Alta Gardens Care Center

In the surveyor’s words

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

• Actual harm, isolatedF684Mar 11, 2026

  Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to maintain the resident's highest practicable well-being for three of five sampled residents (Residents 1, 2, and 3). * The facility failed to ensure the transportation services were properly coordinated to and from the dialysis clinic for Resident 2's hemodialysis treatment. Resident 2 was not picked-up from the dialysis clinic on 3/4/25, as a result, Resident 2 took two public buses and walked the remainder of the way back to the facility. In addition, Resident 2 felt fear and anxiety and was prescribed antianxiety medications related to the incident. […]

• No harm, potential for more than minimal, patternF552Feb 18, 2026

  Based on interview, medical record review, and facility's P&P review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity) for five of five residents reviewed for unnecessary medication (Residents 9, 25, 28, 38, and 47). * The facility failed to ensure the informed consent was obtained from Resident 28 or their representative before administering the sertraline (antidepressant medication) medication to Resident 28. […]

• No harm, potential for more than minimal, patternF605Feb 18, 2026

  Based on interview, medical record review, and facility P&P review, the facility failed to ensure five of five final sampled residents (Residents 3, 9, 28, 38,and 47) reviewed for the unnecessary medications were free from the unnecessary psychotropic medications. * The facility failed to ensure Resident 47 was monitored for the number of episodes of nightmares related to the use of prazosin (medication used to treat high blood pressure; also widely used as off-label medication to manage nightmares and sleep issues). * The facility failed to ensure the nonpharmacological interventions were provided to Resident 28 when Resident 28 had six behavior episodes related to the use of Ativan (medication used to relieve anxiety). […]

• No harm, potential for more than minimal, patternF812Feb 18, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed. * Food items in the refrigerator and dry storage area used for residents' food were not properly labeled and dated. * Expired food were not discarded. * Food contact surfaces were not clean or in a cleanable condition. * The facility failed to ensure the refrigerated food item brought in by visitors was properly labeled and dated. In addition, the refrigerator was not clean and the temperature for the freezer and the refrigerator was not consistently monitored. * The ice machine was not clean. * The hair restraint was not worn by one staff member entering the kitchen. […]

• No harm, potential for more than minimal, patternF880Feb 18, 2026

  Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of March 2025 through January 2026. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and/or symptoms of infection and were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria). […]