Los Altos Post-Acute

In the surveyor’s words

From the most serious findings on record at Los Altos Post-Acute, in the surveyor’s own words.

• Actual harm, patternF684Aug 24, 2026

  Based on interview and record review, the facility failed to provide quality of care for six of 18 residents (Residents 1, 2, 3, 4, 9, and 10) who have Diabetes Mellitus (DM, a chronic disease characterized by high levels of sugar in the blood) when:1. For Resident 1, the facility did not follow the physician's order to monitor blood glucose (BG, blood sugar) every 6 hours by glucometer (a device used to measure the amount of glucose in your blood) from 4/18/25 to 7/7/26 (a period of over 14 months); the facility did not conduct periodic laboratory tests to monitor Resident 1's blood glucose as in accordance with accepted professional standards of practice since 4/21/25 (or more than 14 months ago); the facility did not adequately monitor signs/symptoms (s/s) of hypoglycemia (a medical… […]

• Actual harm, patternF686Aug 24, 2026

  Based on interview and record review, the facility failed to prevent the development and worsening of a pressure ulcer (PU, localized damage to the skin and/or underlying tissue usually over a bony prominence) for six of eight residents (Residents 1, 2, 5, 6, 7, and 8) who have a facility acquired PU when:1. For Resident 1, interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) did not accurately identify and assess the presence of a PU on the left buttock to provide necessary pressure ulcer treatments and nursing interventions to aid wound healing. […]

• Actual harm, isolatedF689Mar 15, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards for two of 24 sampled residents (40 and 94) when: 1. Resident 40 was not properly assessed for Smoking Safety Screen. This failure resulted in Resident 40 sustaining [CONDITION(S)] to face, neck, and chest after smoking unsupervised while on oxygen on 7/31/21; 2. Resident 94 was not provided adequate supervision while smoking as indicated in his smoking care plan. This failure had the potential to result in serious injury to the residents in the facility. Findings: 1. Review of Resident 40's clinical record indicated Resident 40 was admitted on [DATE]. […]

• No harm, potential for more than minimal, widespreadF804Mar 15, 2022

  Based on observations, resident and staff interviews, and facility document review, the facility failed to provide food that was palatable. This failure placed the 114 residents eating at the facility at risk of poor food intake further compromising their nutritional status. Findings: During resident interviews on 3/7/22 starting at 8:30 a.m., multiple residents complained about the food generally being bad. Comments included the ham is salty, the zucchini is soggy and sloppy, the food is just not good. During an interview with Resident 3 on 3/8/22 at 7:42 a.m., Resident 3 stated the food is dreadful for example meals made with ground beef are greasy, the soups are watery, and the toast is dry and brittle. […]

• No harm, potential for more than minimal, widespreadF812Mar 15, 2022

  Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when: 1. Resident food refrigerators and microwaves were not properly monitored, and not maintained in a sanitary condition, and multiple expired, moldy, and/or unlabeled foods were stored in the refrigerators; 2. Time/Temperature Control for Safety (TCS) foods (food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or [CONDITION(S)] organisms capable of causing a disease or toxin formation), were not properly monitored for cool down; 3. TCS foods were not properly labeled, and expired items were in the refrigerator; and 4. […]