Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alhambra Post Acute during CMS and state inspections, most recent first.
A resident with a CRT-D and an order for every-shift pacemaker monitoring reported that the pacemaker defibrillator monitor was serviced for poor signal, then could not be located and was not being monitored at the nurse’s station. The resident contacted the Ombudsman, who found the monitor missing from the nurse’s station and later located it in a supply closet near the station, unplugged and out of staff view. The DON stated the monitor was supposed to remain visible for monitoring, and the DSD said it may have been moved during cleaning because it looked like a router.
Medication administration errors exceeded the allowed rate, with surveyors identifying 5 errors in 27 opportunities. A nurse crushed and mixed four ordered meds for a resident with a G-tube and gave them together instead of separately, and also used tablet Ascorbic acid instead of the ordered liquid form. Another nurse gave a resident Vitamin D 400 IU tablet orally instead of the ordered Cholecalciferol 1000 units daily. Staff interviews confirmed the errors and that the meds were not given as ordered.
Expired medications for a resident with dementia and severe cognitive impairment were found on the south med cart, including Haldol, Olanzapine, Amlodipine, Hyoscyamine, and Ondansetron. In the med storage room, the DON found an opened box of expired 1 ml syringes and an opened PPD vial in the refrigerator with no open date label; the DON and PC stated the items should have been dated or removed per policy.
Expired Dessert Sauces Found in Dry Storage: Three bottles of [NAME] Designer Dessert Sauce were found in the dry food storage area past their use-by dates, including one opened bottle and two unopened bottles. The DM stated daily shelf checks were supposed to remove expired items, but staff missed these products and no logs were provided to verify the checks. The RD's monthly inspection report also noted multiple foods passed use by date, and the ADM stated the DM was responsible for ensuring no expired food items remained in the kitchen.
Improper Storage of Food Brought by Family/Visitors: A resident’s unopened preserves, opened jam, and sealed fruit cups were stored in a plastic container with ice chips, then later in melted ice water with one fruit cup submerged. The resident said she had asked for a refrigerator for her food but was told none was available, and staff stated there was no system to monitor the ice or keep it consistently maintained. The facility policy required perishable foods left for later use to be stored in tightly covered containers in a refrigerator.
Dignity: A resident with moderate impaired cognition and a care plan for 1:1 feeding and aspiration precautions was referred to as a “feeder” by an AC during lunchroom meal service. The AC said the wording came out wrong, and the DSD stated that staff should not use terms like “feeders” when referring to residents and should address them respectfully.
Inadequate indication for Haloperidol use: A resident with dementia and severe cognitive impairment was ordered Haldol for agitation, including scheduled doses throughout the day. Staff stated the resident was not a danger to self or others and would calm when spoken to, while the CP twice requested an approved indication for the medication. The DON confirmed the resident did not have schizophrenia and said agitation was not an appropriate indication for Haldol; the MAR listed anxiety and paranoid behavior without documenting that those behaviors were observed.
Arbitration Agreement Not Explained in an Understandable Manner: A resident with severe cognitive impairment and a DPOA/rep representative was involved in an arbitration agreement process that was not shown to have been explained in a way they understood. The resident said the rep signed all admission documents, while the rep did not remember being told about the arbitration process or signing the agreement. The MD said he and the AD were responsible for explaining and obtaining signatures, but the record showed the resident signed the agreement despite later physician documentation stating the resident lacked capacity to make medical decisions.
Insufficient Room Space in Multiple Resident Rooms: Sixteen resident rooms with multiple beds were observed to provide less than the required square footage per resident, with some 3-bed rooms measuring 200 sq. ft. total and some 2-bed rooms measuring 140 sq. ft. total. The report noted that care could still be provided, no heavy equipment interfered with care, residents had adequate personal space and privacy, and no complaints or negative consequences were identified.
A cognitively intact resident informed the ADM and IDT of a desire to transfer to a SNF in another county to be closer to family and expressed dissatisfaction with remaining in the current facility. An IDT note documented the resident’s preference, and the SSD reported having contacted two SNFs about possible placement, but could not produce any documentation of referrals or outreach efforts. Despite a resident rights policy stating that residents may exercise their rights to the fullest extent possible, there was no documented evidence that the facility actively assisted the resident in locating an alternative placement.
A resident with muscular dystrophy, intact cognition, and a PHQ-9 score indicating moderately severe depression requested talk therapy through the Ombudsman, who relayed the request to the SSD and then verbally to the DON. The DON later reported not becoming aware of the request until receiving an Ombudsman email weeks later, and the referral for psychological services was not initiated until much later, resulting in a 45-day delay before the resident was seen by a psychiatrist or psychologist. During this time, the resident reported auditory disturbances, insomnia, low energy, and was observed sitting quietly in activities with minimal interaction, despite a facility policy requiring provision of needed behavioral health services.
The facility failed to address grievances from residents' group meetings, including noise from CNAs, uncomfortable room temperatures, and cold food. The Activities Director did not communicate these concerns for follow-up, and the Administrator lacked a proper paper trail for grievance resolution, leading to potential emotional distress among residents.
Three residents in the facility were administered antipsychotic medications without adequate indications. A resident with dementia was given Seroquel for wandering, another was prescribed Zyprexa for schizophrenia despite not having the diagnosis, and a third resident received Seroquel without target behavior monitoring. The facility's policy on antipsychotic use was not followed, leading to potential unnecessary medication administration.
The facility failed to maintain sanitary conditions for food storage, with several items in the refrigerator not properly dated and labeled. Observations included discolored cauliflower, withered parsley, and unlabeled watermelon. Temperature logs for the refrigerator and a chest freezer were incomplete or missing. Interviews revealed that new kitchen staff were still in training, despite having received training on food handling procedures.
The facility failed to maintain a sanitary garbage and refuse storage area, as a dumpster was observed overflowing with trash bags and not covered with a lid. The Administrator noted that the contracted company staff did not empty the dumpster, and the Housekeeping Supervisor mentioned that the path to the dumpster was blocked. The facility's policy requires safe and appropriate disposal of waste.
The facility's dining and activity room lacked adequate space for 42 residents, limiting their independent functioning during meals and activities. Observations showed the room was crowded with residents in wheelchairs and those using walkers, requiring staff to rearrange tables to accommodate them. Interviews with a CNA and residents highlighted concerns about congestion, potential falls, and difficulties in positioning residents, with one resident dining in her room due to space limitations.
A facility failed to complete the required Level I PASARR assessment for a resident, which is necessary to ensure appropriate placement in nursing homes. The deficiency was discovered during a review of the resident's admission record, revealing that the screening was not conducted. The DON, who was newly hired at the time, could not provide the documentation and was unaware of the oversight. The Admission Coordinator, also hired after the resident's admission, was not informed about the missing PASARR screening.
A resident with poor cognition and wandering behavior experienced repeated unwitnessed falls in an LTC facility. Despite interventions like verbal reminders and redirection, the resident continued to fall, sometimes resulting in injuries. The facility's failure to provide adequate supervision and effective interventions contributed to these incidents.
A resident with dementia was observed wandering into other residents' rooms, taking belongings, and causing distress. Despite having a care plan, the facility failed to implement effective interventions to address this behavior. Staff reported difficulty in redirecting the resident, and other residents expressed dissatisfaction with the situation.
The facility failed to properly label and dispose of medications for two residents, leading to deficiencies in medication management. One resident had Latanoprost Ophthalmic Solution bottles that were either unlabeled or stored beyond their use-by date, while another resident's Atropine Sulfate Ophthalmic Solution lacked proper labeling. The DSD and DON acknowledged the labeling errors, which violated the facility's medication labeling and storage policy.
A resident's suction machine cannister lid was not changed for 18 days, contrary to the facility's policy of weekly changes. The resident, with an esophageal obstruction, had a cannister filled with phlegm, and staff could not specify the last change date. The Infection Preventionist and DON acknowledged the lapse, which increased infection risk.
A survey identified a deficiency in room size requirements at the facility, with sixteen rooms providing less than the required 80 square feet per resident. Despite this, observations indicated sufficient space for care, no interference from equipment, and no resident complaints about space or belongings. A room size waiver was recommended.
A facility failed to ensure a follow-up call and/or assessment was done to verify that DME was provided to a resident as ordered. The resident, who had hemiplegia and hemiparesis following a cerebral infarction, was discharged without the necessary DME. The Social Service Director did not verify the delivery before discharge and failed to follow up with the home health agency. The Director of Nurses confirmed that the resident should not have been discharged without the necessary equipment to ensure safety.
A resident with muscle weakness and paraplegia did not receive bathing assistance for two extended intervals, despite repeated requests and complaints to the DON. The lack of care led to emotional distress and a feeling of lost dignity for the resident.
Pacemaker Defibrillator Monitor Not Kept in View at Nurse’s Station
Penalty
Summary
The facility failed to ensure that one resident’s pacemaker defibrillator monitor was adequately monitored at the nurse’s station when the device could not be located. The resident had a Cardiac Resynchronization Therapy Defibrillator (CRT-D) and was ordered to have pacemaker status monitored and abnormalities or signs of malfunction reported every shift. The resident was cognitively intact with a BIMS score of 15 out of 15 and reported that the monitor had been serviced because of poor signal and that staff had moved it from the area where the technician placed it. The resident stated the monitor was later unable to be found and that they contacted the Ombudsman because staff were not monitoring it and it was not at the nurse’s station. The resident also stated the monitor had been found under papers on the floor of the nurse’s station and out of staff view at times, which made the resident feel ignored when concerns were raised. The Ombudsman reported that during an onsite visit the monitor was missing from the nurse’s station, and after searching the unit it was found in a supply closet near the nurse’s station. The DON stated the monitor was supposed to be visible at the nurse’s station for monitoring, but it was found in the supply room near the nurse’s station, unplugged and out of view after the nurse’s station was cleaned. The DON was unsure how long it had been there, and the DSD stated it may have been moved during cleaning because it looked like a router. The facility’s neglect policy stated neglect includes failure to provide goods or services a resident requires when the facility is aware of, or should have been aware of, the need.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with surveyors identifying 5 medication errors out of 27 opportunities for an error rate of 18.5%. The deficiencies involved medication administration for two residents and were observed during medication pass observations and confirmed through record review and staff interviews. For one resident with a gastrostomy tube and physician orders for Apixaban 5 mg twice daily, Ascorbic acid liquid 500 mg/5 ml daily, Atorvastatin calcium 40 mg daily, and Spironolactone 25 mg daily via G-tube, RN 1 crushed four medications, mixed them together in one cup, and administered them as a single dose through the G-tube. The nurse also used tablet form Ascorbic acid instead of the ordered liquid form. The resident’s order also directed that the tube be flushed before medication administration, between each medication, and after administration. The Director of Staff Development stated the medications should have been given separately to avoid clogging and drug interactions, and RN 1 acknowledged she should have followed the order for liquid Vitamin C. For another resident with diagnoses including right shoulder osteoarthritis, the physician ordered Cholecalciferol 1000 units daily. During observation, RN 2 administered Vitamin D 400 IU tablet orally instead of the ordered cholecalciferol dose and form. RN 2 acknowledged the wrong form and dosing were given, and the DON and pharmacist consultant both stated the resident should have received the ordered cholecalciferol dose. The facility policy required medications to be administered as prescribed and the administering nurse to verify the right resident, medication, dosage, time, and route.
Expired Medications and Improperly Stored Biologicals
Penalty
Summary
Expired medications for one sampled resident were found stored on the south medication cart during a concurrent observation and interview with the DSD. The medications included Haldol 1 mg tablets, Olanzapine 2.5 mg tablets, Amlodipine 5 mg tablets, Hyoscyamine 0.125 mg tablets, and Ondansetron 4 mg tablets, all of which had expired on 4/3/26 or 4/4/26. The resident had been admitted with diagnoses including dementia, mood disturbance, and anxiety, and the MDS indicated severe cognitive impairment. The DSD stated the expired medications should have been disposed of. During observation in the medication storage room, an opened full box of 1 ml syringes was found with an expiration date of 3/3/26, and the DON stated it should have been disposed and should not have been in the medication storage room. In the medication storage room refrigerator, an opened multidose PPD vial was found without an open date label. The DON stated the vial should have been labeled with the open date, and the pharmacist consultant stated it should have been dated when first opened and was only good for 30 days from the date opened. The facility policy stated outdated medications or biologicals are to be returned or destroyed and opened multidose vials are to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Expired Dessert Sauces Found in Dry Storage
Penalty
Summary
The facility failed to ensure safe food handling and storage practices when three bottles of [NAME] Designer Dessert Sauce were found in the dry food storage area past their use-by dates. During the initial kitchen tour, an opened bottle of Kiwi Lime flavor with a use-by date of 4/4/26 was observed, along with an unopened bottle of Mango flavor with a use-by date of 3/14/26 and an unopened bottle of [NAME] Chocolate flavor with a use-by date of 4/2/26. During follow-up interviews and record review, the Dietary Manager stated that dry food shelves are checked daily for expired or past use-by date items, but staff missed the three dessert sauces and no evidence or logs were provided to show the daily checks were completed. The Registered Dietitian stated that monthly kitchen inspections are completed and the March 2026 inspection report indicated multiple foods passed use by date. The Dietary Manager stated the dessert sauces should not have been kept in storage because they could be mistakenly consumed by residents, and the Administrator stated it was the Dietary Manager's responsibility to ensure there were no expired or past use-by date food items in the kitchen.
Improper Storage of Food Brought by Family/Visitors
Penalty
Summary
The facility failed to ensure a safe and sanitary method for storing food brought to a resident by family and visitors. Resident 42, who was admitted in March 2026, had one unopened jar of blueberry preserves, one opened jar of grape jam, and two sealed fruit cups observed in a rectangular plastic container filled with ice chips in the resident’s room. During the observation, the resident stated she used the jams for peanut butter crackers and had asked for the jam to be placed in a refrigerator, but she was told there was no refrigerator available for residents to store food. On a later observation, the same jars of jam were found in a plastic rectangular container containing melted ice water, and one fruit cup was observed submerged under the water. The DON asked staff to move the container away. CNA 1 stated the resident always asks for ice to keep the jam cold and that staff did not notice when the ice melted into water. RN 2 stated there was no system or log to monitor temperature or ensure ice was consistently maintained in the container. The facility policy stated that perishable foods brought by family or visitors and left for later use are to be stored in re-sealable containers with tightly fitting lids in a refrigerator.
Dignity: Resident referred to as a feeder during meal service
Penalty
Summary
The facility failed to maintain Resident 51’s dignity when staff referred to the resident as a “feeder” in the lunchroom during meal service. Resident 51 was admitted to the facility and had a BIMS score of 9 out of 15, indicating moderate impaired cognition. The resident’s care plan indicated a need for 1:1 feeding and aspiration precautions. During an observation in the lunchroom, Activity Coordinator 1 was heard using the term “feeder” to describe Resident 51 while the resident was seated at the dining table. In an interview shortly afterward, AC 1 stated the wording came out wrong and that the appropriate way to refer to the resident was to indicate whether the resident needed assistance with meals. The Director of Staff Development stated that the term “feeders” should not be used when referring to residents and that staff are expected to address individuals as residents, clients, or patients. The facility’s dignity policy stated that residents must be cared for in a manner that promotes self-worth and self-esteem and that staff must speak respectfully and not label residents by room number, diagnosis, or care needs.
Inadequate indication for Haloperidol use
Penalty
Summary
The facility failed to ensure that one sampled resident had adequate indications for the use of Haloperidol. Resident 6 was admitted with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and the MDS dated 1/23/26 indicated severe cognitive impairment. During observations on 4/20/26 and 4/21/26, the resident was awake, quiet, lying in bed, and later sleeping in bed. Physician orders dated 4/23/26 showed Haloperidol 1 mg by mouth every morning and at bedtime for agitation, and Haloperidol 2 mg by mouth in the afternoon for agitation before lunch. The CNA stated the resident had no behavior of being a danger to herself or others and that yelling would calm when staff talked to her. The consultant pharmacist twice requested an approved indication for the Haldol use, and the DON stated the resident did not have schizophrenia, that schizophrenia had been documented in error on the antipsychotic care plan, and that agitation was not an appropriate indication for Haldol. The MAR for April 2026 showed behavior monitoring for increased anxiety and paranoid behavior, but the MAR did not indicate that the behaviors were observed.
Arbitration Agreement Not Explained in an Understandable Manner
Penalty
Summary
The facility failed to ensure that an arbitration agreement was explained to Resident 36 or the resident representative in a manner they understood. Resident 36 was admitted on [DATE], had a DPOA listed as Resident Representative 1, and the MDS dated 4/1/26 showed a BIMS score of 7 out of 15, indicating severe cognitive impairment. The record also showed a physician order dated 3/28/26 documenting that Resident 36 had capacity to sign documents, entered by the Infection Preventionist based on the nursing admission assessment that described the resident as alert and oriented to time, place, and person; the IP stated the physician should determine capacity. During interviews, Resident 36 stated that Resident Representative 1 signed all documents upon admission, while Resident Representative 1 stated she did not remember being explained the arbitration process or signing an arbitration agreement for Resident 36. The Marketing Director stated he and the Admission Director were responsible for explaining the arbitration process and obtaining signatures, and the arbitration agreement in the record showed both the Admission Director and Resident 36 signed it on 3/30/26. The DON reviewed a physician progress note dated 3/31/26 stating the resident did not have the capacity to make medical decisions and stated that, based on the doctor’s note and the resident’s impaired mental status, Resident 36 should not have signed the arbitration agreement. The facility policy stated that the terms and conditions of a binding arbitration agreement are to be explained to the resident or representative in a way and form that ensures understanding.
Insufficient Room Space in Multiple Resident Rooms
Penalty
Summary
Sixteen resident rooms, identified as Rooms 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, and 18, were observed to have multiple beds but less than 80 square feet per resident. During observation on 4/22/26 at 1:31 p.m., several of the rooms were measured at 200 square feet with three beds, providing 66 square feet per resident space, while other rooms were measured at 140 square feet with two beds, providing 70 square feet per resident space. The report states that these room sizes did not meet the required space standard for multiple-occupancy rooms. During random observations of care and services from 04/20/26 to 04/23/26, there was sufficient space for the provision of care in the rooms, no heavy equipment was present that might interfere with resident care, and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for belongings, and no negative consequences or safety concerns were attributed to the decreased space in the 16 rooms. A room size waiver was recommended.
Failure to Support Resident Choice for Transfer to Another Facility
Penalty
Summary
The facility failed to promote and support a resident's choice to transfer to another skilled nursing facility. The resident, who was cognitively intact with a BIMS score of 15 on an MDS dated 2/2/26, had been admitted on an earlier date and later expressed dissatisfaction with remaining at the facility. An IDT conference note dated 1/15/26 documented that the resident preferred to reside in a skilled nursing facility located in Solano County to be closer to his son and sister. During an interview on 3/5/26, the resident stated he had informed the Administrator and the IDT of his desire to transfer approximately two months earlier but had not received any updates regarding efforts to locate another placement and reported feeling sad and stuck at the current facility. During a concurrent record review and interview on 3/5/26, the SSD acknowledged awareness of the resident's request to transfer and stated she had contacted two skilled nursing facilities regarding possible placement. However, when asked, the SSD was unable to provide any documentation—such as records, notes, referral forms, emails, or other written evidence—showing that outreach had been made to facilitate the transfer. The facility's undated Resident Rights policy indicated that residents are guaranteed certain basic rights under federal and state law, including being informed about their rights and responsibilities and being entitled to exercise their rights and privileges to the fullest extent possible. Despite this policy, there was no documented evidence that the facility actively assisted the resident in locating an alternative placement after the transfer request.
Delay in Providing Requested Behavioral Health Services
Penalty
Summary
The facility failed to provide timely behavioral health services to a resident who requested psychological therapy. The resident, admitted with muscular dystrophy and cognitively intact with a BIMS score of 15, had a PHQ-9 score of 17 indicating moderately severe depression. In mid-January 2026, the resident told the Ombudsman that he wanted talk therapy. The Ombudsman relayed this request to the Social Services Director (SSD), who stated she verbally informed the Director of Nursing (DON) the same day that the resident was asking for psychological therapy. Despite this, no referral for mental health services was initiated at that time. The DON later stated she was not aware of the resident’s request on 1/14/26 and only became aware of it on 2/19/26 after receiving an email from the Ombudsman to the SSD stating that the resident wanted psychological treatment. The referral for treatment was not started until 2/25/26, and the resident was not seen by a psychiatrist or psychologist until 3/2/26, resulting in a 45-day wait from the initial request. During this period, the resident reported feeling like he was going crazy, hearing things loudly, being unsure if the voices were real, being unable to sleep at night, and having no energy during the day. Observation showed the resident sitting quietly in activities and not interacting with others. The DON acknowledged that without timely intervention, the resident could escalate to severe depression with associated decline in ADL function. The facility’s Behavioral Health Services policy stated that residents will receive behavioral health services as needed to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Failure to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly address grievances and recommendations from residents' group meetings, which had the potential to cause emotional distress among residents. During a review of the residents' council minutes from meetings held in August and September 2024, several concerns were raised by residents, including excessive noise from CNAs at night, uncomfortable room temperatures, cold and unappealing food, and a request for a larger activity room. Additionally, residents reported delays in receiving assistance, lack of courtesy and professionalism from CNAs, feelings of neglect, lack of dignity and respect, and safety concerns due to other residents entering their rooms. The Activities Director admitted to not communicating the concerns reported during the residents' group meetings to the appropriate departments for follow-up. The Administrator also acknowledged uncertainty about whether grievances from the resident group meetings were addressed, citing a lack of a proper paper trail for grievance follow-up. The facility's policy and procedure documents indicated that the purpose of the resident council is to provide a forum for residents to discuss concerns and suggestions for improvement, and that a response form should be used to track issues and their resolution. However, these procedures were not effectively implemented, leading to the deficiency.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary drugs, leading to the administration of antipsychotic medications without adequate indications. Resident 27, who had a diagnosis of dementia and poor cognition, was administered Seroquel for wandering and behavioral disturbances despite having no documented behaviors warranting such medication. The resident's PASRR evaluation indicated no serious mental illness, and the consultant pharmacist had previously questioned the indication for Seroquel use. Resident 31, who was admitted with dementia and severe cognitive impairment, was prescribed Zyprexa for schizophrenia, a diagnosis that was not present upon admission. The Director of Nursing and the resident's medical doctor both confirmed that the resident had profound dementia and was not capable of being diagnosed with schizophrenia. Despite this, the resident was administered Zyprexa for agitation, and behavior monitoring was conducted for antipsychotic use, although the resident exhibited no potential indicators of psychosis. Resident 145, diagnosed with Alzheimer's Disease and dementia, was administered Seroquel without specified target behaviors to monitor its effectiveness. The facility's policy required target behaviors to be identified and monitored for antipsychotic use, but this was not done. Interviews with the Director of Nursing, Consultant Pharmacist, and Medical Doctor confirmed the lack of target behavior monitoring, which is essential for evaluating the necessity and effectiveness of the medication.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure the storage of food under sanitary conditions, as observed during a kitchen tour. Several food items in the refrigerator were not dated and labeled with received, open, and use-by dates. Specifically, a bag of cauliflower with brownish-black discoloration, a bag of moist and withered parsley, and three cut-up watermelons were found without proper labeling. Additionally, the refrigerator temperature log was missing entries for several days, and a chest freezer had no temperature log at all. The trash can lid and kitchen floor tiles were also noted to have brownish discoloration. Interviews with dietary staff revealed that there were new hires in the kitchen who were still in training. Despite receiving training on job functions, including dating and labeling food and checking and documenting fridge and freezer temperatures, the deficiencies persisted. The facility's policy and procedure on food receiving and storage, which requires all perishable food items to be stored properly with open and use-by dates, was not adhered to, leading to these deficiencies.
Improper Garbage Disposal and Overflowing Dumpster
Penalty
Summary
The facility failed to maintain the garbage and refuse storage area in a sanitary condition, as observed on November 19, 2024. A dumpster located by the side of the facility was overflowing with trash bags and was not properly covered with a lid. During an interview, the Administrator stated that the contracted company staff came and left without emptying the dumpster, and that housekeeping staff were responsible for ensuring the dumpster was emptied. The Housekeeping Supervisor mentioned that the path to the dumpster was blocked, preventing it from being emptied. The facility's policy and procedure on waste disposal, revised in January 2022, indicated that all infectious and regulated waste should be handled and disposed of safely and appropriately.
Inadequate Dining/Activity Room Space for Residents
Penalty
Summary
The facility failed to provide a dining and activity room with adequate space for its 42 residents, which limited their independent functioning and task performance during mealtime and activity time. On observation, the room was equipped with three square tables and was crowded with five residents in wheelchairs and two ambulatory residents using walkers. The dining room staff had to push tables aside to accommodate the residents in wheelchairs, indicating insufficient space. Interviews with a CNA and two residents confirmed the room's congestion, with concerns about potential falls for ambulatory residents and difficulties in positioning wheelchair-bound residents at the tables. One resident reported having to dine in her room due to the limited space in the dining area.
Failure to Complete PASARR Screening for Resident
Penalty
Summary
The facility failed to complete the Level I Preadmission Screening and Resident Review (PASARR) assessment for a resident, which is a federal requirement to ensure appropriate placement in nursing homes for long-term care. The deficiency was identified during a review of the resident's admission record, which indicated that the resident was admitted without the necessary PASARR screening. During an interview, the Director of Nursing (DON) acknowledged that the PASARR screening was not completed and could not provide the required documentation. The DON, who was newly hired at the time of the resident's admission, was unaware of the reason for the oversight. Additionally, the Admission Coordinator, responsible for coordinating with hospital case managers, was also unaware of the missing PASARR screening as she was hired after the resident's admission.
Inadequate Supervision Leads to Repeated Falls
Penalty
Summary
The facility failed to provide adequate supervision and implement resident-centered care interventions for a resident with poor cognition, leading to repeated unwitnessed falls. The resident, who had a BIMS score of 03 indicating poor cognitive status, was diagnosed with Non-Alzheimer's Disease and exhibited wandering behavior, placing them at significant risk of falling. Despite being independent in ambulation, the resident experienced multiple falls, some resulting in injuries, such as a hematoma on the nose and face, which required hospital evaluation and treatment. The facility's Interdisciplinary Team (IDT) progress notes and care plans indicated that interventions before and after each fall were limited to verbal reminders to ask for help, redirection, and reorientation. However, these interventions were ineffective as the resident continued to wander and fall. Interviews with the Director of Nursing (DON) and a Certified Nursing Assistant (CNA) confirmed the resident's wandering behavior and difficulty in redirection due to confusion. The repeated falls and lack of effective intervention highlight the facility's failure to adequately supervise and address the resident's needs.
Failure to Implement Person-Centered Interventions for Wandering Resident
Penalty
Summary
The facility failed to develop and implement person-centered interventions for a resident diagnosed with dementia, who was observed wandering into the rooms and closets of other residents. This deficiency was identified for a resident with a history of non-traumatic subdural hemorrhage and dementia without behavioral disturbance. The resident's cognitive status was poor, as indicated by a Basic Interview of Mental Status (BIMS) score of 03, and she exhibited wandering and rejection of care behaviors. Despite having a care plan for wandering initiated earlier in the year, the interventions did not address the specific issue of the resident entering other residents' rooms and closets. Multiple interviews with staff and residents revealed that the resident frequently wandered into other residents' rooms, taking belongings and causing distress among other residents. Staff members reported that the resident was difficult to redirect and often confused, with varying responses to redirection attempts. The Director of Nursing acknowledged ongoing complaints from other residents about the wandering behavior. The facility's policy on dementia care indicated that interventions should be adjusted based on individual responses and progression of dementia, but this was not effectively implemented for the resident in question.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to properly label and dispose of medications for two residents, leading to deficiencies in medication management. For one resident, two bottles of Latanoprost Ophthalmic Solution were found on the medication cart; one bottle was not labeled with an open date, and the other was stored beyond its use-by date. The Director of Staff Development (DSD) confirmed that the bottle without an open date should have been labeled, and the bottle with an open date of 9/10/24 should have been disposed of after 28 days. The Director of Nursing (DON) and the Consultant Pharmacist (CP) both acknowledged the risk of reduced potency and potential eye infection from using the expired medication. Another resident's Atropine Sulfate Ophthalmic Solution was found without proper labeling, lacking the resident's name and dosage information. The DSD noted that the medication should have been labeled to prevent errors. The DON confirmed that the Atropine eyedrops should have included the resident's name, dosage, open date, and the initials of the nurse who opened the medication. The facility's policy on medication labeling and storage, dated 2001, requires that medications include specific labeling information, which was not adhered to in these cases.
Infection Control Lapse in Suction Machine Maintenance
Penalty
Summary
The facility failed to maintain an effective infection control program when the lid of a resident's suction machine cannister was not changed for 18 days. The resident, who was admitted with an esophageal obstruction, had a suction machine cannister that was observed to be filled with 100 milliliters of phlegm. The lid of the cannister had a handwritten date indicating it had not been changed since 11/1/24. Both the Licensed Vocational Nurse and the Registered Nurse present during the observation could not specify when the cannister was last changed, indicating a lapse in adherence to the facility's infection control procedures. The Infection Preventionist acknowledged that the cannister lid should have been changed before the observed date and stated that the failure to do so increased the risk of respiratory infection for the resident. The Director of Nursing confirmed that the facility's policy required the suction cannister and its lid to be changed every seven days, as per the order summary report dated 11/19/24. The facility's policy on infection control, revised in October 2018, mandates that all personnel be trained on infection control practices, highlighting a gap in compliance with these procedures.
Deficiency in Room Size Requirements
Penalty
Summary
The facility was found to have a deficiency related to room size requirements, as observed during a survey. Specifically, sixteen resident rooms were identified as providing less than the required 80 square feet per resident in multiple occupancy rooms. The rooms in question were observed to have either two or three beds, with total room sizes of 140 square feet and 200 square feet, respectively. This resulted in only 66 to 70 square feet of space per resident, which is below the regulatory requirement. Despite the deficiency in room size, observations made during the survey period indicated that there was sufficient space for the provision of care, and no heavy equipment was present that might interfere with residents' care. Additionally, residents reportedly had adequate personal space and privacy, and there were no complaints from residents regarding insufficient space for their belongings. No negative consequences or safety concerns were noted as a result of the decreased space, and a room size waiver was recommended.
Failure to Verify DME Delivery Before Resident Discharge
Penalty
Summary
The facility failed to ensure a follow-up call and/or assessment was done to verify that durable medical equipment (DME) was provided to a resident as ordered. The resident, who had hemiplegia and hemiparesis following a cerebral infarction, was discharged to their daughter's home without the necessary DME, including a wheelchair, hospital bed, and patient lift. The Social Service Director (SSD) had arranged for home health services and DME delivery but did not verify the delivery before discharge. The resident's family had to purchase a wheelchair after a few days to safely move the resident around the house, as the resident could not walk and required assistance for transfers. The SSD acknowledged that it was her responsibility to ensure the DME was delivered before the resident's discharge. She made a follow-up call to the family 72 hours after discharge but failed to ask about the DME delivery and did not document the call. Additionally, the SSD did not follow up with the home health agency to verify the DME delivery. The Director of Nurses (DON) confirmed that the SSD should have followed up on the DME and that the resident should not have been discharged without the necessary equipment to ensure safety. The facility's policy and procedure for discharge planning were not followed, as there was no documentation of the resident's post-discharge plan in the medical records.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide bathing assistance for a resident with muscle weakness and paraplegia during two extended intervals. The resident, who was totally dependent on staff for transfers and bathing, did not receive bathing assistance for a five-day interval and a four-day interval. Despite the resident's repeated requests for a shower and complaints to the Director of Nursing (DON), the facility did not provide the necessary care, leading to the resident feeling emotional distress and a lack of dignity. The resident's Bathing Record and Progress notes confirmed the lack of bathing assistance during the specified intervals. The DON acknowledged that the resident was not known to refuse hygiene care and stated that staff should offer a bed bath if a shower was not possible. However, there was no documentation of bathing assistance or refusal of care for the nine days in question. The facility's policy indicated that appropriate care and services should be provided to residents unable to carry out activities of daily living independently, but this was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 910 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Martinez
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy Post Acute Care | 2.5 mi | ★★★★★ | 2 | 0 |
| Bayberry Skilled Nursing & Healthcare Center | 5.4 mi | ★★★★★ | 16 | 0 |
| Rosewood Post Acute | 6.1 mi | ★★★★★ | 15 | 0 |
| Willow Pass Healthcare Center | 6.2 mi | ★★★★★ | 5 | 0 |
| Pleasant Hill Post Acute | 6.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Alhambra Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.