Deficiency Records for The Terraces at Los Altos Health Facility
Updated as of April 01, 2024
A list of the most recent deficiencies for The Terraces at Los Altos Health Facility. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-26 | 2024-02-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-26 | 2024-02-25 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-26 | 2024-02-25 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-10 | 2023-04-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-10 | 2023-04-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-10 | 2023-04-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-10 | 2023-04-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-10 | 2023-04-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-10 | 2023-04-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-10 | 2023-04-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-10 | 2023-04-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-10 | 2023-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-10 | 2023-04-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-10 | 2023-04-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-10 | 2023-04-09 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-10 | 2023-04-09 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-03-15 | 2023-03-31 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-03-15 | 2023-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-15 | 2023-03-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-15 | 2023-03-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-15 | 2023-03-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-03-15 | 2023-03-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-15 | 2023-03-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-15 | 2023-03-31 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-10-24 | 2019-12-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-24 | 2019-12-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-24 | 2019-12-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-09-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-12 | 2019-09-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-11-30 | 2019-01-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-30 | 2019-01-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-30 | 2019-01-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-30 | 2019-01-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-30 | 2019-01-04 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-11-30 | 2019-01-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-30 | 2019-01-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-07 | 2018-09-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-07 | 2018-09-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-07 | 2018-09-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-07 | 2018-09-18 | N |
