Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alhambra Rehab & Healthcare during CMS and state inspections, most recent first.
The Facility did not maintain the required RN staffing for at least eight hours daily, as evidenced by missing RN coverage on specific dates. Despite efforts to hire more nurses, the Facility lacked documentation for RN presence on one of the dates. This issue potentially impacts all 38 residents.
The facility failed to properly store and label medications, affecting all 38 residents. An inspection revealed undated opened bottles of liquid protein and cough syrup on a medication cart, and an unlabeled Tubersol vial in the medication room refrigerator. The LPN acknowledged the errors, and the Regional Director expects adherence to medication storage policies.
The facility failed to maintain an effective infection prevention and control program, lacking proper surveillance for infections and not conducting necessary cultures for urinary infections in two residents. Additionally, during the care of a resident with a pressure ulcer, staff did not adhere to enhanced barrier precautions or perform appropriate hand hygiene, leaving feces on the resident's skin and not wearing required PPE. These actions were contrary to the facility's policies on infection control and hand hygiene.
An LTC facility failed to prevent abuse when two residents, one with severe cognitive impairment and aggressive behaviors, and another cognitively intact but also aggressive, engaged in a physical altercation. The incident resulted in a skin tear on one resident's forearm. The facility's investigation confirmed the injury occurred during the altercation, and both residents were separated and assessed for injuries.
A resident with severe cognitive impairment and incontinence did not receive pressure ulcer treatment as ordered, leading to an exposed stage 2 ulcer with feces present. An LPN and CNA failed to properly apply and monitor the dressing, and the CNA did not report the missing treatment to the nurse. The facility's wound care policy was not followed, contributing to the deficiency.
A facility failed to provide complete incontinent care for a resident with severe cognitive impairment and a history of urinary tract infection. During pressure ulcer treatment, a CNA did not thoroughly clean feces from the resident's rectal area and buttocks before applying a new adult diaper. The resident's care plan lacked specific guidance on incontinence care, contrary to the facility's policy on perineal care.
The facility failed to adhere to its Antibiotic Stewardship Program by not obtaining culture and sensitivity tests before administering antibiotics to two residents with urinary infections. Despite the policy requiring such tests, the residents were prescribed and received antibiotics without confirmation of necessity, as confirmed by the Regional Director of Clinical Operations.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The Facility failed to ensure the presence of a Registered Nurse (RN) for at least eight hours daily, as required by federal guidelines. The RN and LPN schedule for July 2024 revealed that the Facility did not have an RN on duty on specific dates, including 7/9/24, 7/19/24, 7/24/24, 7/27/24, and 7/28/24. Although time cards showed that an RN worked on some of these dates, there was no documentation for 7/28/24. The Director of Nursing acknowledged staffing challenges and efforts to hire more nurses. The Regional Director of Operations confirmed the absence of a specific policy on RN staffing, relying instead on federal guidelines. This deficiency potentially affects all 38 residents in the Facility.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly store and manage medications, which could potentially affect all 38 residents. During an inspection of the medication cart on A Hall, it was found that an opened bottle of over-the-counter liquid protein and an opened bottle of cough syrup were not dated upon opening. The LPN present acknowledged the oversight, noting that the label on the liquid protein must have worn off and that the cough syrup was unused and would be discarded. Further inspection of the medication room on A Hall revealed an opened, unlabeled multi-dose Tubersol vial in the refrigerator. The LPN confirmed that the vial should have been dated upon opening and decided to dispose of it and order a new one. The facility's policy requires medications to be dated upon opening and stored securely, and the Tubersol package specifies that it should be discarded 30 days after opening. The Regional Director of Clinical Operations stated that the facility is expected to adhere to these policies.
Infection Control Deficiencies in Surveillance and Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of a system for surveillance to identify communicable diseases or infections. The facility's infection control log documented urinary infections for two residents, R195 and R196, without conducting necessary culture and sensitivity tests. R195 was prescribed Bactrim DS for a urinary tract infection without documentation of a culture, and R196 was prescribed Cephalexin under similar circumstances. The infection preventionist, who assumed the role in October 2023, admitted to not having started infection tracking for July 2024 and had difficulty locating previous months' tracking due to an office move. The facility's policy from 2001 requires ongoing surveillance for healthcare-associated infections, which was not adhered to. Additionally, the facility failed to maintain enhanced barrier precautions and perform appropriate hand hygiene during the care of a resident with a pressure ulcer. During a treatment session, an LPN and a CNA did not wear gowns as required by enhanced barrier precautions and failed to perform hand hygiene when changing gloves. The CNA did not thoroughly clean the resident's buttocks after incontinence care, leaving feces on the skin before applying a new diaper. The LPN applied a dressing to the pressure ulcer without ensuring the area was properly cleaned, and both staff members neglected to follow the facility's hand hygiene policy, which emphasizes handwashing as a primary means to prevent infection spread. The facility's policies on enhanced barrier precautions and hand hygiene were not followed during the care of a resident with a pressure ulcer. The enhanced barrier precautions policy requires the use of gowns and gloves during high-contact care activities, especially for residents with chronic wounds. The hand hygiene policy mandates washing hands with soap and water when visibly soiled and using alcohol-based hand rubs before and after glove changes. These lapses in infection control practices were acknowledged by the Regional Director of Clinical Operations, who confirmed the expectations for staff to conduct thorough cleaning and adhere to PPE protocols during resident care.
Failure to Prevent Resident Abuse During Altercation
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by an incident involving two residents, one with severe cognitive impairment and aggressive behaviors, and another who was cognitively intact but also exhibited aggressive behaviors. The incident occurred in the TV area where the cognitively impaired resident, who uses a walker, engaged in a verbal confrontation with the other resident. The confrontation escalated when the cognitively intact resident approached the other, stopping her rocking chair and pointing at her, leading to a physical altercation. During the altercation, the cognitively impaired resident attempted to knock the other resident's hand away, resulting in her losing balance and sustaining a skin tear on her right forearm. The facility's Director of Nursing reviewed video footage of the incident, which lacked audio, and noted that the cognitively impaired resident was antagonizing the other resident. The video showed the cognitively intact resident's hand making contact with the other resident's arm, but it was unclear whether the injury was caused by the resident's nails or a nearby wheelchair. The facility's investigation documented that the cognitively impaired resident was verbally aggressive throughout the evening, and the cognitively intact resident attempted to protect himself during the confrontation. The facility's final report confirmed the injury resulted from the altercation, and both residents were separated and assessed for injuries. The facility's abuse prevention policy emphasizes the right of residents to be free from abuse, neglect, and mistreatment.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide pressure ulcer treatment as ordered for a resident, identified as R32, who was reviewed for pressure ulcers. During an observation, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) were providing pressure ulcer treatment to R32. The resident was found to have a stage 2 pressure ulcer in the gluteal cleft that was not covered with a dressing as ordered, and feces were smeared over the exposed ulcer. The LPN attempted to apply a dressing but initially failed to cover the ulcer completely, and the CNA confirmed the ulcer was still visible. The LPN had to discard the initial dressing and apply a new one, which eventually covered the ulcer. Further investigation revealed that the CNA who had changed R32 before breakfast and around lunchtime did not find a treatment in place on the pressure ulcer during those times and failed to report this to the nurse. R32's medical records indicated severe cognitive impairment, incontinence, and a history of pressure ulcers. The physician's orders required daily or as-needed dressing changes, which were not adhered to, leading to the deficiency. The facility's policy on wound care, revised in October 2010, outlines the procedure for wound care, including hand hygiene and proper dressing application. However, the staff did not follow these guidelines, as evidenced by the LPN's failure to perform hand hygiene between glove changes and the CNA's failure to report the missing dressing. The Regional Director of Clinical Operations acknowledged that staff should ensure treatments are done as ordered and report any dislodged dressings to the nurse.
Incomplete Incontinent Care for Resident
Penalty
Summary
The facility failed to provide complete incontinent care for a resident, identified as R32, who was reviewed for incontinent care. During an observation, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) were providing pressure ulcer treatment to R32. The CNA, after rolling the resident onto his side and unfastening his adult diaper, used disposable wipes to clean feces from the area of the pressure ulcer and around it. However, the CNA did not thoroughly clean all feces from the resident's rectal area and buttocks. The soiled diaper, with some feces exposed, was placed on the bed, and a new adult diaper was applied without washing the feces off the resident's buttocks or cleansing his scrotum, penis, or groin. R32's medical history includes diagnoses of Adult Failure to Thrive, Malignant Neoplasm of Prostate, a Urinary Tract Infection, and Unspecified Dementia. The resident is severely cognitively impaired, occasionally incontinent of bladder, and always incontinent of bowel, with an unhealed Stage 2 pressure ulcer. The resident's care plan did not include a focused care plan regarding his incontinence or the assistance required for Activities of Daily Living (ADLs). The facility's policy on perineal care emphasizes the importance of thorough cleaning to prevent infections and skin irritation, which was not adhered to in this instance.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically in the area of antibiotic stewardship, for two residents. For Resident 195, the facility's Infection Control Log indicated that no culture was done for a urinary infection diagnosed on October 10, 2023. Despite this, the resident was prescribed and administered Bactrim DS for seven days, totaling 14 doses, without obtaining a culture and sensitivity test to confirm the necessity of the antibiotic. Similarly, for Resident 196, no culture was performed for a urinary infection noted on July 21, 2023. The resident was prescribed and received 21 doses of Cephalexin, again without a culture and sensitivity test to guide the antibiotic use. The facility's Antibiotic Stewardship Policy, revised in December 2016, mandates that antibiotics should be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program, which includes obtaining culture and sensitivity tests before starting antibiotics. However, the facility did not adhere to this policy for the two residents in question. The Regional Director of Clinical Operations confirmed the expectation that urine cultures should be obtained prior to starting antibiotics, yet this was not done, leading to the inappropriate use of antibiotics and a failure in the facility's infection control program.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 146 citations issued within 25 miles in the last 12 months — including the 16 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Alhambra
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hitz Memorial Home | 0.4 mi | ★★★★★ | 5 | 1 |
| Staunton Health And Rehab Ctr | 9.3 mi | ★★★★★ | 3 | 0 |
| Highland Health Care Center | 11.7 mi | ★★★★★ | 3 | 1 |
| Evercare At Edwardsville | 13 mi | ★★★★★ | 10 | 2 |
| Eden Village Care Center | 14.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.