correct oxygen rate. Despite the incorrect oxygen administration, the resident did not exhibit any immediate distress, and the DON conducted an assessment to ensure the resident's condition was stable. Resident #48, a female with severe cognitive impairment and multiple health issues, was receiving oxygen at 3.5 LPM instead of the prescribed 4 LPM. LVN B, responsible for the resident's care, admitted to adjusting the humidifier, which may have altered the oxygen setting. The DON and other staff members routinely checked oxygen settings, but the discrepancy was not corrected in time. The facility's policy on oxygen administration emphasized the importance of adhering to physician orders, yet the failure to maintain correct oxygen levels for these residents highlighted a lapse in following established procedures.
Failure to Update Oxygen Therapy in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to meet their physical needs. Resident #225, a male with multiple diagnoses including respiratory failure and severe aortic stenosis, was prescribed oxygen therapy at 4LPM via nasal cannula as needed. However, his care plan, dated 8/2/24, did not reflect this oxygen use. Observations confirmed the resident was using oxygen, but the care plan was not updated to include this critical aspect of his care. Interviews with the ADON and MDS/RN revealed that the responsibility for updating care plans lay with the MDS nurses, and the oversight was acknowledged by the DON. Similarly, Resident #48, a female with severe cognitive impairment and a history of cerebral infarction and dementia, was receiving continuous oxygen therapy at 4L/min via nasal cannula. Despite this, her care plan, dated 5/30/24, lacked any focus, goals, or interventions related to her oxygen therapy. Observations confirmed her use of oxygen, and interviews with the MDS/RN and DON indicated that the care plan had not been updated to reflect her current needs. The MDS/RN acknowledged the potential negative effects of not having oxygen therapy care planned, such as hypoxia and respiratory distress. The facility's Comprehensive Person-Centered Policy, dated December 2023, mandates the development of a comprehensive care plan for each resident, including measurable objectives and timeframes. This policy was not adhered to in the cases of Residents #225 and #48, as their care plans did not include necessary information regarding their oxygen therapy, potentially placing them at risk of not receiving appropriate care.
Failure to Update Resident's Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. Specifically, the care plan for a resident was not updated to reflect a new oxygen order effective on a specified date. The resident, an elderly female with multiple health conditions including respiratory failure, vascular dementia, congestive heart failure, and end-stage renal disease, had a physician's order for oxygen at 2L/min continuous. However, her care plan still reflected an outdated intervention of oxygen therapy at 4L/min. Observations and interviews revealed discrepancies in the oxygen settings being administered to the resident. On one occasion, the oxygenator was set at 3L/min, contrary to the physician's order of 2L/min. The LVN acknowledged the discrepancy and noted that the nursing staff should monitor oxygen settings once per shift, but had not done so since the start of his shift. The MDS/RN confirmed that the care plan was not updated in a timely manner, and the DON acknowledged the oversight, noting that the care plan should have been updated on the day the new oxygen order was received to prevent confusion.
Failure to Check G-Tube Residuals Before Medication Administration
Penalty
Summary
The facility failed to ensure that a nurse, LVN A, demonstrated competency in administering medication via a G-tube for Resident #48. LVN A did not check for gastric residual before administering medication, which is a required procedure according to the facility's protocol. Resident #48, who was admitted with diagnoses including moderate protein-calorie malnutrition, dysphagia, and gastrostomy status, was dependent on staff for all activities of daily living and had a feeding tube for nutritional support. The resident's care plan specifically required checking for tube placement and gastric contents/residual volume before feeding, with instructions to hold feeding if residuals exceeded 150 mL and notify the physician. During an observation, LVN A was seen administering medication without checking for residuals, and she confirmed in an interview that she did not perform this check, believing it was only necessary before feeding. However, the facility's policy and the Director of Nursing (DON) clarified that checking residuals is mandatory before administering medications via G-tube. The DON stated that nurses were trained and evaluated on this skill, and LVN A had been checked off on the competency checklist for enteral med pass, which included checking gastric residuals. Despite this, LVN A did not follow the protocol, leading to the deficiency.
Failure to Label and Date Food in Resident's Mini Refrigerator
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as evidenced by the improper handling of food in a resident's mini refrigerator. The resident, who had severe cognitive impairment and multiple health conditions, including chronic obstructive pulmonary disease, dementia, and end-stage renal disease, had a mini refrigerator in his room containing unlabeled and undated food items. These included a plastic container with beans and several mini containers with salsa, which were brought by the resident's daughter. The facility's policy required that all outside food be labeled and dated by the charge nurse to prevent foodborne illnesses. Interviews with various staff members, including the Dietary Manager, LVN, DON, and the Business Office Coordinator, revealed a breakdown in the process of managing outside food brought into the facility. The staff confirmed that the procedure involved the front receptionist handing over the food to the resident's charge nurse, who was responsible for checking the food against the resident's diet plan and labeling and dating it if approved. However, this process was not followed in the case of the resident's mini refrigerator, as the food items were neither labeled nor dated, and the Business Office Coordinator admitted to noticing the unlabeled food but failing to address it. The facility's policy on food brought by family or visitors, revised in 2007, stipulated that non-perishable foods should be stored in plastic containers with tight-fitting lids and that perishable foods must be destroyed daily. Despite this policy, the facility did not maintain a log of outside food, and the oversight in labeling and dating the food in the resident's mini refrigerator posed a risk of foodborne illnesses. The administrator acknowledged the importance of labeling and dating food to track how long it had been stored, but the deficiency in this case highlighted a lapse in the facility's adherence to its own procedures.
Failure to Timely Report Alleged Neglect
Penalty
Summary
The facility failed to report an alleged incident of neglect involving a resident to the State Survey Agency within the required 24-hour timeframe. The incident involved a resident who was reportedly found on the floor by two CNAs, one of whom later alleged that the other CNA had verbally and physically abused the resident. The Director of Nursing (DON) at the time did not report the allegation to the State, and the facility administrator only became aware of the situation upon returning from vacation, at which point she reported it. The resident involved was a male with a history of sepsis, requiring assistance with personal care, and had mild cognitive impairment. During the facility's investigation, the resident denied any abuse from the CNAs involved, and no other staff or residents reported abuse by the accused CNA. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment be reported immediately, but this protocol was not followed, leading to a deficiency in the facility's compliance with reporting requirements.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mesa Hills Post Acute | 1.4 mi | — | 6 | 0 |
| Las Alturas Nursing & Transitional Care Brownsvill | 1.4 mi | — | 2 | 0 |
| Ebony Lake Nursing And Rehabilitation Center | 1.5 mi | — | 14 | 0 |
| Fox Hollow Post Acute | 1.7 mi | — | 10 | 1 |
| Spanish Meadows | 2.2 mi | — | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.