Alhambra Healthcare & Wellness Centre, LP

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a bed rail (side rails - metal or plastic bars attached to the sides of a bed to help prevent falls, provide support and assist patients with moving or getting out of bed) assessment was completed to assess for risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about) for three (3) of 3 sampled Residents (Residents 7, 59 and 104) reviewed for accidents as indicated on the facility policy and procedure (P&P). This failure had the potential to result in the inappropriate use of bed rails for Residents 7, 59 and 104, which could pose a safety risk and result in injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with the facility's policy and procedure titled Food Storage and Handling by failing to ensure:1. The chopped lettuce salad in a small styrofoam container was prepared fresh on the same day and labeled with the resident's name.2. Dietary staff washed her hands prior to touching clean food containers and plate covers after touching the floor. 3. A tray with three (3) small cups of watermelon and 3 cups of Jell-O pudding with strawberry sauce inside walk-in refrigerator was labeled with its preparation date. These deficient practices have the potential to result in foodborne illness (illness that comes from eating contaminated food) in a population of 79 residents who consume the food prepared by the facility every day.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a cord with a button next to the bed which turns on a light or makes a sound when pushed to alert staff) was within resident's arm's reach for two (2) of (2) sampled residents (Residents 11 and 59) reviewed for environment in accordance with the facility's policy. This deficient practice had the potential for Resident 11 and 59 not to be able to call the facility staff for help or assistance, especially during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the wheelchair was at the right height to ensure the resident's feet were resting on the foot pedals (the flat platform at the front of a wheelchair where a user places their feet) for one (1) of two (2) sampled residents (Residents 72) reviewed for positioning according to the facility policy. This deficient practice placed Resident 72 at risk for poor posture and poor body alignment and potential for fall due to unsafe weight shifts during transfers.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized resident-centered care plan (CP, a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one (1) of two (2) sampled residents (Resident 19) reviewed for pain, as indicated on the facility policy by failing to have a care plan for Resident 19's use of pain medication, tramadol hydrochloride (Hcl, a drug used to treat moderate to severe pain in adults). This deficient practice had the potential to result in medication misuse, or failure to achieve optimal pain relief for Resident 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 11) reviewed for Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) was provided care and services to maintain good grooming and personal hygiene by failing to ensure Resident 11's long and jagged fingernails (rough and uneven nails) were cleaned and trimmed. This deficient practice resulted in multiple scattered scratch marks on Resident 11's left lower flank area, across right outer arm and upper right side of the resident's body.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LAL mattress, a specialized medical bed mattress designed to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence] by constantly blowing a tiny amount of air through) for one (1) of three (3) sampled residents (Residents 97) reviewed for pressure ulcers was set according to the residents' current weight as indicated on the Physician's order and facility policy. This deficient practice placed Resident 97 at risk for development of new pressure ulcer and progression of moisture associated skin damage (MASD, caused from prolonged exposure to moisture) to Sacro-coccyx (pertains to both large triangular shaped bone in the lower spine that forms part of the pelvis and the tailbone) area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer gastrostomy tube (G-tube, a tube inserted through the abdomen to deliver nutrition directly to the stomach) feeding for one (1) of two (2) sampled residents (Resident 5) reviewed for tube feeding in accordance with the physician's order and facility's policy. This failure had the potential to result in Residents 5 experiencing fluid overload (when the body has too much water which can raise the blood pressure, force the heart to work harder and make it hard to breathe) which could then also lead to aspiration (when food, liquid or other material enters a person's airway and eventually the lungs by accident which can happen as a person swallows or when food comes back up from the stomach).

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the fluid restriction (a dietary change that limits the amount of liquid a person can consume in a day) for one (1) of three (3) sampled residents (Resident 10), reviewed and receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed) as indicated on the physician order and facility's policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a container of 18 ounces (oz, unit of measurement used to describe weight or volume) perishable (spoils quickly) raw organic kraut (uncooked, naturally fermented cabbage grown without chemical compound used to control pests) stored in the residents' refrigerator was properly labeled with the storage and expiration dates. This deficient practice had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) to Resident 83 if the food was consumed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for one (1) of seven (7) sampled residents (Resident 52) reviewed for infection control in accordance with the facility's policy and procedure (P&P) when:The facility failed to ensure trash bag was not placed on top of Resident 52's bed, next to Resident 52's right leg while Licensed Vocational Nurse (LVN) 1 was providing the resident's wound dressing change. 2. Housekeeping (HK) 1 used her feet with a small towel to clean a large puddle of liquid leaks coming out of the broken trash bag inside Rooms A and B. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete record for one (1) of two (2) sampled residents (Resident 1) as indicated in the facility's policy and procedure. This deficient practice had the potential for delayed or unnecessary treatment which could negatively affect the overall wellbeing of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of two sampled residents (Resident 23 and 59) were treated with respect and dignity in accordance with the facility policy by failing to ensure: 1. Resident 23's clothes were clean and free of food particles. 2. Resident 59 was called by preferred name. This deficient practice has the potential to affect the residents' self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement proper gastrostomy tube (GT - a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications) practices and procedures for two of three sampled residents (Residents 61 and 69) by failing to ensure: 1. Resident 69's head of bed was elevated at least 30 degrees while receiving enteral feeding (a method of providing nutrition directly to the gastrointestinal tract when a person cannot eat by mouth) in accordance with the facility's policy and physician's order. 2. [...]

Inspectors wrote2. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness one side of the body), dementia (a progressive state of decline in mental abilities), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and dysphagia (difficulty swallowing). During a review of Resident 61's Order Listing Report, revised 3/26/2025, the Order Listing Report indicated an order to swab/suction every shift as appropriate. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of expired vegetables stored in the facility kitchen's refrigerator during a kitchen observation conducted on 6/23/2025. This deficient practice had the potential to cause food-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage properly in the facility's garbage disposal area during kitchen observation conducted on 6/23/2025. This deficient practice had the potential to attract pests and spread disease.

Inspectors wrote2. During a review of Resident 38's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of exposure to COVID and bullous pemphigoid (a chronic autoimmune skin disorder characterized by itchy, blistering skin lesions, most commonly affecting older adults). During a review of Resident 38's Minimum Data Set (MDS, resident assessment tool), dated 4/8/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 38 was dependent (Helper does all of the effort. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its protocol for Antibiotic (medication used to kill bacteria and to treat infections) Stewardship Program by failing to complete the Surveillance Data Collection form prior to the administration of antibiotic therapy for three (3) of 3 sampled residents (Residents 34, 35, and 88). This deficient practice had the potential for Residents 34, 35, and 88 to be prescribed inappropriate antibiotics and increased the risk for developing antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics) and suffer adverse side effects from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs for one (1) of 21 sampled residents by failing to ensure Resident 17's Low Air Loss (LAL, operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers[wound that occurs as a result of prolonged pressure on a specific area of the body]) mattress was at comfort level per physician's order. This deficient practice has the potential for skin issues and complications of immobility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, sanitary, and homelike environment for one of 21 sampled residents (Resident 61), as indicated the facility's policy and procedure (P&P). This failure resulted in an unclean environment and accident hazard for Resident 61, other residents, and facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 61), was provided Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting performed daily) care. On 6/24/2025, Resident 61 was observed in bed with brown residue on right inner thigh and brown smear on the outside and top of the incontinent brief (a disposable diaper used for adults). This failure had the potential for Resident 61 to experience skin breakdown and/or discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the fluid restriction (a dietary change that limits the amount of liquid a person can consume in a day) as indicated on the physician order for one (1) of two (2) sampled residents (Resident 12), who was receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed) treatment. This deficient practice has the potential for fluid overload (a condition where there is too much fluid in the body which could result in swelling, particularly in the ankles and legs, and shortness of breath and health complications) for Resident 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a scheduled medication on time for one (1) of 21 sampled residents (Resident 35) per physician's order, in accordance with the facility's Medication Administration policy and procedure (P&P). This deficient practice had the potential to cause Resident 35's medical condition to worsen.

Inspectors wroteBased on observation, interview, and record review of the facility menu, the facility failed to ensure one (1) of two sampled residents (Resident 17) was provided with a therapeutic (food that does not require much chewing and are soft on the mouth) diet (dysphagia [difficulty swallowing] mechanical soft diet) as ordered by the physician. This deficient practice had the potential for Resident 17 not to receive proper nutrition and experience weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy by not checking the food brought in by family members for one (1) of two (2) sampled residents (Resident 73). This deficient practice has the potential for Resident 73 to choke (severe difficulty in breathing because of a constricted or obstructed throat or a lack of air) and aspirate (when food, liquid, or other material enters a resident's airway and eventually the lungs by accident) on food which can lead to death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 47 rooms (map diagram labeled rooms [ROOM NUMBERS], separated by a wall in the middle with two [2] beds on 1 side and three [3] beds on the other side with only 1 door for entry and exit) did not have more than four (4) residents in one shared room. This deficient practice had the potential to cause the residents in these rooms not to have enough privacy and had the potential to affect residents' delivery of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a toileting schedule (timed voiding) for three (3) of 3 sampled residents (Resident 40, 16, and 82), who were assessed as candidates on the bowel and bladder (B&B) program screener (an assessment of the bowel and bladder to see if residents are candidates to join a scheduled toileting) as indicated on the facility policy and procedure. This deficient practice has the potential for Residents 40, 16, and 82 to become incontinent (loss of bowel and bladder control).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for four (4) of 4 sampled residents (Resident 2, 49, 63, and 641) in accordance with the facility's policy and procedure. 1. For Resident 2, the facility failed to ensure the oxygen via nasal cannula (a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) was administered according to physician's order. This deficient practice had the potential for Resident 2 not being able to receive the benefits of the supplemental oxygen ordered if the oxygen tubing is not in an optimal working condition. 2. For Resident 2 and 49, the facility failed to ensure the nasal cannula was placed in a clean plastic bag when not in use. This deficient practice had the potential for the residents to develop a respiratory infection. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to ensure: 1. A container of rice was sealed properly. 2. A container of brown sugar was sealed properly. 3. A can opener was clean and free of gunk (unpleasantly sticky or messy substance) and rust (a reddish-brown substance that forms on the surface of iron and steel as a result of reacting with air and water). These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, which can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices by failing to: 1. Change gloves while providing incontinence (inability to control bowel and bladder function) care for Resident 40. This deficient practice had the potential to spread infection to staff and residents. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have an appropriate call light (an alerting device for nurses or other nursing personnel to assist a resident in need) according to the resident's condition and to have the call light within reach for 1 of 20 sampled residents (Resident 5). This deficient practice had the potential to delay in the necessary care and services for Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to maintain a current copy of the resident's advanced directive (a legal document that provide instructions for medical care and only go into effect if the resident cannot communicate his/her wishes) in the resident's medical record for one (1) of 1 sampled resident (Resident 46). This deficient practice had the potential for Resident 46 to not have her wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition).

Inspectors wrote(Cross reference F686) Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was initiated for one (1) of 20 sampled residents (Resident 26). This deficient practice resulted in the delayed care and services for Resident 26's pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care plans were revised for one (1) of 20 sampled residents (Resident 5) This deficient practice had the potential to inadequately care for resident's needs, resulting in a decline in Resident 5's functionality.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (2) of 20 sampled residents (Residents 643 and 10) were provided one to one (1:1, one staff to one resident) feeding assistance as ordered. This failure had the potential to put Residents 643 and 10 at risk for weight loss and aspiration (accidentally inhaling a foreign object, food or liquid through the vocal cords into the airway).

Inspectors wrote(Cross reference F656) Based on interview and record review the facility failed to ensure one (1) of two (2) sampled residents (Resident 26) was given appropriate treatment for a Stage 2 (the skin breaks open; it can look like an abrasion, blister, or a shallow crater of the skin) Pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin). This deficient practice resulted in Resident 26's pressure injury progressing from a Moisture-Associated Skin Damage (MASD, inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine stool, sweat, wound drainage, saliva, or mucus) wound, to a stage 2 pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 5 (five) sampled residents (Resident 54) had sufficient supply of gabapentin (nerve pain medication) to administer in accordance with the physician's order and facility's policy and procedure. These deficient practices resulted to a delay in the administration of the medication and had the potential to create medication - related adverse consequences such as unrelieved nerve pains to Resident 54.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its Medication Storage policy by failing to: 1. Refrigerate Residents 48's unused Novolin R Flex Pen (form of insulin, a naturally occurring hormone, used to control blood sugar in patients with diabetes). 2. Refrigerate Residents 59's unused Basaglar Kwik Pen (is a long-acting insulin that helps lower high blood sugar levels). This deficient practice increased the risk for Residents 48 and 59 to receive insulin that had become ineffective or toxic due to improper storage possibly leading to health complications, which may result to harm and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 47 rooms (map diagram labeled rooms [ROOM NUMBERS], separated by a wall in the middle with two [2] beds on 1 side and three [3] beds on the other side with only 1 door for entry and exit) did not have more than four (4) residents in one shared room. This deficient practice had the potential to cause the residents in these rooms not to have enough privacy and also had the potential to affect residents' delivery of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent fall () for one (1) of three (3) sampled residents (Resident 1), assessed as high risk for falls when Resident 1 was not provided assistance when getting up from the bed to go to the bathroom and failing to initiate a fall care plan (a document created for a resident receiving healthcare, personal care, or other forms of support) , as indicated on the facility policy and procedure. This deficient practice resulted to Resident 1 ' s fall on 5/19/2024 and transfer to General Acute Care Hospital (GACH 1).

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 1) was provided with cardiopulmonary resuscitation (CPR-a lifesaving emergency procedure for a victim who has signs of cardiac arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse]), in accordance with the standard of practice on basic life support and the facility's cardiopulmonary resuscitation policy by failing to: 1. Ensure facility staff immediately start CPR when Resident 1 was found unresponsive (no movement or response to stimuli and no pulse or respirations). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order to give mechanical soft texture (food item that has been blended, mashed, mixed, or processed into a smooth and uniform texture) diet for one (1) of three (3) sampled residents (Resident 1) in accordance with the facility's policy on nutrition management of dysphagia (difficulty swallowing) by facility staff failing to : 1. Ensure Certified Nursing Assistant (CNA 1) did not instruct Uncertified Assistive Personnel 1 (UAP 1) to obtain a sandwich from the facility's refrigerator for Resident 1 to consume on 4/17/24. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the doctor for one of one sampled resident (Resident 1), of Resident 1's change in condition of a decreased oxygen saturation (the amount of oxygen carried by red blood cells) of 78% (a normal level is between 95% and 100%) once identified as indicated in facility's policy and procedure. This failure had the potential to result in delayed treatment and provision of services for Resident 1, negatively affecting the resident's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1), had an active doctor's order for oxygen (O2) therapy (helps people with lung diseases or breathing problems get the oxygen their bodies need to function) administration and an indication (the condition that leads to the requirement of a treatment) for oxygen use, before and during oxygen administration. This failure placed resident at risk for inadequate oxygen with the potential to negatively impact Resident 1's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of two sampled residents (Resident 1), who was assessed at risk for falls as indicated in the resident's Fall Risk Evaluation. This deficient practice had the potential for Resident 1 to incur avoidable falls while in the facility and sustain injury from falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a diagnosis of dementia and severely impaired with cognition (thought process) was provided with adequate supervision, in accordance with the facility's policy and procedure on Resident Safety. This deficient practice resulted in Resident 1 eloping from the facility on 12/9/2023 from 12:50 PM to 1:21 PM (approximately 30 minutes), when the resident was left unsupervised while sitting on the wheelchair and was allowed to get out of the facility's backdoor. Resident 1 was found on the same day, 12/9/2023 after a police officer notified the facility to report that Resident 1 was brought by the Fire Department to the acute hospital. Resident 1 was readmitted back to the facility on [DATE] at 5:10 PM. Resident 1 sustained an abrasion to the forehead.