Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alhambra Hospital Med Ctr Dp/snf during CMS and state inspections, most recent first.
An LVN and another LVN left computer screens open during medication administration, exposing residents’ electronic medical information instead of locking or logging off the workstation. The screens displayed identifying and medication details for residents with serious conditions such as chronic respiratory failure, tracheostomy status, and persistent vegetative state. The DON stated staff were supposed to lock the screen before walking away to maintain privacy and confidentiality.
Failure to Maintain Oral and Personal Hygiene: Two dependent residents did not receive adequate hygiene assistance. One resident with chronic respiratory failure, persistent vegetative state, and candidal stomatitis was observed with a dry tongue, white coating, and red spots, despite being dependent on staff for oral care. Another resident with respiratory failure, vent dependence, dysphagia, and quadriplegia was observed with dry nasal mucus outside the nostril and mouthed that it was uncomfortable; the DON stated the resident should have been cleaned.
Respiratory care was not provided as ordered for several residents with tracheostomy and ventilator needs. A resident had dry blood and mucus buildup in a t-piece, another resident’s cool aerosol t-piece was not connected as ordered, a third resident had mucus overflowing from the t-piece onto the bed and call light, and a fourth resident had an uncovered Yankauer attached to suction plus another used Yankauer left on the bed. The DON and RT stated these conditions were not consistent with ordered respiratory care and facility policy.
Anticoagulant Given Despite Tracheostomy Bleeding: A resident with hypoxia, chronic respiratory failure, and ventilator dependence had a care plan identifying risk for bleeding and tracheal bleeding related to Xarelto and tracheostomy care. Staff observed dried blood and mucus in the tracheostomy t-piece and suction catheter, but the physician was not notified and Xarelto was not held as indicated; RN and DON stated the medication should have been on hold and not administered.
Pureed Diet Served With Crusted Edges: A resident with chronic respiratory failure, tracheostomy status, ventilator dependence, and swallowing difficulty was ordered a pureed diet with honey thick liquids. During observation, the resident’s tray included pureed chicken with crusted edges, and RN, LC, DFN, and DON all stated the crusted edges were not acceptable because they could pose a choking hazard. The facility’s diet guideline required pureed foods to be smooth, lump free, and easy to swallow.
Food Handling and Storage Deficiencies: A cook with a long beard was observed preparing vegetables without a beard net, and multiple dry goods, refrigerated produce items, and opened bags of bean sprouts and cilantro were found without use-by dates. The interior of the ice machine also had brown smudges and black particles, and the DFN stated the machine was supposed to be cleaned weekly but no cleaning log was maintained.
An LVN used a contaminated medication cup and contaminated G-tube declogger during medication administration for a resident with a feeding tube, while another resident had G-tube residue and a CNA failed to remove gloves or perform hand hygiene after incontinent care before touching clean linens and repositioning the resident. In addition, an LVN provided G-tube medication administration to three residents on EBP without wearing the required isolation gown, despite care plans and facility policy calling for PPE use during these high-contact care activities.
Two residents with g-tube feedings were observed to have their feeding tube tips left uncapped and uncovered when not in use, despite manufacturer guidelines requiring the connector cap to be replaced. Both residents had complex medical conditions and were dependent on staff for care. Facility staff, including the DON and an LVN, confirmed that the g-tube tips should be capped to prevent contamination, but this practice was not included in the facility's policy and procedure.
Staff failed to follow infection prevention and control practices, including not sanitizing pulse oximeters between residents, not wearing required PPE during G-tube care, and not changing gloves or sanitizing surfaces during tracheostomy care. These actions involved residents with complex medical needs, such as ventilator dependence and indwelling devices, and were confirmed by staff interviews and policy reviews.
A resident with severe cognitive impairment and multiple medical conditions was found to have a room sink with stripped Formica and exposed rough wood, creating an unsanitary environment. Facility staff, including the DON, Maintenance Assistant, and an LVN, confirmed the condition and acknowledged it did not meet the facility's standards for a safe and comfortable environment.
A resident with a stage 4 pressure ulcer was found to have their low air loss mattress set at an incorrect firmness level for their weight, contrary to care plan instructions and manufacturer guidelines. Nursing staff and the DON confirmed the mattress was not set properly, which could impact wound healing.
A resident with a midline catheter did not have swab caps covering the two lumen injection ports as required by facility policy and care plan. Staff confirmed that the ports should have been capped to prevent infection, and observations showed the ports were left uncovered despite established protocols.
A resident with a G-tube did not receive the full prescribed doses of glycopyrrolate and Vitamin C when an LVN failed to properly mix and dissolve the medications in water before administration, leaving visible residue in the medication cups. The DON confirmed this was not in accordance with facility policy, resulting in incomplete medication delivery.
A nurse failed to fully administer glycopyrrolate and Vitamin C to a resident with a G-tube by not properly dissolving the medications, resulting in visible residue left in the cups and an overall medication error rate above 5%. Both the nurse and DON confirmed the medications were not fully given as required by facility policy.
Surveyors identified deficiencies in food handling and equipment sanitation, including unsealed food containers, a soiled soy sauce container, and a chipped, rusted can opener. These issues were confirmed by the RD and KS, who acknowledged that the practices did not meet facility policies for food storage and cleanliness.
The facility failed to use dignity bags for the catheter drainage bags of two residents, compromising their dignity and privacy. One resident, who was comatose, had an exposed catheter bag in their private room. Another resident, with impaired cognitive skills, had an exposed catheter bag visible to visitors and from the hallway. The DON acknowledged that dignity bags should be used to respect residents' privacy, indicating a lapse in policy adherence.
The facility failed to document advance directives for several residents, including those with chronic conditions and dependencies, potentially violating their rights to have their healthcare preferences respected. Interviews and record reviews confirmed the absence of advance directive forms in both paper and electronic records, despite facility policy requirements.
The facility failed to properly implement gastrostomy tube feeding practices for two residents. One resident's feeding solution was not labeled correctly, risking delayed feedings and incorrect amounts. Another resident's water bag flush was not labeled, risking improper replacement timing. Observations and interviews revealed non-compliance with facility policies requiring proper labeling to ensure adherence to physician orders.
The facility failed to provide necessary respiratory care services for three residents, leading to potential infection risks. A resident's nasal cannula tubing was not changed weekly, and two residents had suction tubing touching the floor, which could lead to respiratory infections. The DON acknowledged the lack of a policy for changing nasal cannula tubing weekly, and the facility's policy indicated that all tubing should not touch the floor.
The facility failed to follow proper food handling practices, including labeling food items with open and use-by dates, discarding expired items, and maintaining proper drainage. Observations revealed unlabeled food items, improper storage of salsa, and a drainpipe not meeting the required gap. Trash was also found in the kitchen floor drain, contrary to facility policies.
The facility failed to educate, offer, and document COVID-19 vaccinations for three residents, including those with severe health conditions. Despite the availability of updated vaccines, there was no record of consent, refusal, or administration for these residents, nor evidence that their responsible parties were informed. This oversight violated the facility's policy and placed residents at risk.
A resident with significant medical conditions, including anoxic encephalopathy and chronic respiratory failure, was found to have the call light placed on the side of the body they could not move. The resident's MDS indicated dependency on assistance and impairment in both upper and lower extremities. RN 1 and the DON confirmed the call light should be on the resident's strong side to ensure it was within reach, as per facility policy.
Two residents' confidentiality was breached when LVNs left computer monitors displaying medication lists visible to passersby. One LVN left a monitor on for over an hour, while another did so twice for shorter periods. Both acknowledged the importance of securing monitors to protect resident privacy, as required by facility policy and HIPAA rules.
A facility failed to update a resident's care plan to include a low air loss mattress (LAL) for pressure ulcer prevention, despite a physician's order. The resident, with multiple health issues and severe cognitive impairment, was dependent on assistance for daily activities. The Director of Nursing confirmed the oversight, noting that care plans are reviewed every shift and should be updated immediately with any changes.
A resident in an LTC facility did not receive the correct dosage of Mylicon due to an error by an LVN, who administered only 0.6 ml instead of the prescribed 2 ml. Additionally, the LVN left the medication unattended on a cart in the hallway, violating the facility's policy requiring medications to be securely stored. The Pharmacy Director and DON confirmed the importance of adhering to these policies to ensure safety.
A resident with a seizure disorder did not have their Keppra level checked as recommended by a pharmacist and approved by a physician. The facility failed to enter the order into the electronic health record, and the charge nurse did not follow up, leading to a deficiency in medication monitoring.
A resident's inhaler was improperly stored at the bedside instead of in a locked compartment, contrary to facility policy. The resident was in a persistent vegetative state and dependent on staff for care. Additionally, medication carts were found unclean, with expired and unnecessary items, violating the facility's policies on medication storage and infection control.
The facility failed to offer and document influenza vaccinations for two residents, both in a persistent vegetative state and with significant medical conditions, during and after the influenza season. Despite the facility's policy to offer vaccinations annually and throughout the season, the residents were not provided with the opportunity to receive the vaccine, nor was there documentation of consent or declination. The Director of Nursing and Infection Control Director acknowledged the oversight, highlighting a lapse in following the facility's infection control policy.
Failure to Secure Electronic Resident Records During Medication Administration
Penalty
Summary
Staff failed to keep resident medical records private and confidential during medication administration observations. On 7/16/2026 at 8:00 AM, an LVN was observed preparing medications for Resident 6, who had diagnoses including chronic respiratory failure, tracheostomy status, dysphagia, seizure disorder, diabetes mellitus, and was in a persistent vegetative state with dependence for multiple activities of daily living. After preparing the medications, the LVN walked away from the computer and left the monitor on with Resident 6’s medical records visible. During additional medication administration observations, LVN 2 walked away from the computer without logging off or turning off the screen after preparing medications for Resident 21, Resident 10, and Resident 14. For Resident 21 and Resident 10, the screen displayed identifying and clinical information including the resident’s name, age, date of birth, room number, medical record number, height, weight, drug allergies, and medications. Resident 21 was documented as comatose and in a persistent vegetative state with dependence for toileting hygiene, shower/bathe self, and personal hygiene. Resident 10 was documented as comatose and in a persistent vegetative state with dependence for toileting hygiene, shower/bathe self, and personal hygiene. For Resident 14, who had diagnoses including acute and chronic respiratory failure, tracheostomy status, and gastrostomy status, LVN 2 was observed twice leaving the computer screen open during medication administration, including once after preparing medications and again after administering medication to obtain a vital sign machine. The screen displayed the resident’s identifying and medication information each time. LVN 2 stated she was not supposed to leave the screen open because it exposed residents’ personal information, and the DON stated staff were supposed to lock the screen before walking away to maintain privacy and confidentiality.
Failure to Maintain Oral and Personal Hygiene
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary assistance to maintain personal and oral hygiene. Resident 7 was admitted with diagnoses including chronic respiratory failure, persistent vegetative state, and candidal stomatitis. The MDS indicated the resident was comatose, in a persistent vegetative state with no discernible consciousness, and dependent on staff for oral hygiene, toileting hygiene, and personal hygiene. The care plan identified a need for assistance with oral care and monitoring of dental condition. During observations, Resident 7 was found lying in bed with the mouth open and the tongue dry, with whitish coating, darkish red spots, and redness noted on the tongue tip. A CNA stated the resident always had the mouth open, the tongue was a little dirty and dried, and oral care was needed right then. The MDS nurse reviewed photos and stated the resident had white spots, darkish red spots, and a dry tongue tip, and noted that oral care needed to be provided very consistently and routinely to prevent recurrence of candida stomatitis or other mouth diseases. The DON stated the resident was unable to perform oral hygiene independently and that poor oral hygiene could result in candida stomatitis coming back. Resident 12 was admitted with respiratory failure and vent dependence, and had diagnoses including dysphagia, quadriplegia, and status epilepticus. The care plan stated the resident was unable to do self-daily hygiene and grooming and that daily personal care needs would be met during the facility stay. The MDS indicated the resident was dependent for oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. During observation, Resident 12 was noted to have dry nasal mucus outside the left nostril, and the resident mouthed words that it made him uncomfortable. The DON stated the resident should have been cleaned and that the dry nasal mucus should not have been on the resident's nose, describing it as a dignity issue that can affect self-esteem.
Respiratory Equipment and Suctioning Not Maintained as Ordered
Penalty
Summary
Respiratory care was not provided as ordered for multiple residents receiving tracheostomy and ventilator-related services. Resident 1 was admitted with hypoxia, chronic respiratory failure, and ventilator dependence, and the MDS indicated the resident received tracheostomy care and was on an invasive mechanical ventilator. On observation, the resident’s t-piece had dry blood and mucus buildup, and this was seen again later the same day. The DON stated the dry blood and mucus could obstruct airflow or become dislodged and block the airway. RT 1 stated the t-piece should be changed twice weekly and as needed, including when blood or mucus is built up, and the facility policy required the suction catheter to be changed twice weekly and as needed to decrease infection risk. Resident 3 was admitted with respiratory failure and ventilatory support via tracheostomy. The MDS indicated the resident was comatose, in a persistent vegetative state/no discernible consciousness, and dependent for multiple activities of daily living, with tracheostomy care and invasive mechanical ventilation. The physician ordered ongoing aerosol at 35% FIO2 with a cool aerosol t-piece and to keep SPO2 greater than 92%. During observation, the resident’s t-piece was not connected to the cool aerosol. The DON stated the t-piece should always be connected to the cool aerosol because the resident could go into respiratory distress if it was not connected, and stated staff were not following the MD order when the t-piece was not connected to the cool aerosol or oxygen. Resident 8 was admitted with acute and chronic respiratory failure with hypoxia, gastrostomy, and tracheostomy status. The MDS indicated the resident was comatose and in a persistent vegetative state/no discernible consciousness, and the care plan identified a potential for infection related to the tracheostomy tube with interventions for tracheostomy care every shift and suction every 2 hours and as needed. The monthly orders also directed tracheal suction every 2 hours and as needed. During observation, mucus was noted in the inner t-piece and was overflowing out of the t-piece down the resident’s body and onto a towel and the call light. The MDS nurse stated the t-piece needed to be changed and the mucus needed to be suctioned, and the DON stated the resident needed suctioning every 2 hours and as needed because of excessive mucus. Resident 14 was admitted with acute and chronic respiratory failure, tracheostomy status, and gastrostomy status. The MDS indicated the resident’s cognitive skills for daily decision making were intact, and the care plan identified a potential for infection related to the tracheostomy tube with tracheostomy care every shift and suction every 2 hours and as needed. During observation, the Yankauer was left uncovered attached to the suction tube and another used Yankauer with dried mucus was left on the resident’s bed. RN 1 stated the Yankauers were dirty, the attached Yankauer was supposed to be kept in a bag, and the used Yankauer should have been discarded rather than left on the bed. The DON stated the Yankauer should be placed in a bag to avoid cross contamination and the detached used Yankauer should be disposed of rather than left on the bed.
Anticoagulant Given Despite Tracheostomy Bleeding
Penalty
Summary
The facility failed to ensure one resident’s drug regimen was free from unnecessary medication use by not monitoring for signs and symptoms of bleeding, not notifying the physician, and not holding Xarelto when tracheostomy bleeding was present. The resident was admitted with hypoxia, chronic respiratory failure, and ventilator dependence, and the MDS indicated the resident was cognitively independent and required assistance with several activities of daily living. The resident also received tracheostomy care and was on an invasive mechanical ventilator. The resident’s care plan identified a risk for bleeding, bruising, and complications of anticoagulant therapy related to Xarelto, with interventions to closely assess and monitor for signs and symptoms of bleeding and report abnormal findings to the MD. A second care plan entry identified a risk for tracheal bleeding associated with routine tracheostomy tube changes and anticoagulant use, with interventions to assess for tracheal bleeding closely and notify the MD. During observations, dried blood and mucus buildup were seen in the suction catheter and t-piece attached to the tracheostomy, and the DON acknowledged the dried blood and mucus in the t-piece. The resident’s active orders included rivaroxaban (Xarelto) 10 mg via feeding tube every afternoon, and the MAR showed Xarelto was administered on 7/15/2026. RN 1 stated the progress notes indicated Xarelto was to be held as needed for tracheostomy bleeding and that the resident had tracheostomy bleeding on 7/13/2026, so the physician should have been notified and Xarelto should have been placed on hold. RN 1 further stated the anticoagulant should have been held on 7/14/2026 and 7/15/2026 but was administered when it should not have been. The DON also stated Xarelto should have been on hold on those dates and should not have been given.
Pureed Diet Served With Crusted Edges
Penalty
Summary
Resident 18 was admitted with chronic respiratory failure, tracheostomy status, and ventilator dependence. The resident’s physician orders dated 9/3/2025 specified a pureed diet with honey thick liquids. The resident’s MDS dated 4/30/2026 indicated moderate cognitive impairment, dependence for eating and multiple activities of daily living, difficulty swallowing, tracheostomy care needs, and use of a therapeutic diet. The care plan identified an alteration in nutrition related to swallowing problems and directed staff to provide the diet as ordered by the physician and assess diet texture and tolerance. During a concurrent observation and interview on 7/14/2026 at 12:45 PM, Resident 18’s meal tray contained pureed chicken with crusted edges, pureed broccoli, and honey thick milk. RN 1 stated the crusted edges on the pureed chicken were hard and could pose a choking hazard for the resident. In later interviews, the LC, DFN, and DON each stated that crusted edges on a pureed diet were not acceptable because they present a choking hazard. The facility’s Diet Order Guideline stated that pureed foods should be easy to swallow, smooth, lump free, not firm, and not sticky.
Food Handling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper food handling practices in accordance with its policy and procedure when a cook with a long beard was observed preparing vegetables without wearing a beard net. During the same observation, the lead cook stated the beard net should have been worn because hair from the beard could fall into the food and contaminate it. The facility’s General Rules - Food and Nutrition Services policy stated that beards, moustaches, and sideburns must be neatly trimmed and that hair nets for these types of hairs should be worn during food preparation. The facility also failed to ensure food items were properly labeled with use-by dates in dry storage and in the refrigerator. In dry storage, pure white sugar, low-sodium brown gravy mix, plain gelatin, sugar-free lemon gelatin dessert mix, strawberry gelatin mix, and raisins were observed without use-by dates. In the refrigerator, jalapeno, green tomatoes, green bell peppers, red potatoes, yam, apples, pineapples, daikon radish, tomatoes, opened bags of bean sprouts, and cilantro were observed without use-by dates. The interior of the ice machine was also observed with brown smudges and black particles. The lead cook and Director of Food and Nutrition stated that food items should be labeled before storage and that the ice machine should be clean; the Director also stated the facility did not have a cleaning log for the ice machine.
Infection Control Failures During G-Tube Care and Resident Contact
Penalty
Summary
Standard infection prevention and control practices were not followed during care for multiple residents who had feeding tubes, tracheostomies, and, in some cases, enhanced barrier precautions ordered. The facility identified failures involving contaminated equipment, hand hygiene, and PPE use during direct resident care activities. For one resident with chronic respiratory failure, tracheostomy status, persistent vegetative state, and a feeding tube, an LVN dropped a medication cup on the floor, picked it up, and placed it on the workstation on wheels. The LVN then placed a G-tube declogger on top of that contaminated cup and was about to place medications into the cup before the surveyor intervened. The LVN later used the same declogger to flush the resident’s G-tube, and stated the cup and declogger should have been discarded after contamination. For another resident with respiratory failure, tracheostomy, and G-tube feeding, the G-tube port was observed with buildup and residue. During incontinent care, a CNA used the same gloves after wiping the resident’s peri-area to touch clean bed sheets and reposition the resident without removing gloves or performing hand hygiene. The CNA stated gloves should have been changed and hand hygiene performed before continuing care. Facility leadership and the infection control supervisor acknowledged that the residue buildup and the glove and hand hygiene lapse were not acceptable under the facility’s infection control policies. Three additional residents with tracheostomy and gastrostomy needs were on enhanced barrier precautions, with care plans directing staff to perform hand hygiene and use PPE per protocol. During medication administration through the G-tube, an LVN entered each of these residents’ rooms wearing a mask and glove but without an isolation gown. The LVN stated she was supposed to wear an isolation gown during these medication passes, and the DON stated PPE such as gloves, gown, and a mask were needed for G-tube medication administration as a high-contact activity.
Failure to Cap G-Tube Feeding Tips When Not in Use
Penalty
Summary
The facility failed to ensure that the purple cone tip of the gastrostomy tube (g-tube) feeding apparatus was capped when not connected to the resident for two sampled residents. For both residents, observations revealed that the g-tube feeding tips were left uncapped and uncovered in their rooms. Record reviews indicated that both residents had orders for continuous tube feeding and care plans specifying the prevention of tube feeding-related infections. The manufacturer's guidelines for the feeding equipment directed that the connector cap should be replaced when not in use. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the g-tube tips should be capped to prevent contamination, as outlined in the manufacturer's instructions, although this requirement was not included in the facility's policy and procedure. Both residents involved had significant medical conditions, including respiratory failure, ventilator dependence, dementia, hypertension, and dysphagia, and were dependent on staff for personal care and nutrition via g-tube. The failure to cap the g-tube tips was observed directly and acknowledged by facility staff as inconsistent with manufacturer guidelines.
Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
Facility staff failed to follow standard infection prevention and control practices for four sampled residents, as observed through direct care activities and confirmed by staff interviews and record reviews. For two residents requiring pulse oximetry monitoring, the respiratory therapist did not sanitize the pulse oximeter and sensor before and after each use, despite handling the device between residents and storing it in a shirt pocket. Both the infection prevention director and the director of nursing confirmed that the facility's policy required sanitizing the device before and after use, and that failure to do so could transmit infectious organisms between residents. In another instance, a registered nurse did not don a gown while administering medications and checking the gastrostomy tube of a resident with an indwelling device, despite the facility's policy requiring enhanced standard precautions, including gown use, for such procedures. The nurse acknowledged the omission and stated that PPE is necessary to prevent contamination and infection from bodily fluids. The infection prevention director and director of nursing both confirmed that a gown should have been worn to prevent cross-contamination. Additionally, during tracheostomy care for another resident, a registered nurse failed to change gloves and perform hand hygiene between tasks, placed used dressings and an inner cannula on the resident's bedside table alongside clean supplies, and did not sanitize the table after disposing of the used items. The nurse admitted to not following the facility's policy for glove changes and proper disposal of used supplies. The infection prevention director and director of nursing confirmed that these actions were inconsistent with facility policies and could result in contamination of the environment and equipment.
Unsanitary Sink Condition in Resident Room Due to Damaged Surface
Penalty
Summary
A deficiency was identified when a resident's room was found to have a sink with the Formica surface stripped off, leaving exposed rough wood. Observations confirmed the unsanitary condition, and interviews with facility staff, including the Director of Nursing (DON), Maintenance Assistant, and a Licensed Vocational Nurse (LVN), acknowledged the presence of chipped and water-damaged wood. The exposed wood was noted to be a potential site for mold growth and was considered unacceptable by staff due to the risk of infection and possible harm to both residents and staff. The resident involved had a history of acute chronic hypoxic respiratory failure, hypertension, and seizures, and was assessed as severely impaired in cognitive skills and dependent on staff for daily living activities. The facility's own policy and procedure for management of the environment of care emphasized the importance of maintaining a safe, comfortable, and appropriately furnished environment, which staff admitted was not met in this instance.
Failure to Set Low Air Loss Mattress Correctly for Pressure Ulcer Management
Penalty
Summary
The facility failed to follow its policy and procedure on pressure ulcer prevention and wound management for one resident by not ensuring that the low air loss (LAL) mattress was set according to the resident's weight. The resident, who had a stage 4 sacral/coccyx pressure ulcer and was dependent on care for activities of daily living, was observed with the LAL mattress set at a firmness level appropriate for a much heavier individual (setting 4 for 175 lbs), while the resident's actual weight was 123 lbs, which required a lower setting (2 to 3). This discrepancy was confirmed through interviews with nursing staff, who acknowledged that the mattress was not set correctly and that this could impact the effectiveness of the pressure injury management. Record reviews showed that the resident's care plan and facility policy specifically required the use of the LAL mattress per manufacturer guidelines, including setting the firmness based on the resident's weight. Staff interviews and documentation confirmed that these guidelines were not followed, and the care plan intervention to educate staff on proper mattress settings was not implemented. The Director of Nursing also acknowledged that the failure to follow the care plan and manufacturer’s instructions could negatively affect the resident’s wound healing.
Failure to Cover Midline Catheter Injection Ports with Swab Caps
Penalty
Summary
A deficiency was identified when a resident with a midline catheter featuring two lumen injection ports did not have a swab cap covering the ports when not in use, as required by facility policy. The resident, who had diagnoses including anemia, seizure disorder, and quadriplegia, was severely cognitively impaired and dependent on staff for all activities of daily living. The resident's care plan and active orders specified that injection ports should be covered with swab caps and changed daily or as needed after use, in accordance with infection prevention protocols. During observations, it was noted that the midline catheter's injection ports were left uncapped. Interviews with nursing staff and the DON confirmed that the ports should have been covered with swab caps to prevent infection, and that this was the facility's established practice. The facility's policy also indicated that injection caps should be changed whenever removed. The failure to follow these protocols was directly observed and acknowledged by staff.
Incomplete Administration of G-Tube Medications Due to Improper Mixing
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to ensure the complete administration of two prescribed medications, glycopyrrolate and ascorbic acid (Vitamin C), to a resident with a G-tube. The LVN prepared the medications by adding water to the medication cups but did not stir or ensure the medications were fully dissolved before administration. After administering the medications via the resident's G-tube, a white pasty residue was observed remaining in the cups, indicating that not all of the medication had been delivered to the resident. The resident involved had a history of respiratory failure, a tracheostomy, and was dependent on a G-tube for feeding due to swallowing difficulties. The resident was assessed as having severely impaired cognitive skills and required maximal assistance with daily activities. Physician orders were in place for the administration of glycopyrrolate and Vitamin C via the feeding tube, with specific dosages and frequencies. During interviews, the LVN acknowledged that the medications were not completely dissolved and that the resident did not receive the full prescribed doses. The Director of Nursing (DON) confirmed that facility policy required medications to be mixed and fully dissolved before administration, and that no residue should remain in the medication cups. The failure to follow these procedures resulted in the resident not receiving the entire dose of the prescribed medications.
Medication Error Rate Exceeds Acceptable Threshold Due to Incomplete Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 7.41 percent during a medication pass observation. Specifically, two medication errors were identified out of 27 opportunities, involving the incomplete administration of glycopyrrolate and ascorbic acid (Vitamin C) to a resident. The errors occurred when the nurse did not ensure the medications were fully dissolved and administered, leaving a white pasty residue in the medication cups after administration via the resident's G-tube. The resident involved had significant medical needs, including respiratory failure, a tracheostomy, and a G-tube for feeding, and was assessed as having severely impaired cognitive skills and high dependence on staff for daily activities. Physician orders required the administration of glycopyrrolate and Vitamin C via the feeding tube, but the nurse failed to properly mix and dissolve the medications before administration, resulting in the resident not receiving the full prescribed doses. Both the nurse and the Director of Nursing confirmed during interviews that the medications were not fully administered as required, and that facility policy mandates medications be properly mixed and fully delivered with no visible residue left in the cups. The failure to follow these procedures led to the resident not receiving the complete doses of their prescribed medications.
Improper Food Handling and Equipment Sanitation
Penalty
Summary
Surveyors observed multiple failures in food handling practices within the facility's kitchen. Specifically, a box of Kosher salt was found unsealed, a container of soy sauce had drippings on it, and a container of Japanese curry powder was not properly sealed. Additionally, the can opener in use was chipped and rusted. These observations were confirmed during interviews with the Registered Dietitian (RD), who acknowledged that food containers should be properly sealed and free of drippings to prevent contamination, and that the can opener's condition was unacceptable due to the risk of contamination. Further review of the facility's policies and procedures with the Kitchen Supervisor (KS) revealed that the facility's guidelines require food items to be stored appropriately, covered, and labeled, and that all work areas and equipment must be kept clean and in good repair. The KS confirmed that the observed practices did not align with these policies, as food items were not properly sealed or stored, and equipment was not maintained in a sanitary condition.
Failure to Use Dignity Bags for Catheter Drainage
Penalty
Summary
The facility failed to provide dignity bags for the urinary catheter drainage bags of two residents, compromising their dignity and privacy. Resident 14, who was comatose and dependent on assistance for daily activities, was observed with an exposed Foley catheter drainage bag in their private room. The Director of Nursing (DON) acknowledged that dignity bags should be used even in private rooms if the catheter bag is visible to visitors, indicating a lapse in adhering to the facility's policy on patient dignity and privacy. Similarly, Resident 126, who had severely impaired cognitive skills and was dependent on assistance, was observed with an exposed Foley catheter bag while having visitors in their private room. The catheter bag was also visible from the hallway. A registered nurse stated that the dignity bag was not used to allow easy monitoring of the urine, but the DON later confirmed that the catheter bag should not be visible to visitors, highlighting a failure to respect the resident's privacy and dignity as per the facility's policy.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to reflect discussions and documentation of advance directives for six out of eight sampled residents. This deficiency was identified through interviews and record reviews, revealing that the facility did not provide or document the provision of advance directive information to residents or their representatives. This oversight potentially violated the residents' rights to be fully informed about their options to formulate advance directives, which are crucial for ensuring that their healthcare preferences are respected. Resident 3, who was admitted with chronic respiratory failure, a chronic vegetative state, and anoxic encephalopathy, had no advance directive documented in their medical records from March 2023 to June 2024. Similarly, Resident 16, who was comatose and dependent on a ventilator, also lacked documentation of advance directive information in their records. Resident 21, with moderate cognitive impairment and ventilator dependence, had no advance directive on file, and there was no evidence that such information was provided to the resident or their representative. The deficiency extended to Residents 22, 23, and 19, all of whom had significant medical conditions and dependencies, yet lacked documented advance directives in their medical records. Interviews with the Director of Nursing (DON) confirmed the absence of advance directive forms in both paper and electronic records for these residents. The facility's policy required that advance directives be offered and documented, but this was not adhered to, leading to the potential bypassing of residents' healthcare preferences.
Deficiencies in Gastrostomy Tube Feeding Practices
Penalty
Summary
The facility failed to implement proper gastrostomy tube (GT) feeding practices for two residents, leading to deficiencies in their care. For Resident 21, the facility did not properly label the opened gastrostomy feeding solution bottle at the bedside. This oversight had the potential to result in delayed feedings and incorrect total feeding amounts received by the resident. Resident 21 was admitted with multiple diagnoses, including chronic respiratory failure, ventilator dependency, and quadriplegia, and was dependent on a feeding tube for nutrition. Observations revealed that the feeding solution was set up prior to the allowed time, and the label on the Jevity formula was dated and timed incorrectly, which could lead to confusion about when the feeding should be administered. For Resident 19, the facility failed to ensure that the GT water bag flush was labeled completely, including the total number of hours as per the physician's order. This deficiency posed a risk of the water flush bag not being replaced on time, potentially leading to complications. Resident 19, who was also dependent on a ventilator and had a history of anoxic encephalopathy and ischemic stroke, required careful management of their feeding and hydration needs. During an observation, it was noted that the water bag was not labeled, and the only information present was the rate of 50 cc per hour written directly on the bag. Interviews with nursing staff and the Director of Nursing (DON) highlighted the importance of proper labeling to ensure adherence to physician orders and prevent errors. The facility's policies and procedures required that feeding solutions and water bags be labeled with the date and time to ensure they were changed and administered correctly. However, these practices were not followed, leading to the deficiencies observed during the survey.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for three residents, leading to potential risks of respiratory infections. Resident 21's nasal cannula tubing was not changed weekly as required, and there was no date label on the tubing to indicate when it was last changed. The Director of Nursing (DON) acknowledged that the facility lacked a policy for changing nasal cannula tubing weekly, which could prevent infections. The Respiratory Therapist stated that nasal cannula tubing should be changed every three days or as needed, but this was not consistently documented or followed. For Resident 19, the suction tubing connected to the ventilator was observed touching the floor, which was identified as a potential source of respiratory infection due to contamination from the dirty floor. Licensed Vocational Nurse 2 (LVN 2) confirmed that the suction tubing should not be in contact with the floor and needed to be changed immediately to prevent infection. Similarly, Resident 1's suction tubing was also found lying on the floor, posing a similar infection risk. The DON reiterated that medical equipment should not touch the floor due to infection control concerns. The facility's policy on respiratory services indicated that all tubing should not be in contact with the floor, highlighting a failure to adhere to established infection control procedures.
Deficiencies in Food Handling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as observed during a survey. Several food items in the kitchen, including vinegar, turmeric, cinnamon sticks, black pepper, and cooking wine, were found without labels indicating the open date and use-by date. The Registered Dietician (RD) confirmed that these items should have been labeled and that the cinnamon sticks were expired and should have been discarded. Additionally, a container of salsa was improperly stored with labeling supplies, and the RD stated it needed to be discarded due to improper storage. The facility's policy requires all food items to be labeled with the open date and expiration date, which was not followed in these instances. Further observations revealed issues with the facility's drainage system and food storage. The Engineer Supervisor (ES) noted that the drainpipe did not meet the required one-inch gap from the drain, which is a guideline specified in the facility's safety policies. In the walk-in freezer, several food items, including waffles, chicken patties, green beans, and bacon bits, were found without labels indicating the item name, open date, and use-by date. The Lead confirmed that these items should have been labeled and discarded if the expiration date was not known. Additionally, trash and debris were found in the kitchen floor drain, which the RD stated should have been clear to allow proper drainage.
Failure to Educate, Offer, and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to provide education, offer, and document COVID-19 vaccinations for three of five sampled residents, placing them at risk for possible infection. Resident 15, who was admitted to the facility with chronic respiratory failure and other serious conditions, had not received an updated COVID-19 vaccination since 2021. There was no documentation of consent, refusal, or administration of the updated vaccine, nor any indication that the resident's responsible party was informed or offered the vaccine. Similarly, Resident 22, who was dependent on a ventilator and had other significant health issues, had not received an updated COVID-19 vaccination since 2021. The records lacked any documentation of consent, refusal, or administration of the updated vaccine, and there was no evidence that the resident's responsible party was educated or offered the vaccine. The Director of Nursing confirmed these omissions during an interview. Resident 23, who was also in a persistent vegetative state and had multiple health conditions, had no record of receiving any COVID-19 vaccination. The facility's policy required that all residents be offered the vaccine and that any declinations be documented, but this was not followed. The Infection Control Director acknowledged that the updated vaccine was available and should have been offered to eligible residents, but this was not done for the sampled residents.
Call Light Accessibility Deficiency for a Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the residents, identified as Resident 19, as per the facility's policy and procedure. Resident 19 was admitted with significant medical conditions, including anoxic encephalopathy, chronic respiratory failure, and was ventilator-dependent. The resident's Minimum Data Set (MDS) indicated intact cognitive skills but showed dependency on assistance for various activities and impairment in both upper and lower extremities. During an observation, it was noted that the call light was placed next to the resident's left arm, which he could not move, as confirmed by the resident and Registered Nurse 1 (RN 1). RN 1 acknowledged that Resident 19 could only use his right hand and stated that the call light should be placed near the resident's right hand to ensure it was within reach. The Director of Nursing (DON) also confirmed that the call light should be on the resident's strong side to allow them to call for assistance. The facility's policy on the Patient Call Light System emphasized the importance of having the call light within reach to address patient needs promptly. This oversight had the potential to prevent Resident 19 from calling for assistance, thus not meeting the resident's needs and preferences.
Confidentiality Breach of Residents' Medical Records
Penalty
Summary
The facility failed to protect the confidentiality of personal and medical records for two residents, violating their rights to privacy. For Resident 1, the deficiency occurred when a Licensed Vocational Nurse (LVN 2) left a computer monitor on in the hallway outside the resident's room, displaying the resident's medication list. This occurred from 4:47 PM to 5:51 PM, during which time the LVN entered the resident's room without securing the monitor. The LVN acknowledged forgetting to turn off the monitor, which is necessary to comply with HIPAA privacy and security rules. Similarly, for Resident 14, another LVN (LVN 1) left a computer monitor on by the resident's door, displaying the medication list visible to passersby. This happened twice, once from 5:25 PM to 5:29 PM and again for four minutes while the LVN checked the resident's gastrostomy tube and administered medication. The LVN admitted to not turning off the monitor, recognizing the importance of doing so for resident privacy. The facility's policy requires maintaining the confidentiality and security of Protected Health Information (PHI) in any form, which was not adhered to in these instances.
Failure to Revise Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to revise the comprehensive care plan for the prevention of pressure ulcers for one of the residents, identified as Resident 126. The resident was admitted to the facility with several active diagnoses, including cerebral vascular accident, chronic respiratory failure, and hypertension, and was noted to have severely impaired cognitive skills. The Minimum Data Set (MDS) indicated that Resident 126 was dependent on assistance for various activities of daily living. Despite these needs, the care plan dated 6/17/2024 did not include interventions for the use of a low air loss mattress (LAL), which was ordered by the physician on 6/25/2024 for pressure injury management. During an interview with the Director of Nursing (DON), it was confirmed that the LAL should have been included in the care plan as part of the pressure injury intervention. The DON acknowledged that the care plan is reviewed every shift and should be revised immediately if there are any changes, a responsibility typically handled by the charge nurses. The facility's policy on pressure injury prevention and management, revised in 6/2019, mandates that appropriate care should be planned and documented in the patient's care plan, which was not adhered to in this case.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, identified as Resident 21, by not ensuring the correct dosage of Mylicon was administered according to the physician's order. During a medication pass observation, a Licensed Vocational Nurse (LVN 3) was observed preparing and administering only 0.6 ml (40 mg) of Mylicon instead of the prescribed 2 ml (80 mg) via the resident's gastrostomy tube. This error was acknowledged by LVN 3, who admitted that the resident would not receive the intended relief from abdominal gas with the incorrect dosage. Additionally, the facility did not ensure the safe storage of medications during administration. LVN 3 left the Mylicon medication unattended on top of the medication cart in the hallway while administering other medications to Resident 21 in their room. This practice was against the facility's policy, which requires medications to be stored and locked to prevent unauthorized access and potential safety risks. The Pharmacy Director and Director of Nursing confirmed that medications should not be left unattended and must be stored securely to prevent loss, theft, or misuse. The facility's policies on medication administration and storage were not adhered to, leading to potential safety concerns for residents and visitors in the unit.
Failure to Follow Pharmacist's Recommendation for Medication Monitoring
Penalty
Summary
The facility failed to act upon a pharmacist's recommendation, which was approved by the physician, during the Medication Regimen Review (MRR) for a resident. The pharmacist recommended checking the Keppra level for a resident who was on Keppra medication for a seizure disorder. The physician agreed to this recommendation, but the necessary blood test was not performed, which could lead to adverse consequences due to potential incorrect dosage of the medication. The resident in question was admitted with chronic respiratory failure, status post tracheostomy, and a seizure disorder. The resident was comatose and in a persistent vegetative state, dependent on staff for all activities of daily living. The resident's last Keppra level was checked in January 2024, and the pharmacist recommended another check in May 2024, which was not carried out. The facility's policy required licensed personnel to recap all current orders at the monthly team conference and resolve any discrepancies, but this was not done. Interviews with the pharmacist, pharmacy director, and director of nursing revealed that the order for the Keppra level check was not entered into the electronic health record, and the charge nurse did not follow up on the physician's order. The director of nursing acknowledged that the Keppra level should have been ordered immediately after the MRR meeting, but this did not occur, resulting in the deficiency.
Medication Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to store a resident's respiratory inhaler in accordance with its policy, which required medications to be stored in locked compartments. The inhaler was observed in a clear bag hanging on the wall at the head of the resident's bed. The resident, who was in a persistent vegetative state and dependent on staff for all activities, had an order for Albuterol inhaler to be administered every six hours. Despite this, the inhaler was not stored in the medication room as per the standard practice, and there was no order to keep it at the bedside. The Pharmacy Director confirmed that inhalers should be stored in the medication room, especially since the residents were not alert to administer the inhalers themselves. Additionally, the facility's medication carts were found to be unclean and contained expired and unnecessary items. Observations revealed dust, adhesives, and discoloration on the carts, as well as expired medical supplies and non-medical items like pens and rubber bands in the drawers. The Director of Nursing and a pharmacist acknowledged the need for regular cleaning of the medication carts and the removal of expired items to prevent contamination and infection. The facility's policies required medications to be stored in lockable cabinets and for all expired items to be removed from inventory. However, these policies were not followed, leading to the potential for unauthorized access to medications and the risk of infection due to unclean equipment. The staff admitted to not cleaning the medication carts regularly due to being busy, which contributed to the deficiencies observed.
Failure to Offer and Document Influenza Vaccination
Penalty
Summary
The facility failed to provide education, offer, and document influenza immunization for two residents, placing them at higher risk of complications from the influenza disease. Resident 22, who was admitted to the facility in May 2024, had a history of respiratory failure with ventilator dependence, Type 2 Diabetes Mellitus, seizure disorder, and cerebrovascular accident. The resident was comatose and in a persistent vegetative state, fully dependent on assistance for daily activities. Despite these conditions, there was no record of influenza vaccination being offered or administered to Resident 22 since their last vaccination in September 2021. The Director of Nursing (DON) confirmed that the influenza vaccination was not offered to Resident 22 due to their admission being after the typical influenza season, and there was no documentation of consent or declination. Similarly, Resident 23, who was readmitted during the influenza season in March 2024, also did not have any record of being offered or receiving the influenza vaccination. Resident 23 had diagnoses of respiratory failure with ventilator support, cerebrovascular accident, and atrial fibrillation, and was also comatose and in a persistent vegetative state. The DON acknowledged that there was no documentation of the influenza vaccination being offered or declined for Resident 23, despite the resident being readmitted during the influenza season. Interviews with the Infection Control Director (ICD) and the DON revealed that the facility's policy was to offer the influenza vaccination annually and throughout the influenza season. However, the policy was not followed for Residents 22 and 23. The ICD emphasized the importance of offering the influenza vaccination to all residents, regardless of the season, to protect them from complications. The facility's policy indicated that newly admitted residents should be assessed for prior receipt of the influenza vaccine and offered the vaccination if not previously administered, but this was not documented for the two residents in question.
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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.
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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 |
| Sunny Village Care Center | 0.9 mi | ★★★★★ | 23 | 0 |
| Royal Gardens Healthcare | 1.1 mi | ★★★★★ | 32 | 0 |
| Alhambra Healthcare & Wellness Centre, Lp | 1.1 mi | ★★★★★ | 15 | 0 |
| Royal Vista Care Center | 1.8 mi | ★★★★★ | 33 | 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 October 2026) and official state health department websites.