Almond View Care Center

In the surveyor’s words

From the most serious findings on record at Almond View Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Nov 22, 2024

  Based on Observation, Interview, and Record Review the facility failed to ensure federal regulations related to the certification qualification requirement of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with resident assessment accuracy, meal distribution accuracy, safe food handling, and sanitation guidelines. Findings: According to the HSC 1265.4 (a) Shall employ a full-time, part-time, or consulting dietitian. […]

• No harm, potential for more than minimal, patternF812Jul 23, 2026

  Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed in the kitchen when opened food items were not labeled and dated.This failure increased the risk of residents being served unsafe food, placing them at risk for foodborne illness. Findings:During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2023, indicated, that all food items stored in the storeroom, refrigerator, and freezer must be labeled and dated. […]

• No harm, potential for more than minimal, patternF880Jul 23, 2026

  Based on observation, interview, and record review the facility failed to maintain adequate measures of infection control while administering medications. Licensed Nurse (LN) D failed to properly clean or sanitize medical equipment and medication containers for one of two residents sampled (Resident 40) when:1.The blood pressure cuff (medical device placed on the arm to measure blood pressure), was not cleaned nor sanitized prior to nor after it was used on Resident 40.2.The pulse oximeter (medical device clips on finger to measure blood oxygen saturation and heart rate), was not cleaned nor sanitized prior to nor after it was used on Resident 40.3.The Lidocaine Pain Relief Patch (a pain patch) 4% (percent), package was opened prior to administration, taken into Resident 40's room, and set… […]

• No harm, potential for more than minimal, patternF600Jun 4, 2026

  Based on interview and record review the facility failed to ensure vulnerable demented residents were free from physical abuse and inappropriate sexual behaviors for 12 of 23 sampled residents when:1. Resident 8 was on top of Resident 7 with his genital (male private part) in her mouth.2. Resident 13 was holding Resident 23's hand over his penis and stroking it.3.Resident 11 was using his hand on Resident 14's hand to stroke his penis.4. a. Resident 4 struck Resident 11 in the face. b. Resident 4 grabbed Resident 1's wrist very aggressively. c. Resident 4 pushed Resident 6 to the ground. d. Resident 4 walked up to Resident 18 and pushed her forehead back. e. Resident 19 would not let go of Resident 4 hand then he grabbed Resident 19's arm. f. […]

• No harm, potential for more than minimal, patternF725Jun 4, 2026

  Based on observation, interview, and record review, the facility failed to ensure the residents in the secured dementia unit (unit that is a specialized residential setting for individuals with Alzheimer's (a disease characterized by a progressive decline in mental abilities) or dementia (a progressive state of decline in mental abilities) that uses secured perimeters, such as locked exterior doors or fenced areas, to prevent wandering while maintaining a safe, structured environment) had sufficient and competent nursing staff and were available to provide nursing and related services to meet the residents' needs when:1 Acuity (complexity and intensity rather than just resident numbers) levels for dementia residents and increased resident altercations were not considered when scheduling… […]