Alhambra Hospital Med Ctr Dp/SNF

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative) of the resident's medical records for four (4) of 4 sampled residents (Residents 6, 10, 14, and 21) observed for medication administration by not locking the screen prior to walking away from the computer. This deficient practice had the potential to expose Residents 6, 10, 14, and 21's medical records to others and violated the residents' right for privacy and confidentiality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) receive the necessary services to maintain good personal and oral hygiene for two (2) of 2 sampled residents (Residents 7 and 12) reviewed for ADLs to ensure:Resident 7's oral hygiene was maintained when resident's tongue was observed dry with white coating and red spots on the tongue bed. Resident 12 did not have dry nasal mucus outside the left nostril (outer opening of the nose). This deficient practice had the potential to result in a decrease in quality of life, oral health, and higher risk or oral infections for Resident 7 and had the potential to result in a negative impact on Resident 12's self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for four (4) or eight (8) sampled residents (Residents 1, 3, 8, and 14) reviewed under respiratory in accordance with the facility policy by:Failing to ensure Resident 1 [NAME] Suction Catheter (t-piece- used to deliver oxygen therapy and suction in an intubated resident) was changed when there were dry blood and mucus- build up on 7/14/2026. Failing to ensure Resident 3 t- piece was connected to the cool aerosol to administer oxygen to the resident per physician's (MD) order. Failing to ensure Resident 8's did not have mucus flowing out of the t-piece onto a towel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 1) reviewed for unnecessary medications (medication prescribed or consumed without a valid clinical indication for an excessive duration, at too high a dose, or when potential risks outweigh the benefits) was free from unnecessary medication use by failing to monitor signs and symptoms of bleeding, notify the physician and hold Resident 1's Xarelto (a prescription blood thinner used to treat and prevent dangerous blood clots) on 7/14/2026 and 7/15/2026 due to the presence of tracheostomy bleeding, as indicated on the resident's care plan and facility's policy and procedures (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 18) reviewed for nutrition was provided with a therapeutic diet (a diet ordered by a physician as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet or to increase specific nutrients in the diet, or to provide food the resident is able to eat such as mechanically altered diet [diet where the texture of the food is changed so it is easier and safer to chew and swallow for people with swallowing or chewing difficulties]) as indicated on the physician's order and facility's policy and procedure (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling practices in accordance with the facility's policy and procedure (P&P) by failing to ensure:Cook wore a beard net when preparing vegetables on 7/14/2026. Dry food items were labeled with use-by date. Fruits and vegetables in the refrigerator had a use-by date. Opened bags of cilantro and beansprouts had a use-by date. The interior of the ice machine was free of brown smudges and black particles. These deficient practices have 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) and can lead to other serious medical complications and hospitalization.

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 five (5) of 14 sampled residents (Residents 2, 6, 10, 14, and 21) reviewed for infection control as indicated on the facility policy by failing to ensure:1. Licensed Vocational Nurse 1 (LVN 1) used a clean medication cup to administer Resident 6's morning medications on 7/16/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to cap the purple cone tip of the gastronomy tube feeding (g-tube; a tube inserted through the belly that brings nutrition directly to the stomach) when not connected to resident for two (2) of 2 sampled residents (Resident 17 and 22). This deficient practice had the potential to result in complications including infections and stomach discomfort.

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 four (4) of four sampled residents (Residents 5, 11, 21, and 6) in accordance with the facility's policy and procedure (P&P) by failing to: 1. and 2. Sanitize (make clean and hygienic) the pulse oximetry (pulse ox- a non-invasive method used to measure the oxygen saturation [the percentage of hemoglobin in the blood that is carrying oxygen] level in a resident's blood) monitor before and after each resident's use for Resident 5 and Resident 11. 3. Ensure facility staff donned (wear) personal protective equipment (PPE- a barrier precaution which includes use of gloves, gown, mask, face shield, shoe covers, head covers, respirators, etc. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment by failing to ensure one (1) of 12 sampled residents (Resident 19) had a sink in the resident's room with a Formica (hard durable plastic laminate used for countertops, cupboard doors, and other surfaces) that was stripped off and with an exposed rough wood. This deficient practice caused an unsanitary environment and had potential for resident and staff to be placed at risk of injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its Policy and Procedure on pressure ulcer (localized damage to the skin and underlying soft tissue caused by prolonged pressure) prevention and wound management for one (1) of two (2) sample residents ( Resident 13) by failing to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer ) was set at the correct setting in accordance with the resident's weight. This deficient practice had the potential for Resident 13's pressure ulcer to worsen and develop complications which will negatively affect the resident's overall wellbeing.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the midline catheter (a specific type of intravenous [IV] catheter designed for administering fluids, medications, and sometimes for drawing blood over an extended period) with 2 lumen injection ports had a swab cap (a disinfecting cap, often used in healthcare settings, designed to cover and disinfect needleless connectors on IV lines) when not in use for one (1) of 12 sampled residents (Resident 9) in accordance to the facility policy. This deficient practice had the potential to result in Resident 9 developing IV complications which can lead to infection and possible hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of one (1) of six (6) sampled residents (Resident 24) by failing to ensure two (2) of 6 medications, mixed with water, were completely administered during medication administration. This deficient practice resulted in Resident 24 not being able to take the full amount/dose of the prescribed medications which had the potential to result in harm due to unmet individual medication needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles out of 27 opportunities (observed administered medications) for error, to yield an overall medication error rate of 7.41 percent (%) for one (1) of six (6) sampled residents (Resident 24) observed during medication administration (med pass). [...]

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 box of Kosher salt was not open and unsealed. 2. A container of soy sauce was free of drippings. 3. A container of Japanese curry powder was properly sealed. 4. The can opener was clean, not chipped, and free of rust. 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) and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignity bag (a bag used to cover and hold the catheter drainage/collection bag) for two (2) of three (3) sampled residents (Resident 14 and 126) who has a urinary indwelling catheter (tube inserted into the bladder to drain urine to a collection bag). This deficient practice had failed to safeguard the residents' dignity and had a potential to affect the residents' emotional and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or resident representatives for six (6) of eight (8) sampled residents (Residents 3, 16, 21, 22, 23, and 19). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to unwanted treatment with the residents' wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement proper gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) feeding practices and procedures for two (2) of two sampled residents (Resident 21 and 19) by failing to: 1. Properly label Resident 21's opened gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage) feeding solution bottle at the bedside. This deficient practice had the potential to result in Resident 21's delayed feedings and incorrect total feeding amount received in a day. 2. Ensure Resident 19's GT water bag flush was labeled completely to include the total number of hours in accordance with the physician's order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for three (3) of three sampled residents (Residents 21, 1, and 19) by failing to ensure: 1. Resident 21's nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostril) tubing was changed weekly. 2. Resident 19's suction tubing was not touching the floor. 3. Resident 1's suction tubing was not touching the floor. These deficient practices had the potential for the residents to develop a respiratory infection.

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: a. Label foods in the kitchen with item 'use by' date (the last date recommended for the use of the product) or open date. b. Discard expired food in the kitchen. c. Ensure drainpipe (a pipe that carries wastewater away from the building) had a 1 inch and more gap from the drain (plumbing fixture installed in the floor designed to direct water to a sewer or municipal storm drain so floor stays dry, and rooms do not flood). d. Ensure a container of salsa was discarded when found in a bin with labeling supplies. e. Ensure drainage on kitchen floor was clear of debris and trash. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide education, offer, and document Covid-19 (Coronavirus Disease 19, a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing) vaccinations for three (3) of five (5) sampled residents (Residents 15, 22, and 23). This deficient practice placed the residents and staff at risk for possible Covid-19 infection due to missed vaccination dosage and violated the residents or responsible parties' rights to make an informed decision.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one (1) of 12 sampled residents (Resident 19) as indicated in the facility's policy and procedure. This deficient practice had the potential not to meet the Resident 19's needs and preference.

Inspectors wroteBased on interview and record review, the facility failed to protect the confidentiality of the information of two (2) of 12 sampled residents (Resident 1 and Resident 14) in accordance with the facility's policy and procedure. This deficient practice violated the rights of Resident 1 and 14 for privacy and confidentiality of personal and medical records which can lead into exposure and misuse of Resident 1 and 14's Protected Health Information (PHI).

Inspectors wroteBased on interview and record review the facility failed to revise the comprehensive care plan for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) for one (1) of 12 sampled residents (Resident 126) as indicated on the facility's policy. This deficient practice had the potential for Resident 126 not to be monitored for the specific interventions and to be at risk for progression of pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, and administering of all drugs and biologicals to meet the needs of each resident for one (1) of 10 sampled residents (Residents 21) by failing to: a. Ensure Resident 21 received the correct dose of Mylicon (medication used to relieve painful pressure caused by excess gas in the stomach and intestines) per physician order. This deficient practice had the potential to place Resident 21 to receive an ineffective medication dose. b. Ensure Resident 21's Mylicon was not left unattended on the medication cart in the hallway. [...]

Inspectors wroteBased on interview and record review, the facility failed to act upon a pharmacist's recommendation, as approved by the physician, in the Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with their medications) for one (1) of five sampled residents (Resident 15) in accordance with the facility policy. This deficient practice resulted in a recommended blood test not performed for Resident 15, which could result in adverse consequence (a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status) due to potential for incorrect dosage of resident's medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store one of 12 sampled residents (Resident 3) respiratory inhaler in accordance with the facility's policy. This deficient practice had the potential for unauthorized persons to access the medication.

Inspectors wroteBased on interview and record review, the facility failed to provide education, offer, and document influenza immunization (flu shots, vaccine that protect against infection by the flu virus) as consistent with professional standards and current guidelines for two (2) of five sampled residents (Residents 22 and 23). This deficient practice placed Residents 22 and 23 at higher risk of acquiring and transmitting complications from the influenza disease and violated the residents or responsible parties' rights to make an informed decision.