Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alhambra Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
Incomplete Documentation for Lorazepam Consent: A resident with CVA, depression, and dementia had an order for PRN Lorazepam for anxiety-related behaviors, but the informed consent form was not marked to show consent from the resident or responsible party. The NPN also lacked documentation of the phone discussion, and the LVN acknowledged he spoke with the responsible party but failed to document it, leaving the record incomplete.
Two residents were not treated with dignity: one was left with food particles on her clothing and bed after a meal, and another was addressed by staff with a term she did not prefer, rather than her chosen name. Staff acknowledged these actions did not align with facility policy requiring respect for resident preferences and cleanliness.
Two residents with feeding tubes did not receive care according to physician orders and facility policy: one resident's head of bed was not elevated to the required angle during enteral feeding, and another resident's feeding tube was not properly connected, resulting in nutritional supplement leaking onto the bed and floor. The DON and staff confirmed these practices did not meet established procedures for safe and effective enteral feeding.
Two residents did not receive respiratory care in accordance with facility policy: one resident's suction equipment was not discarded and replaced after use as required, and another resident received oxygen therapy without a physician's order. These deficiencies were confirmed through observation, record review, and staff interviews.
Expired vegetables, including lettuce, cilantro, parsley, and cucumbers, were discovered in the kitchen refrigerator during an observation. A dietary aide confirmed the items were past their expiration dates and acknowledged the risk of illness from consuming expired food. The registered dietitian reviewed facility policy and confirmed the vegetables had not been checked or discarded as required.
Surveyors observed improper disposal of garbage, including overflowing trash bins, uncovered containers, trash bags on the floor, and the use of a hamper as a trash can. Dietary staff confirmed that these practices did not follow facility policy, which requires waste to be placed in closable, covered containers.
Staff and a visitor failed to follow infection control protocols, including improper glove removal and hand hygiene after providing peri-care to a resident with severe cognitive impairment and multiple diagnoses, and incorrect use of PPE such as not wearing a face shield and improper N-95 mask placement in isolation rooms, contrary to facility policy during a COVID-19 outbreak.
The facility did not complete required surveillance data collection forms before administering antibiotics to three residents with various infections and impairments. The IPN and DON confirmed that these forms, which are necessary to assess the need for antibiotics and are mandated by facility policy, were not filled out prior to starting antibiotic therapy.
A resident with significant physical and cognitive impairments was not provided with a Low Air Loss (LAL) mattress set to their comfort level as ordered by the physician. Despite ongoing complaints from the resident and their responsible party about the mattress being too hard and lacking air, staff did not adjust the mattress settings for several months. Staff interviews confirmed awareness of the issue, and facility policy required mattresses to promote comfort, but this was not implemented.
A resident dependent on staff for daily care and receiving tube feeding was left in an unclean and unsafe environment after Glucerna formula spilled onto their bedding, bedrail padding, and the floor. Staff did not promptly clean the spill or replace soiled items, resulting in unsanitary conditions and an accident hazard, in violation of facility policy.
A resident with significant physical and cognitive impairments, fully dependent on staff for hygiene and incontinence care, was found with dried stool on the skin and soiled incontinent brief, indicating staff did not provide required cleaning. Staff and DON interviews confirmed this was not in accordance with facility protocols for maintaining resident cleanliness and dignity.
A resident with end stage renal disease and generalized edema, who required dialysis, was given more fluids than prescribed by the physician on multiple occasions. Despite a care plan and physician order limiting fluid intake to 1000cc per day, records showed the resident received up to 1420cc on several days. Staff interviews and record reviews confirmed that the fluid restriction was not followed as required by facility policy.
A resident with paraplegia and dizziness did not receive a scheduled dose of Meclizine at the prescribed time, as it was administered over an hour late by an LVN. Facility policy requires medications to be given within one hour of the scheduled time, and both the LVN and DON confirmed the importance of timely administration for effective treatment.
A resident with malnutrition and dysphagia was repeatedly served a pureed diet instead of the physician-ordered mechanical soft diet, despite documented complaints and clear dietary orders. Staff interviews and observations confirmed the mismatch between the prescribed and provided diets.
A resident with dysphagia and a mechanically altered diet order was fed regular food brought by family, which was not checked by an LVN as required by facility policy. The DON confirmed that the food should have been reviewed for compliance with the resident's diet, and the family was not educated on safe food handling or dietary restrictions.
A room was found to house more than four residents, exceeding regulatory limits. The room was divided by a wall with two beds on one side and three on the other, but only had a single entry/exit door, making it a single room with five residents. Interviews and observations confirmed that residents and staff had sufficient space and no concerns about care or privacy, but the room did not meet occupancy requirements.
The facility failed to implement a scheduled toileting program for three residents who were assessed as candidates for the bowel and bladder program. Despite being identified as good candidates, there were no orders or care plans for scheduled toileting, which could aid in improving continence status. Interviews with staff confirmed the absence of necessary orders and care plans, contrary to the facility's policy and procedure.
The facility failed to provide necessary respiratory care services for four residents, leading to several deficiencies. A resident's oxygen was not administered as ordered, and nasal cannulas for two residents were not stored properly, risking contamination. Another resident's oxygen equipment was not labeled with the date of use, and a fourth resident lacked necessary suction equipment at the bedside. These actions violated the facility's policy on safe and sanitary oxygen therapy.
The facility failed to follow proper food handling practices, as observed during a survey. A container of rice and a container of brown sugar were not sealed properly, and a can opener was found dirty with dried food residue, gunk, and rust. The Dietary Supervisor confirmed these deficiencies, which were against the facility's policies requiring tight-fitting lids for food storage and sanitation of the can opener between uses.
The facility failed to follow infection control practices during incontinence care for a resident, as a CNA did not change gloves before touching the resident's personal items, increasing infection risk. Additionally, the facility did not conduct water testing for legionella or other pathogens, contrary to guidelines, as they believed it unnecessary without reported cases of legionnaires' disease. This lack of testing contradicts both the facility's policy and national guidelines, which recommend regular water quality assessments.
A facility failed to provide an appropriate call light system for a resident with severe cognitive and physical impairments, resulting in the call light being inaccessible. The resident's care plan required the call light to be within reach, but it was found on the floor, and the DON acknowledged the need for a padded alarm instead of a button due to the resident's condition.
A facility failed to maintain a current copy of a resident's advance directive in their medical record. The resident, admitted with cancer and immunodeficiency, had the capacity to make decisions but was moderately impaired in cognitive skills. Despite facility policy requiring the inclusion of advance directives in medical records upon admission, the document was missing, as confirmed by the DON and Social Services.
A facility failed to initiate a comprehensive care plan for a resident's pressure injury, resulting in delayed care. The resident, at risk for pressure injuries, developed a stage 2 pressure injury, but no treatment orders or care plan were in place. Interviews with staff confirmed the absence of a care plan, despite facility policies requiring timely development and updates of care plans.
A resident with muscle weakness and osteoarthritis experienced a decline in mobility, but the care plan was not updated to reflect these changes. Despite therapy evaluations indicating impairments in both upper and lower extremities, the care plan remained unchanged, leading to inadequate care. Facility staff acknowledged the need for revision, and the facility's policy requires updates for new problems or changes in condition.
Two residents in an LTC facility did not receive the required one-to-one feeding assistance as ordered, leading to untouched meal trays and inadequate supervision during meals. Resident 643, with severe cognitive impairment and dysphagia, was not included in the feeding assistance list, while Resident 10, with cognitive impairment and other health issues, was left to feed herself unsupervised. These actions were contrary to the facility's policies on resident care and dignity.
A resident with a history of muscle weakness and osteoporosis developed a Stage 2 pressure injury due to the facility's failure to notify the physician and update care plans. The resident's initial MASD progressed without proper treatment orders or a wound consult, contrary to the facility's policies.
A resident with diabetic neuropathy missed a dose of gabapentin due to the facility's failure to maintain an adequate supply. The medication was not reordered in time, despite the facility's policy requiring refills to be ordered three to four days in advance. This oversight was identified during a medication pass observation and confirmed through staff interviews.
The facility failed to refrigerate unused insulin pens for two residents, as required by its Medication Storage policy. During an observation, a Novolin R Flex Pen and a Basaglar Kwik Pen were found in a medication cart instead of being refrigerated. LVN 4 and the ADON confirmed the need for refrigeration to maintain medication potency, as per the facility's policy.
The facility was found to have a room exceeding the maximum allowed number of residents, with five beds in a room divided by a wall but sharing a single entry door. Despite this, residents could move freely, and staff had enough space to provide care. A waiver request was submitted and recommended for approval, with no resident concerns reported.
A resident assessed as high risk for falls was not provided necessary assistance when getting up from bed to go to the bathroom, resulting in an unwitnessed fall and head injury. The facility failed to initiate a fall care plan as required by their policy, despite the resident's need for substantial assistance with daily activities. The lack of communication between physical therapy and nursing staff contributed to the incident.
A resident with a history of dysphagia and generalized muscle weakness was found unresponsive and without a pulse. Instead of immediately initiating CPR, an LVN checked the resident's code status at the nurses' station, causing a delay. The resident was also moved to his bed before CPR was started. The resident had been given a regular-texture sandwich, posing a choking risk. The delay in CPR and inappropriate diet contributed to the resident's death, as paramedics pronounced the resident dead 35 minutes after becoming unresponsive.
A resident with dysphagia was given a regular texture sandwich instead of a mechanical soft texture diet as ordered by the physician. The CNA did not verify the resident's diet order, and the UAP provided the inappropriate sandwich. The DSS confirmed the resident's diet required a mechanical soft texture with nectar thick consistency. The facility's Snack Spreadsheet also indicated that sandwiches were not recommended for residents on a dysphagia diet with thick liquids. This led to the resident choking, losing consciousness, and subsequently passing away.
A resident with a history of respiratory issues experienced a significant drop in oxygen saturation, which was not promptly reported to the doctor by the facility staff. Despite the facility's policy requiring immediate notification, the doctor was only informed after the resident became unresponsive and expired.
A resident with multiple respiratory and cardiac conditions was given oxygen therapy without an active physician's order. Staff assumed there was an order and did not follow protocol to inform the doctor, placing the resident at risk for inadequate oxygen therapy.
Incomplete Documentation for Lorazepam Consent
Penalty
Summary
The facility failed to maintain a complete medical record for one resident who was admitted with diagnoses including CVA, major depressive disorder, and dementia, and whose MDS showed severely impaired cognitive skills for daily decision making and need for partial/moderate assistance with multiple activities of daily living. The resident had an OSR order dated 10/20/2025 for Lorazepam 0.5 mg by mouth every six hours as needed for 14 days for anxiety disorder and manifested behavior episodes of easily getting anxious, starting to tremble, and having shaky hands. During review of the informed consent documentation for Lorazepam, the form dated 10/21/2025 was not marked to show that consent had been obtained from the resident or responsible party. The resident's NPN for 10/21/2025 did not document that licensed staff spoke with the resident or responsible party, and the DON confirmed there was no documentation that consent was obtained from the responsible party. LVN 1 stated he spoke with the resident's responsible party by phone to obtain consent but did not document the conversation in the progress notes or on the consent form, and acknowledged that the consent form was incomplete.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Two residents were not treated with respect and dignity according to facility policy. One resident, who had severe cognitive impairment and required assistance with most activities of daily living, was observed with food particles on her gown and bed linen after a meal. Staff interviews confirmed that the resident was not cleaned up after eating, and that it is the responsibility of staff to ensure residents are clean from food particles to maintain their dignity. Facility policy requires provision of a clean, comfortable bed and environment to support resident dignity and well-being. Another resident, who was moderately impaired cognitively and required some assistance with personal care, was addressed by a staff member as "grandma" rather than by her preferred name. The resident expressed that she did not like being called "grandma" and preferred to be addressed as "Miss." Staff and the Director of Nursing acknowledged that addressing the resident by a name other than her preference was inappropriate and not in accordance with the facility's policy, which requires staff to speak respectfully and use residents' names of choice.
Failure to Ensure Proper Gastrostomy Tube Practices and Procedures
Penalty
Summary
The facility failed to implement proper gastrostomy tube (GT) practices and procedures for two residents. For one resident with a history of hemiplegia, hemiparesis, acute respiratory failure, and dementia, the head of bed was observed to be elevated at only 20 degrees during enteral feeding, despite physician orders and care plan interventions requiring elevation to at least 30-45 degrees. The Director of Nursing confirmed that the observed bed elevation was below the required angle, and facility policy also specified a minimum of 30 degrees during enteral feedings. For another resident with diagnoses including gastrostomy, dementia, and dysphagia, the GT feeding was not properly connected, resulting in Glucerna leaking into the resident's bed and onto the floor. The resident was dependent on staff for most activities and received more than half of their nutrition through the feeding tube. The nurse present acknowledged that the feeding should not be leaking and that staff are responsible for ensuring all tubing is properly connected so the resident receives the prescribed nutrition. Facility policy required that enteral feedings be administered as ordered by the attending physician, with procedures to check tube placement and ensure proper connection of feeding containers and tubing. The Director of Nursing confirmed that improper connection of the GT feeding could result in the resident not receiving the full prescribed amount of nutrition.
Failure to Follow Respiratory Care Protocols and Physician Orders
Penalty
Summary
Two deficiencies were identified during the review of respiratory care provided to residents. For one resident with hemiplegia, hemiparesis, dementia, gastrostomy, and dysphagia, there was an order to swab/suction every shift as appropriate, and a separate order to suction as needed for excessive secretions. However, observation revealed that suction equipment, including a yankauer, suction tubing, and a collection canister, remained at the bedside well beyond the facility's policy for single-use items. The equipment was dated several days prior and had not been discarded or replaced after use, contrary to the facility's protocol and infection control policy. Staff interviews confirmed that the equipment should have been changed after each use to prevent contamination and infection, but this was not done. A second deficiency involved another resident with diagnoses including type 2 diabetes, cerebral infarction, and dependence on oxygen. This resident was observed receiving oxygen therapy at two liters per minute, but a review of the medical record revealed there was no physician's order for the administration of oxygen. Staff confirmed that the resident was receiving oxygen without a doctor's order, which was not in accordance with the facility's policy that requires a physician's order for oxygen therapy. The DON also confirmed that the policy mandates administration of oxygen only per physician orders. Both deficiencies were substantiated through direct observation, record review, and staff interviews. The facility failed to follow its own policies regarding the safe administration of respiratory care, specifically in the areas of equipment management and ensuring proper physician authorization for oxygen therapy.
Expired Vegetables Found in Kitchen Refrigerator
Penalty
Summary
During a kitchen observation, expired vegetables including lettuce, cilantro, parsley, and cucumbers were found stored in the facility's refrigerator, with expiration dates ranging from 6/19/2025 to 6/22/2025. The dietary aide present confirmed that the vegetables were expired and acknowledged that consuming expired food could make residents sick. Review of the facility's Food Storage and Handling policy indicated that fresh vegetables should be checked, sorted, labeled, and dated, but the registered dietitian confirmed that the expired vegetables had not been checked or discarded as required. The dietitian also stated that the labels clearly indicated the vegetables were expired and should have been thrown away.
Improper Disposal of Garbage in Facility's Disposal Area
Penalty
Summary
During a kitchen observation, surveyors found that the facility failed to properly dispose of garbage in the designated disposal area. Specifically, trash bins were seen overflowing, some bins had lids that were not fully closed, trash bags were left on the floor, a hamper was being used as a trash can, and some trash cans were uncovered. A dietary aide confirmed that trash bags should not be on the floor, trash should be covered, and hampers are not appropriate for use as trash cans, noting that uncovered trash can attract animals and spread disease. Review of the facility's waste management policy indicated that waste containers must be closable, waste must be disposed of in appropriate non-combustible containers, and waste bags must be placed in covered bins. The dietary supervisor also confirmed that trash should be disposed of in closable containers and not left on the floor or in hampers.
Deficient Infection Control Practices and Improper PPE Use
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as outlined in its own policies and procedures. Certified Nurse Assistant 1 (CNA 1) was observed exiting a resident's room after providing peri-care while still wearing contaminated gloves and used those gloves to close the resident's door. CNA 1 acknowledged during an interview that gloves should have been removed and hand hygiene performed before leaving the room. The Infection Preventionist Nurse (IPN) and Director of Nursing (DON) both confirmed that this action was not in accordance with facility policy and could contribute to the spread of infection, especially during an ongoing COVID-19 outbreak in the facility. The facility's policies require gloves to be discarded in the room where care is provided and for staff to perform hand hygiene before and after glove removal and upon exiting a resident's room. Additionally, there were failures related to the use of personal protective equipment (PPE) in rooms under novel respiratory precautions. CNA 1 was observed entering an isolation room without wearing a required face shield, despite signage and facility policy indicating that a face shield, N-95 mask, gown, and gloves must be worn before entry. CNA 1 admitted knowledge of the requirement but did not comply. In another instance, a family member (FM 2) was observed entering a resident's room with an N-95 mask worn incorrectly, with the metallic strip under the chin instead of over the nose, which was confirmed by a Licensed Vocational Nurse (LVN 2) to be improper and not in line with the facility's instructions for proper fit and use. The facility's policies on management of COVID-19 and transmission-based precautions require strict adherence to PPE protocols, including correct donning and doffing procedures and proper use of equipment to prevent the spread of communicable diseases. Observations and interviews confirmed that staff and visitors did not consistently follow these protocols, resulting in deficiencies in infection control practices.
Failure to Complete Antibiotic Surveillance Forms Prior to Administration
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program protocol by not completing the required surveillance data collection forms prior to administering antibiotic therapy to three residents. For each of these residents, antibiotics were prescribed and administered without the documented assessment to determine if the criteria for antibiotic use were met, as required by facility policy. The Infection Preventionist Nurse (IPN) confirmed in interviews that the surveillance data collection forms were not completed for any of the three residents before antibiotics were given. One resident was readmitted with diagnoses including sepsis and contact dermatitis and was prescribed Cephalexin for a urinary tract infection. Another resident, admitted with immune system disorder and malnutrition, received Sulfamethoxazole-Trimethoprim for a left buttock ulcer secondary to a ruptured abscess. The third resident, admitted with MRSA and malnutrition, was prescribed Ciprofloxacin for a urinary tract infection. In each case, the Minimum Data Set (MDS) assessments indicated varying levels of cognitive and physical impairment, and the physician orders for antibiotics were documented in the residents' records. Interviews with the IPN and the Director of Nursing (DON) confirmed that the surveillance data collection forms, which are intended to evaluate the necessity of antibiotic use and prevent antibiotic resistance, were not completed as required by the facility's policies. The facility's policies specify that the IPN is responsible for collecting and analyzing infection surveillance data and ensuring adherence to antibiotic stewardship processes, including the completion of surveillance forms prior to antibiotic administration.
Failure to Adjust LAL Mattress to Resident Comfort Level
Penalty
Summary
A deficiency occurred when the facility failed to accommodate the needs and preferences of a resident by not ensuring that the resident's Low Air Loss (LAL) mattress was set to the comfort level as ordered by the physician. The resident, who was admitted with diagnoses including scoliosis, chest and rib deformity, and muscle weakness, was dependent on staff for most activities of daily living and was moderately impaired in cognitive skills. Physician orders specified that the LAL mattress should be adjusted for the resident's comfort, yet observations revealed that the mattress had very little air, and the metal part of the bed could be felt with minor pressure. The resident repeatedly complained about the mattress being uncomfortable and lacking sufficient air. Interviews with staff and the resident's responsible party confirmed that complaints about the mattress had persisted for two to three months, with both the resident and their responsible party noting the mattress was hard and uncomfortable. Staff acknowledged that the mattress should be set to the resident's comfort level in accordance with physician orders and resident rights. Facility policies also required providing a comfortable mattress to promote comfort and prevent complications of immobility, but these were not followed in this instance.
Failure to Maintain Clean and Safe Resident Environment After Enteral Feeding Spill
Penalty
Summary
Facility staff failed to maintain a safe, clean, and homelike environment for a resident who was dependent on staff for most activities of daily living and received the majority of nutrition through a gastrostomy tube. The resident, who had diagnoses including dementia and dysphagia, was found with spilled Glucerna formula on their fitted bed sheet, bed sheet, bedrail padding, and the floor. Staff present at the time acknowledged that the enteral feeding formula had leaked and that the environment was not clean or sanitary. Housekeeping had not been called to clean the floor, and the bedrail padding had not been replaced or cleaned at the time of observation. The facility's policy and procedure required staff to provide a safe, clean, and comfortable environment and to pay close attention to cleanliness and order. Despite this, staff did not promptly address the spill or ensure the resident's environment was sanitary. The Director of Nursing confirmed that the situation was unacceptable and that any staff member could have assisted in cleaning the environment and bedside padding. This failure resulted in an unclean environment and accident hazard for the resident, other residents, and facility staff.
Failure to Provide Adequate Incontinence and Hygiene Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including perineal hygiene and incontinence care, was found in bed with brown residue on the right inner thigh and a brown smear on the outside and top of the incontinent brief. The resident had a history of hemiplegia, hemiparesis, dementia, and Parkinson's disease, and was documented as always incontinent and requiring total assistance for toileting and hygiene. Staff interviews confirmed that the presence of stool on the resident's skin and brief indicated that the resident had not been fully cleaned or checked as required. Facility policy required that residents who are incontinent be kept clean, dry, and comfortable, and that perineal care be provided to maintain cleanliness and prevent skin breakdown. Both the CNA and LVN present at the time of observation acknowledged that the resident should have been cleaned properly, and the DON confirmed that facility protocol mandates residents be left clean, presentable, and odor free. The failure to provide adequate assistance with hygiene and incontinence care was directly observed and confirmed through staff interviews and record review.
Failure to Follow Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
The facility failed to adhere to a physician-ordered fluid restriction for a resident receiving dialysis, resulting in the resident being given more fluids than prescribed on multiple occasions. The physician's order and care plan specified a strict fluid restriction of 1000cc per 24 hours, divided among the three nursing shifts. However, medication administration records showed that the resident received a total of 1420cc of fluid on several days, exceeding the prescribed limit. This discrepancy was confirmed during interviews with both a licensed vocational nurse and the director of nursing, who acknowledged that the physician's order was not being followed. The resident involved had diagnoses of end stage renal disease and generalized edema, and required dialysis as well as assistance with daily activities. The facility's policies on fluid restriction and dialysis management required strict adherence to physician orders, but these were not followed in practice. The failure to comply with the fluid restriction was documented through record reviews, staff interviews, and review of facility policies.
Failure to Administer Scheduled Medication on Time
Penalty
Summary
A scheduled medication was not administered on time to a resident with paraplegia and dizziness. The resident was admitted with these diagnoses and was assessed to have intact cognitive skills, requiring varying levels of assistance for daily activities. The resident had a physician's order for Meclizine to be given three times daily for dizziness. On the day in question, the medication was scheduled for 8:00 AM but was not administered until 9:40 AM, as observed by surveyors and confirmed by the LVN responsible for medication administration. The facility's Medication Administration policy requires medications to be given within one hour before or after the scheduled time, and emphasizes the importance of administering medications at the right time. The LVN acknowledged the medication was given late and stated that late administration could result in symptoms not being relieved on time. The Director of Nursing confirmed the policy and the importance of timely medication administration to ensure proper treatment of residents' medical conditions.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
A deficiency occurred when a resident with diagnoses of protein-calorie malnutrition and hyperlipidemia, who was moderately cognitively impaired and dependent on staff for several activities of daily living, was not provided with the therapeutic diet as ordered by the physician. The resident's Minimum Data Set and speech therapy evaluation indicated a need for a carbohydrate-controlled, mechanical soft diet with regular/thin liquid consistency, and the physician's order specified a dysphagia mechanical soft texture. However, multiple observations revealed that the resident was consistently served a pureed diet instead of the ordered mechanical soft diet. Interviews with the resident, a CNA, and the Director of Dietary Services confirmed that the resident had been complaining about the food texture for at least a week, and possibly as long as six months. The Director of Dietary Services acknowledged that the resident's tray did not match the physician's order, and the DON confirmed that the diet should have followed the speech therapy evaluation and physician's order. The facility's policy required meals to be consistent with physician orders and resident preferences, but this was not followed in the resident's case.
Failure to Review Family-Brought Food for Resident with Dysphagia
Penalty
Summary
The facility failed to implement its policy regarding the review and storage of food brought in by family members for a resident with significant swallowing difficulties. Specifically, a resident with diagnoses including dysphagia, hyperlipidemia, and adult failure to thrive, and who was on a mechanically altered, fortified diet as ordered by the physician, was observed being fed a regular diet of wonton soup and kiwi by a family member. The resident's care plan and physician orders required adherence to a mechanically altered diet due to the risk of choking and aspiration. Despite this, the food brought in by the family was not checked by the Licensed Vocational Nurse (LVN) as required by facility policy. Interviews with the LVN and the Director of Nursing (DON) confirmed that the food was not reviewed for compliance with the resident's prescribed diet, and that the family was not educated on the facility's policy or the resident's dietary needs. The facility's policy required staff to review the diet order with the resident's representative and assist families in understanding safe food handling practices, but this was not followed in this instance.
Room Occupancy Exceeds Regulatory Limit
Penalty
Summary
The facility failed to ensure that one of its rooms did not exceed the maximum occupancy of four residents per room, as required by regulations. Specifically, the room in question was separated by a wall into two sections, with two beds on one side and three beds on the other, but only had a single door for entry and exit, effectively making it a single room with five residents. This arrangement was confirmed through observation, interviews, and record review, including a review of the facility's room waiver, which acknowledged the configuration and the number of residents in the room. Interviews with the administrator, residents, and nursing staff confirmed the presence of more than four residents in the combined room. Despite the room's size and the ability for residents and staff to move freely and provide care, the room did not meet the regulatory requirement for maximum occupancy. The residents and staff did not express concerns about space, privacy, or the ability to provide care, and observations indicated that the room's configuration did not adversely affect health or safety at the time of the survey.
Failure to Implement Scheduled Toileting Program
Penalty
Summary
The facility failed to implement a toileting schedule for three residents who were assessed as candidates for the bowel and bladder (B&B) program. Resident 40, who was occasionally incontinent with urinary continence and always continent with bowel continence, was identified as a good candidate for retraining on multiple occasions. Despite this, there was no order for a scheduled toileting program, as confirmed by interviews with the Certified Nursing Assistant and Licensed Vocational Nurse. The Assistant Director of Nursing acknowledged that without a scheduled toileting order, Resident 40's incontinence may not improve. Resident 16, who was always incontinent for bowel continence, was also identified as a good candidate for scheduled toileting. However, the Director of Nursing confirmed that there was no physician's order for scheduled toileting, which could aid in restoring bowel and bladder continence. The lack of a scheduled toileting program for Resident 16 was a missed opportunity to improve their continence status. Resident 82, who was frequently incontinent and had a Foley catheter, was assessed as a candidate for scheduled toileting. Despite this, there was no care plan implemented for a scheduled toileting program. The Assistant Director of Nursing stated that a scheduled toileting program could help improve incontinence status and promote dignity, but it was not in place for Resident 82. The facility's policy and procedure emphasized the importance of providing appropriate treatment and services to restore bowel and bladder function, which was not adhered to in these cases.
Deficiencies in Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary respiratory care services for four residents, leading to several deficiencies. For Resident 2, the facility did not administer oxygen via nasal cannula according to the physician's order, as the nasal cannula was found hanging at the back of the wheelchair and not in use. This oversight was confirmed by both a CNA and an LVN, who acknowledged that the nasal cannula should have been placed in a plastic bag to prevent contamination. Additionally, the Assistant Director of Nursing (ADON) noted that the resident could develop shortness of breath and hypoxia if the oxygen was not provided as ordered. For Residents 2 and 49, the facility failed to ensure that the nasal cannula was stored in a clean plastic bag when not in use, which could lead to respiratory infections. Resident 49's nasal cannula was observed wrapped around the bedside rail, exposed to potential contamination. Both an LVN and the ADON confirmed that the nasal cannula should be stored in a plastic bag to avoid exposure to germs. The facility's policy on oxygen therapy, which requires oxygen to be administered under safe and sanitary conditions, was not followed. Resident 641's oxygen nasal cannula and water container for humidified oxygen were not labeled with the date of first use or change, as observed by a physical therapist and a CNA. This lack of labeling is against the facility's policy, which requires such equipment to be changed and dated every seven days. Additionally, Resident 63, who required suctioning as needed, did not have a suction canister or yaunker readily available at the bedside, and the nebulizer tubing was found on the floor. The Infection Preventionist and the Director of Nursing acknowledged the absence of a policy for suctioning and proper storage of oxygen and nebulizer tubing, which are crucial for infection control and resident safety.
Improper Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as observed during a survey. Specifically, a container of rice and a container of brown sugar were not sealed properly, which was confirmed by the Dietary Supervisor (DS) during an interview. Additionally, a can opener was found to be dirty, with dried food residue, gunk, and rust present. These observations were made during a kitchen inspection, and the DS acknowledged the improper sealing of the containers and the unclean state of the can opener. The facility's policies and procedures, as reviewed, require that opened food products be stored in containers with tight-fitting lids and that all storage products be labeled and dated. The policy also mandates routine monitoring for pest activity. Furthermore, the can opener is supposed to be sanitized between uses according to the manufacturer's guidelines. The DS confirmed that all food containers should be tightly closed to prevent pest infestation and that the can opener should be cleaned after each use.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident. The resident, who was admitted with diagnoses of muscle weakness and hypertension, was observed to be severely impaired in cognitive skills and required assistance with daily activities, including toileting hygiene. During an observation, a Certified Nursing Assistant (CNA) was seen providing perineal care to the resident without changing gloves before touching the resident's personal items, such as the call light, blanket, bed rail, and bed remote. This action was acknowledged by the CNA and the Infection Preventionist Nurse as a breach of infection control protocol, as it increased the risk of spreading infection. Additionally, the facility did not implement water sample testing to validate its water management program's control measures. Interviews with the Infection Preventionist and Maintenance Supervisor revealed that the facility did not conduct testing for legionella or other waterborne pathogens, as they believed there was no need due to the absence of reported cases of legionnaires' disease among residents. The facility's policy and procedure on water management, as well as guidelines from the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention, emphasize the importance of environmental testing to validate the effectiveness of control measures in preventing waterborne pathogens. The facility's failure to conduct initial or ongoing water testing for legionella and other pathogens was further confirmed by the Administrator, who stated that testing was not deemed necessary unless there were issues with water temperature. This lack of testing contradicts the facility's own policy and national guidelines, which recommend regular water quality assessments to prevent conditions conducive to legionella growth, especially in healthcare settings serving at-risk populations.
Inadequate Call Light Accessibility for Resident with Severe Impairments
Penalty
Summary
The facility failed to provide an appropriate call light system for a resident, identified as Resident 5, who was admitted with diagnoses of muscle weakness and osteoarthritis. The resident's care plan, revised on two occasions, indicated the need for the call light to be within reach due to the resident's risk for injury and falls. However, during an observation, it was noted that the call light was on the floor and not accessible to the resident, who had both arms and legs contracted. The Director of Nursing (DON) acknowledged that the call light should have been a padded alarm instead of a button due to the resident's condition and inability to use the standard call light. The resident's medical records, including an Occupational Therapy Evaluation and Minimum Data Set, highlighted severe impairments in cognitive skills and physical abilities, indicating dependency on assistance for daily activities. Despite these documented needs, the facility's policy on call systems, which required call cords to be within the resident's reach, was not adhered to. This oversight had the potential to delay necessary care and services for the resident, as the call light was not appropriately adapted to the resident's physical limitations.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to maintain a current copy of a resident's advance directive in the medical record, which is a legal document that provides instructions for medical care if the resident cannot communicate their wishes. This deficiency was identified for one resident who was admitted with diagnoses of malignant neoplasm of the left lower limb and immunodeficiency. The resident had the capacity to understand and make decisions as per the History and Physical dated January 8, 2024, but was noted to be moderately impaired in cognitive skills for daily decision-making according to the Minimum Data Set dated May 17, 2024. During a record review on June 25, 2024, it was found that there was no advance directive in the resident's chart. Interviews with the Director of Nursing (DON) and Social Services (SS) confirmed that the facility did not have the resident's advance directive and acknowledged that it should have been followed up shortly after admission. The facility's policy, revised in July 2018, requires that a copy of the advance directive be obtained upon admission and included in the resident's medical record, which was not adhered to in this case.
Failure to Initiate Comprehensive Care Plan for Pressure Injury
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was initiated for a resident, resulting in delayed care and services for the resident's pressure injury. The resident was admitted with diagnoses of muscle weakness and osteoporosis and was at risk of developing pressure injuries, as indicated by the Braden Scale. Despite these risks, the facility did not develop a care plan to address the resident's pressure injury, which was observed by a CNA and later classified as a stage 2 pressure injury by a treatment nurse. Interviews with facility staff, including a CNA, a treatment nurse, the DON, and the ADON, revealed that there were no orders for treatment of the resident's pressure injury, and the facility did not have a care plan in place for the injury. The facility's policies required the development of a comprehensive care plan within seven days of the MDS assessment and updates to the care plan with the onset of new problems or changes in condition. However, these procedures were not followed, leading to the deficiency.
Failure to Revise Care Plan for Resident with Declining Mobility
Penalty
Summary
The facility failed to revise the care plan for one of the sampled residents, identified as Resident 5, which led to inadequate care for the resident's needs. Resident 5 was admitted with diagnoses of muscle weakness and osteoarthritis and was noted to have impaired cognitive skills, requiring extensive assistance with daily activities. Despite the resident's declining mobility, as evidenced by occupational and physical therapy evaluations indicating impairments in both upper and lower extremities, the care plan was not updated to reflect these changes. Observations showed the resident with contracted arms and legs, and interviews with facility staff confirmed that the care plan should have been revised to address the resident's declining condition. The Assistant Director of Nursing acknowledged that the care plan needed revision since the resident was no longer in the Restorative Nursing Assistant program and had experienced a decline in mobility. The Director of Rehabilitation also noted the resident's declining mobility and recommended splinting to prevent contractures. The facility's policy on comprehensive person-centered care planning requires care plans to be revised at the onset of new problems or changes in condition, which was not adhered to in this case.
Failure to Provide Required Feeding Assistance
Penalty
Summary
The facility failed to provide one-to-one feeding assistance for two residents, Resident 643 and Resident 10, as ordered. Resident 643, who was admitted with a displaced intertrochanteric fracture and dysphagia, was observed multiple times with untouched meal trays and no staff assistance, despite having an order for 1:1 feeding assistance. The Assistant Director of Nursing (ADON) confirmed that Resident 643 was not included in the list of residents requiring feeding assistance, which was an oversight. The Speech Therapist and Director of Rehab noted that Resident 643 needed 1:1 support for feeding to ensure safety and adequate food intake. Resident 10, admitted with anemia, malnutrition, and end-stage heart failure, also required assistance with feeding. Observations revealed that Resident 10 was feeding herself with food all over her mouth and clothes, contrary to the care plan that required staff supervision during meals. The ADON confirmed that Resident 10's care plan indicated a need for assistance with eating and personal hygiene due to cognitive impairment and other health issues. CNA 7 admitted to leaving Resident 10 to feed herself, which was not in line with the required supervision for safety and dignity. The facility's policies on resident rights and quality of life emphasize the need for individualized care to maintain residents' dignity and well-being. However, the failure to provide the necessary feeding assistance for Residents 643 and 10, as per their care plans, put them at risk for weight loss, aspiration, and compromised dignity. The oversight in including Resident 643 in the feeding assistance list and the lack of supervision for Resident 10 highlight deficiencies in the facility's adherence to its policies.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate treatment for a Stage 2 pressure injury for one of the sampled residents, Resident 26. Initially, Resident 26 had Moisture-Associated Skin Damage (MASD) on the sacrum area, which progressed to a Stage 2 pressure injury. Despite this progression, the facility did not notify the physician, resulting in no wound treatment orders being issued. Additionally, there was no Change of Condition form completed to document the progression of the wound. Interviews and record reviews revealed that Resident 26's physician orders did not reflect the presence of a pressure injury, and there was no order for a wound consult. Consequently, Resident 26 had not been seen by a wound doctor after the wound progressed. Furthermore, Resident 26's care plan did not indicate any pressure injuries, contrary to the facility's policies and procedures, which require care plans to be reviewed and revised upon the onset of new problems or changes in condition. The facility's policies also mandate daily observation and reporting of any signs of active pressure injuries, which was not adhered to in this case.
Failure to Maintain Adequate Medication Supply
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with type 2 diabetes mellitus and diabetic neuropathy, had a sufficient supply of gabapentin, a nerve pain medication, as per the physician's order and facility policy. The physician's order required the administration of gabapentin 100 mg twice daily for neuropathy. However, during a medication pass observation, it was noted that the resident did not have any gabapentin available in the medication cart, resulting in a missed morning dose. Interviews with the Licensed Vocational Nurses (LVN) and the Assistant Director of Nursing (ADON) revealed that the licensed nurse responsible for the resident's medication should have ordered a refill when the stock was low. The facility's policy required medications to be reordered three to four days in advance to ensure an adequate supply. The failure to reorder the medication in a timely manner led to the resident missing a dose, which could potentially result in unrelieved nerve pain.
Improper Storage of Insulin Pens
Penalty
Summary
The facility failed to adhere to its Medication Storage policy by not refrigerating unused insulin pens for two residents, which is a requirement for maintaining the medication's effectiveness. During an observation of Medication Cart 3, it was found that a Novolin R Flex Pen belonging to one resident and a Basaglar Kwik Pen belonging to another resident were not stored in the refrigerator as required. Both insulin pens had green stickers indicating the need for refrigeration, yet they were found in the medication cart instead. Licensed Vocational Nurse (LVN 4) confirmed that the insulin pens should have been refrigerated, and the Assistant Director of Nursing (ADON) reiterated the importance of proper storage to maintain the potency of the medications. The facility's policy, dated August 2019, specifies that medications should be stored according to the manufacturer's recommendations, which include refrigeration for these insulin pens. The failure to store these medications properly could compromise their effectiveness, posing a risk to the residents' health.
Room Capacity Exceeded in Shared Resident Room
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents in a shared room to no more than four. During an observation, it was noted that one room, identified by specific room numbers, was divided by a wall and contained a total of five beds, with two beds on one side and three on the other, accessible through a single door. This setup did not meet the requirement of having no more than four residents per room. Despite the room's configuration, residents were able to move freely, and nursing staff had adequate space to provide care with dignity and privacy. The facility had submitted a room waiver request, indicating sufficient space and safety for residents, and the Department recommended approval of this waiver. Interviews with residents revealed no concerns about room size.
Failure to Prevent Fall for High-Risk Resident
Penalty
Summary
The facility failed to prevent a fall for a resident who was assessed as high risk for falls. The resident, admitted with diagnoses including muscle weakness, history of falling, and abnormality of gait and stability, had a high fall risk score of 11. Despite requiring substantial assistance with daily activities such as toileting and transfers, the resident was not provided assistance when getting up from the bed to go to the bathroom. This lack of assistance led to an unwitnessed fall in the resident's room, resulting in a head injury and transfer to a general acute care hospital. The facility did not initiate a fall care plan for the resident, as required by their policy and procedure. The Director of Nursing acknowledged that the resident was assessed as high risk for falls and should have had a fall care plan in place. Additionally, the Physical Therapy Director noted the need for communication with nursing staff regarding the resident's assistance needs. The facility's policy on fall management emphasizes the importance of documenting interventions on the resident's care plan when a fall risk factor is identified, which was not done in this case.
Delayed CPR Initiation and Inappropriate Diet Lead to Resident Fatality
Penalty
Summary
The facility failed to ensure immediate initiation of CPR for Resident 1, who was found unresponsive and without a pulse. Instead of starting CPR right away, LVN 1 walked to the nurses' station to check on Resident 1's code status before beginning CPR. Additionally, Resident 1 was moved from outside his room to his bed before CPR was initiated, causing a delay in life-saving measures. Despite Resident 1's need for immediate CPR due to cardiac and respiratory arrest, the staff did not act promptly, resulting in the resident being pronounced dead by paramedics 35 minutes after becoming unresponsive. Resident 1 had a history of dysphagia and generalized muscle weakness, requiring a specific diet and supervision with eating. Despite these known conditions, Resident 1 was given a sandwich of regular texture, which posed a choking risk. The staff's delay in recognizing the severity of the situation and the failure to provide appropriate care, such as immediate CPR and addressing the choking incident effectively, contributed to the tragic outcome. The facility's policy on cardiopulmonary resuscitation was not followed, as staff did not initiate CPR promptly upon finding Resident 1 unresponsive.
Failure to Adhere to Dysphagia Diet Order Results in Resident's Death
Penalty
Summary
The facility failed to follow the physician's order to provide a mechanical soft texture diet for a resident with dysphagia, resulting in a tragic incident. Despite the resident's documented need for a specific diet due to difficulty swallowing, the Certified Nursing Assistant (CNA) did not verify the resident's diet order before allowing them to consume a sandwich of regular texture and unknown content. This failure led to the resident choking and subsequently losing consciousness, ultimately resulting in their death. The deficiency was exacerbated by the actions of the Uncertified Assistive Personnel (UAP), who handed the inappropriate sandwich to the resident despite being instructed by the CNA to obtain it from the facility's refrigerator. The Dietary Service Supervisor (DSS) confirmed that the resident should not have been given a sandwich due to being on a dysphagia mechanical soft diet with nectar thick consistency. Additionally, the facility's Snack Spreadsheet indicated that sandwiches were not recommended for residents on a dysphagia diet with thick liquids, highlighting a breakdown in communication and adherence to established protocols.
Failure to Notify Doctor of Resident's Low Oxygen Saturation
Penalty
Summary
The facility failed to notify the doctor of a resident's change in condition, specifically a decreased oxygen saturation level of 78%. The resident, who had a history of pneumonia, acute respiratory failure, moderate persistent asthma, and congestive heart failure, was found by an LVN to be short of breath with uneven breathing. Despite the facility's policy requiring immediate notification of significant changes in condition, the LVN did not inform the doctor of the resident's low oxygen saturation level. The Director of Nursing (DON) was informed of the situation but also did not notify the doctor until after the resident became unresponsive and expired. Interviews and record reviews revealed that the resident's vital signs, including the low oxygen saturation level, were documented but not communicated to the doctor in a timely manner. The medical doctor confirmed that he was only informed of the resident's condition after the resident had already passed away. The facility's policy and procedure clearly stated that physicians should be informed immediately of any significant changes in a resident's condition, which was not followed in this case, leading to a failure in providing timely medical intervention for the resident.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident had an active doctor's order for oxygen therapy before and during its administration. The resident, who had diagnoses including pneumonia, acute respiratory failure, moderate persistent asthma, and congestive heart failure, was given oxygen at 2 liters per minute on multiple occasions without a physician's order. This was confirmed through a review of the resident's Medication Administration Records and Order Summary, which did not indicate an active physician's order for the oxygen therapy during the specified period. Interviews with the CNA, LVN, and DON revealed that the staff assumed there was an active order and did not follow the facility's protocol to inform the doctor and obtain a proper order for the oxygen therapy. The resident's primary doctor confirmed that he did not order oxygen administration and was unaware that the resident was receiving oxygen therapy. The facility's policy and procedure for oxygen therapy, which requires licensed nursing staff to administer oxygen as prescribed by the doctor, was not followed. This failure placed the resident at risk for inadequate oxygen therapy, which could negatively impact their health and well-being. The DON acknowledged that administering oxygen without a physician's order is a significant problem that could lead to respiratory distress and potentially fatal outcomes for the resident.
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What surveyors actually found near you
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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.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Alhambra
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atherton Baptist Home | 0.6 mi | ★★★★★ | 10 | 0 |
| Royal Vista Care Center | 0.6 mi | ★★★★★ | 31 | 0 |
| Live Oak Rehab Center | 0.9 mi | ★★★★★ | 38 | 1 |
| Ivy Creek Healthcare & Wellness Centre | 1 mi | ★★★★★ | 13 | 0 |
| San Gabriel Valley Medical Ctr D/p Snf | 1 mi | ★★★★★ | 17 | 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 July 2026) and official state health department websites.