Alhambra Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for Residents 1-3, the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staffed and supervised by a qualified social worker which affected all 20 residents for at least 3 months. This failure resulted in all residents receiving social services from unqualified staff. During an interview on 2/4/26 at 2:48 p.m., with social services director (SSD), SSD stated they had been in the position since December 2025. SSD stated they were a certified nursing assistant prior to taking the position. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pacemaker defibrillator monitor (a remote monitor that automatically collects device data and sends it to the healthcare team) for one of four residents (Resident 1) was adequately monitored at the nurse's station when Resident 1's pacemaker defibrillator monitor was unable to be located. This failure had the potential to increase Resident 1's risk of cardiovascular accidents and decline in health condition. During record review of admission record, printed on 6/2/26, Resident 1 was admitted on [DATE]. During record review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 4/14/26, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool used to assess mental status) score was 15 out of 15, which indicated Resident 1's cognition was intact. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of five percent (5%) or greater, as evidenced by the identification of five medication errors out of 27 opportunities, to yield a facility error rate of 18.5 % as evidenced by:1. For Resident 1, Registered Nurse (RN) 1 crushed four different medications, mixed them together in one cup, and administered them in a single administration via resident's gastrostomy tube (also called G-tube, is a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications).2. RN 2 did not administer Cholecalciferol (Cholecalciferol is Vitamin D3, a supplement essential for bone health) as ordered by the physician, to Resident 8. These failures had the potential to compromise the residents' medical health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure:1. Expired medications for one of 14 sampled residents (Resident 6) were properly disposed.2. An opened, full box of expired one ml. needles (ml. or milliliters is a form of measurement) was not stored in the facility medication storage room.3. An opened, multidose PPD vial (PPD is purified protein derivative. PPD vial is used for PPD test, a skin test used to check if you have been infected with the bacteria that causes tuberculosis- an infectious lung disease; multidose vial is a small bottle of medicine designed to be punctured multiple times, allowing healthcare professionals to draw out several doses over a period of time) in the medication storage room refrigerator, had no date opened label. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling and storage practices when three bottles of [NAME] Designer Dessert Sauce were found past their use-by dates at the dry food storage area. This failure had the potential to cause foodborne illnesses when consumed by residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary method for storing residents' food brought from outside for one of six sampled residents (Resident 42) when a jar of jam and fruit preserve and fruit cups were stored in a rectangular plastic container with ice and ice water. This failure has the potential to place the resident at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 51) dignity was maintained when staff referred to the resident as a feeder in the lunchroom. This failure had the potential to result in Resident 51 feeling disrespected, demeaned, embarrassed, or devalued, thereby negatively affecting the resident's sense of self worth and well being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of 14 sampled residents (Resident 6) had adequate indications for the use of Haloperidol (or Haldol, is a strong antipsychotic. An antipsychotic is a medication that is used for the mind to manage delusions, hallucinations, and disordered thoughts. Antipsychotic medications can cause severe side effects). This failure had the potential for increased risks associated with the use of psychotropic (psychotropic medications are prescription drugs that affect how the brain works, changing a person's mood thoughts, feelings or behavior. Antipsychotic medication like Haldol is a psychotropic medication) medications that could negatively affect the residents' physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 36) the facility failed to ensure that an arbitration agreement (Arbitration is a method of settling disputes between individuals, the two parties choose some disinterested and qualified person or people-the arbitrator-to judge the matter) was explained to the resident or resident representative in a manner that they understood. This failure had the potential for Resident 36's rights to be compromised by preventing the resident and the resident's representative from making fully informed choices about matters affecting the resident's care and well being.

Inspectors wroteBased on observation and interview, the facility had sixteen resident rooms (Rooms 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17 and 18) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings.

Inspectors wroteBased on interview and record review, the facility failed to promote and support the resident's choice when Resident 1 asked for assistance with transferring to another skilled nursing facility on 1/15/26, but the facility did not provide evidence that it actively helped the Resident 1 to locate an alternative placement. This failure placed Resident 1 at risk for emotional distress, reduced control over decisions about their living arrangement, and delays in accessing a facility that could better meet the resident's preferences and needs. A record review of Resident 1 's admission Record (AR) printed on 3/5/26, indicated, Resident 1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely treatment to one of five sampled residents (Resident 1) when Resident 1 had asked for psychological therapy on 1/14/26. The facility did not start the referral for treatment for Resident 1 until 2/25/26. Resident 1 was not seen by a psychiatrist or psychologist until 3/2/26. Resident 1 waited 45 days before receiving mental health services. This failure placed Resident 1 at risk for worsening depressive symptoms and decline in overall well-being while awaiting mental health services. A review of Resident 1 's admission Record (AR) printed on 3/5/26, the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnosis that included muscular dystrophy (a group of diseases that cause muscle to become weaker and lose mass over time, ultimately leading to loss of function). [...]

Inspectors wroteBased on interview and record review, the facility failed to act promptly upon the grievances and recommendations from the residents' group meetings concerning residents care and life in the facility. This failure had the potential to cause residents' emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three (Resident 27, 31 and 145) of five sampled residents were free from unnecessary drugs when; 1. Resident 27 was administered Seroquel (an antipsychotic - drugs used to treat schizophrenia and bipolar serious mental health conditions and not approved for use in psychotic conditions related to dementia.) medication for wandering; 2. Resident 31 had a new diagnosis of schizophrenia (a serious mental health conditions capable of affecting the mind, emotions, and behavior); 3. Resident 31 with diagnosis of dementia was administered Zyprexa (an antipsychotic) medication for yelling and screaming; 4. Resident 145 was administered antipsychotic medication without adequate indication for use. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure storage of food under sanitary conditions when the following food items in the refrigerator were not dated and labeled with received, open and use-by dates : - One bag of cauliflower with brownish black discoloration - One bag of parsley moist and withered - Three cut up watermelon not labeled with date - One chest freezer had no temperature log. - Refrigerator temperature log missing entries - Trash can lid with brownish discoloration - Kitchen floor tiles with brownish stain and discoloration These failures had the potential to result in food borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage and refuse storage area was maintained in a sanitary condition when the dumpster was overflowed with bags of trash and not properly contained with lid. This failure had the potential of harborage and feeding of pest.

Inspectors wroteBased on observation and interview, the facility failed to provide a dining/activity room with adequate space for 42 residents. This failure resulted in limiting the independent functioning and task performance of the residents during mealtime and activity time.

Inspectors wroteBased on interview and record review, the facility failed to complete the Level I Preadmission Screening and Resident Review (PASARR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) assessment for one of one sampled resident (Resident 31). This failure had the potential for residents to not received appropriate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent falls and implement resident-centered care interventions for one (Resident 31) of four sampled residents when, Resident 31 had repeated unwitnessed falls. This failure caused Resident 31 to continued to fall and had the potential to result in injuries.

Inspectors wroteBased on observation, interview and record review, for one of two sampled residents (Resident 31), the facility failed to developed and implement person-centered interventions to prevent Resident 31 with dementia from wandering into the rooms and closets of other residents. Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptom and rates of progression. (Adapted from: About Dementia. Alzheimer's Foundation of America. 30). This failure had the potential to cause residents increase confusion and distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to label medications and properly dispose of a medication beyond the use by date for two of 14 sampled residents (Resident 36 and Resident 5), when while inspecting medication cart two (use by date is the date at which the manufacturer can still guarantee the full potency and safety of the drug): 1. Resident 36's one bottle of Latanoprost Ophthalmic Solution 0.005 % ( Latanoprost ) was not labeled with an open date. Another bottle Resident 36's Latanoprost was stored beyond the use by date in the medication cart (Latanoprost is an eyedrop used to treat a condition in which increased pressure in the eye can lead to gradual loss of vision). 2. A bottle of Atropine Sulfate Ophthalmic solution 1% was not properly labeled (Atropine Sulfate Ophthalmic solution is an eyedrop used to treat certain eye conditions).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection control program when the lid (cover) of Resident 144's suction machine cannister was not changed for 18 days (Suction machine is a device that is used for removing secretions like mucus, phlegm, saliva from a person's airway; the suction machine cannister is where the secretions are collected). This failure placed the resident at increased risk of healthcare associated infections.

Inspectors wroteBased on observation and interview, the facility had sixteen resident rooms (Rooms 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17 and 18) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings.

Inspectors wroteBased on interview and record review, the facility failed to ensure a follow up call and /or assessment was done to verify durable medical equipment was provided to Resident 1 as ordered (DME, are equipment and supplies for everyday or extended use). This failure posed a risk for an unsafe transition from the facility to the home setting.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide bathing assistance for one of two sampled residents (Resident 1) for two extended intervals: a five-day interval from 3/25/24 to 3/29/24 and a four-day interval from 3/31/24 to 4/3/24. This failure resulted in Resident 1 feeling emotional distress and that the facility did not support Resident 1's need for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications appropriately when the following were noted: 1. Resident 5's Lotemax eye drops bottle was not labeled with open date. 2. Facility did not dispose or destroy medications for discharged residents and/or expired 11 of 11 sampled residents (Residents 37, 40, 33, 20, 301, 302, 303, 32, 99, 21, 304). 3. Facility did not dispose of expired over the counter (OTC) medications and stored open bottles of OTC medications mixed with ready-to-use medication in the medication storage room. 4. Facility did not monitor and maintain a temperature log for medication storage room for September, October, and November of 2023. These failures had the potential to result in unsafe medication administration and storage practices.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to follow their policy for the Use and Storage of Food & beverages Brought in for Resident and provide safe and sanitary storage, handling, and consumption of food brought to residents by family and visitors for two of 44 residents, when: 1. The staff refrigerator contained Resident 198's food that was not dated and stored with other unlabeled and undated staff food. This had the potential for cross contamination. 2. Resident 298 wanted to eat food brought for her birthday and have it for dinner and was told staff could not warm the food and ate cold lobster that was unpalatable. These failures had the potential for food contamination and food borne illness, and food not served at the preferred temperature diminished the enjoyment of the meal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection prevention and control practices when the following were noted: 1. Oxygen tubing nasal canula for four of four sampled residents (Resident 18, 298, 11 and 30) was unlabeled and undated. 2. Two Licensed Vocational Nurses (LVN 3 and LVN 1) did not perform hand hygiene during medication administration for two of the seven sampled residents (Resident 16 and 11). 3. Medication storage refrigerator in the medication storage room was dusty and sticky to touch. 4. Licensed Nurse did not label a wound dressing for a gastrostomy tube (GT, a tube inserted into the stomach to provide liquid nutrition, fluids, and medications) site with date and staff initials. Licensed Nurse did not perform hand hygiene during wound care for one of two residents (Resident 12). 5. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure privacy and right to send secure mail when a stack of residents' mail was left unattended on top of an unlocked mail box located outside the building. This failure had the potential to cause mail and identify theft.

Inspectors wroteBased on interview and record review, the facility failed to offer and facilitate the preparation of an advance directive, including the right to accept or refuse medical-surgical treatment for seven of seven sampled residents upon admission. These failures resulted in Resident 3, 12, 24, 29, 30, 38, and 200 not being aware of their right to specify their wishes for medical-surgical care should they become incapacitated.

Inspectors wroteBased on observation, interview and record review the facility failed to make information on how to file a grievance or complaint available to six (3, 19, 22, 24, 26 and 38) of seven sampled residents. This deficient practice had the potential to cause residents fear and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe pharmacy services when the following were noted: 1. Facility did not have morning medications readily available for administration for two of two sampled residents (Resident 22 and Resident 11). Resident 22 did not receive antidepressant medication. Resident 11 did not receive anticoagulant (used to prevent blood clots) as prescribed by the physician. (Cross reference F 759). 2. Facility did not maintain accounting records for controlled medications (medications with potential for abuse) for an active resident (Resident 19) and a discharged resident (Resident 299). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (Resident 19 and 38) of five sampled residents were free from unnecessary drugs when - Resident 19 was administered Zyprexa (antipsychotic) medication for yelling and verbally abusive behavior. - Resident 38 was administered an antipsychotic medication without adequate behavior and adverse medication side effect monitoring. These failures had the potential for residents to receive unnecessary drugs and to suffer adverse medication side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of six sampled residents for medication administration observation (Residents 200, 11, and 5) received medications per the physician's orders. This failure resulted in a 13.16% medication error rate and Resident 200, 11 and 5 to not receive prescribed medications as ordered.

Inspectors wroteBased on interview and record review, the facility failed to implement the pneumococcal immunization (a vaccine to protect against pneumonia, an infection of the lungs caused by bacteria, fungi or viruses) policy for three of five sampled residents (Resident 12, Resident 13, and Resident 38) when they did not receive a pneumonia vaccine immunization. This failure placed Resident 12, 13 and 38 at risk for pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a medication self-administration assessment prior to allowing Resident 12 to self-administer medications. This failure resulted in Resident 12 not taking ordered medication at the appropriate time, with the potential for adverse health outcomes related to incorrect medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure that missing property for one of one sampled resident (Resident 24) was accounted for and addressed. This failure placed Resident 24 at risk for psychosocial stress and feeling vulnerable.

Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive Minimum Data Set assessment (MDS, an assessment tool used to direct resident care) for one (Resident 249) sampled resident as required within 14 calendar days after admission. This failure had the potential to result in no assessment of the residents' needs, strengths, and goals of care.

Inspectors wroteBased on interview, record review, the facility failed to follow federal requirements to submit Quarterly Minimum Data Set (MDS, an assessment tool used to guide care) assessment for one of 14 sampled residents (Resident 28) within 14 days after its completion. The failure resulted in late submission of Resident 28's quarterly MDS assessment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate for two ( Residents 5 and 6) of two sampled residents when; -MDS section G did not reflect Resident 5's contractures (fixed tightening of muscle, tendons, ligaments, or skin. It prevents normal movement of the associated body part) to lower extremities (hip, knee, ankle, foot) and limitation in range of motion. -MDS section G did not reflect Resident's 6 contractures to upper extremities (shoulder, elbow, wrist and hand). These failure had the potential for residents to not receive appropriate care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered care plan for one of 14 sampled residents (Resident 38). Resident 38 did not have an individualized plan of care for her new diagnosis of Schizophrenia (a mental disorder usually exhibited with delusions - false beliefs, hallucinations - seeing or hearing things that don't exist), and new use of Seroquel (antipsychotic for Schizophrenia) medication. This failure placed Resident 38 at risk and not receive individualized care for her clinical condition. (Cross Reference F758)

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise one of one sampled resident (Resident 6), the Activities of Daily Living (ADL) care plan for almost seven years. This failure placed Resident 29 at risk for impaired psychosocial and physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a shower for two of two sampled Residents (Residents 18 and 298) accoridng to the shower schedule. The failure resulted in Resident 298 not feeling important and placed Resident 18 and Resident 298 at risk for compromised hygiene and at risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were served palatable food when, 1. The lunch for Resident 17 was not fortified as ordered by the physician. 2. The evening snack of Peanut Butter and Jelly (PB&J) sandwiches were not prepared according to the menu. This deficient practice placed the residents at risk of decreased nutrient intake and bland food, and potential weight for 2 residents who received food from the kitchen out of a census of 44.

Inspectors wroteBased on observation and interview, the facility had sixteen residents (Rt) rooms (room [ROOM NUMBER], 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17 and 18) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings.

Inspectors wroteBased on interview and record review, for one of one sampled resident (Resident 1), the facility failed to allow Resident 1's Representative (RR) to obtain a copy of the medical records within the required time frame. This failure resulted in violation of Resident 1's rights.