Alhambra Healthcare Facility Cited for Delays in Pressure Injury Treatment and Inadequate Care Oversight
ALHAMBRA, CA - State health inspectors documented multiple care deficiencies at Alhambra Healthcare & Wellness Centre during a June 2024 inspection, including delayed treatment for a developing pressure injury, failure to update care plans for declining residents, and inadequate feeding assistance for vulnerable residents requiring one-on-one support.
Delayed Response to Progressing Pressure Injury
Inspectors identified serious gaps in the facility's wound care management after staff failed to document or treat a resident's deteriorating skin condition for several days. The case involved a resident with muscle weakness and osteoporosis who had been identified as at-risk for pressure injuries based on facility assessments.
A certified nursing assistant observed a pressure injury on the resident's sacrum area during the week of June 17-21, 2024. However, when treatment staff evaluated the wound on June 21, they found it had progressed from moisture-associated skin damage to a Stage 2 pressure injury—indicating the outer layer of skin had broken open. Despite this advancement in severity, no treatment orders had been initiated.
The facility's Director of Nursing confirmed during interviews that no care plan existed to address the pressure injury, even after it had progressed to Stage 2. This represented a significant breakdown in the facility's care coordination, as the resident's condition required immediate intervention to prevent further deterioration.
Pressure injuries develop when prolonged pressure on the skin reduces blood flow to the tissue. Stage 2 injuries involve partial-thickness skin loss and can appear as blisters, abrasions, or shallow craters. Without prompt treatment, these wounds can advance to deeper stages involving muscle and bone damage, creating serious infection risks and significantly impacting quality of life.
The facility's own assessment tools had flagged this resident as high-risk in March 2024, yet the protective measures apparently failed. According to facility policy, care plans should be updated within seven days of assessment completion and revised whenever new problems emerge or conditions change. The absence of treatment orders and care plan updates violated these protocols and left the resident without appropriate interventions during a critical window.
Care Plans Not Updated Despite Documented Functional Decline
Inspectors found that facility staff failed to revise care plans even when residents experienced significant changes in mobility and function. One resident admitted in 2022 with muscle weakness and osteoarthritis demonstrated progressive decline that was documented in therapy evaluations but not reflected in nursing care plans.
Occupational therapy evaluations from August 2023 showed impairment in the resident's right upper extremity, with the left side functioning normally. By March 2024, both upper extremities were documented as impaired. Similarly, physical therapy initially found both lower extremities within normal limits in October 2023, but by March 2024, both legs showed impairment.
Despite these documented changes indicating bilateral functional decline, the resident's care plan from January 2024 remained unchanged. When inspectors observed the resident in June 2024, they found contracted arms and legs—a sign of progressive immobility that typically requires aggressive preventive interventions.
The facility's rehabilitation director acknowledged that splinting should be recommended for the resident's left arm and both lower extremities to prevent contractures. Contractures occur when muscles, tendons, joints, or other tissues tighten and shorten, causing deformity and permanent loss of motion. This condition is largely preventable with proper positioning, range-of-motion exercises, and assistive devices—interventions that should have been incorporated into an updated care plan.
The care plan still referenced participation in a restorative nursing program that the resident was no longer receiving. This disconnect between actual care and documented plans creates risks for inadequate intervention and makes it difficult for staff to provide consistent, appropriate assistance. The Assistant Director of Nursing acknowledged that care plans guide staff in providing continuity of care and monitoring whether residents are improving or declining, making their accuracy essential for proper care delivery.
Feeding Assistance Orders Not Followed
The inspection revealed that two residents with physician orders for one-on-one feeding assistance were not receiving the required support, placing them at risk for malnutrition and aspiration. One resident with displaced hip fracture and swallowing difficulties had been ordered to receive individualized feeding assistance with all meals since April 2024.
During multiple observations on June 26, inspectors found this resident sitting in bed with meal trays placed in front of her but no staff present to provide assistance. The food remained untouched during observations at 8:03 AM for breakfast and again at 12:30 PM, 12:40 PM, 12:56 PM, and 12:59 PM for lunch. While staff briefly entered to set up the tray, they left without providing the ordered feeding support.
When administrators reviewed the facility's list of residents requiring feeding assistance, this resident was not included—despite the clear physician order in the medical record. The Assistant Director of Nursing could not explain why the resident had been omitted from the feeding assistance list and acknowledged the resident had been "missed."
A second resident with anemia, malnutrition, and end-stage heart failure also had orders for assisted feeding. During a morning observation, nursing staff found this resident attempting to self-feed with food covering the resident's mouth and clothing. While the resident had capability for some self-feeding, the care plan specified that supervision was required for safety and dignity.
Why One-on-One Feeding Assistance Matters
Feeding assistance serves multiple critical functions beyond simply providing nutrition. For residents with swallowing difficulties (dysphagia), proper supervision ensures they maintain correct positioning, wear necessary devices like dentures, chew slowly, and remain upright during meals—all factors that reduce aspiration risk.
Aspiration occurs when food, liquid, or other materials enter the airway instead of the esophagus. This can cause choking, pneumonia, or respiratory distress. Residents with cognitive impairment may forget to chew adequately or attempt to swallow too quickly, increasing aspiration risk. Those with physical limitations may fatigue before consuming adequate nutrition, contributing to weight loss and weakness.
The speech therapist who evaluated one of these residents explained that cognitive impairment created variable needs—some days the resident managed independently, while other days required substantial support. Without consistent assistance, the resident's nutritional intake became unpredictable, and safety protocols were not reliably followed.
The facility's own policy emphasized accommodating individual needs and preferences to support independent functioning, dignity, and well-being. When ordered assistance is not provided, residents face compromised nutrition, increased fall risk from weakness, and potential aspiration events that can be life-threatening.
Additional Issues Identified
The inspection documented several other areas where facility practices fell short of regulatory requirements:
Incomplete Assessment Implementation: The facility conducted risk assessments using the Braden Scale to identify residents at risk for pressure injuries but failed to consistently implement preventive interventions when risks were identified.
Care Plan Development Delays: Facility policy required care plans to be developed within seven days of comprehensive assessment completion and revised when conditions changed, but documentation showed significant delays in both initial development and updates.
Staff Communication Gaps: Information about care requirements, such as feeding assistance needs, was not consistently communicated across departments, resulting in residents not receiving ordered services.
Documentation Accuracy: Care plans referenced services residents were no longer receiving, creating confusion about actual care requirements and making it difficult for staff to provide appropriate assistance.
These deficiencies reflect systemic issues with care coordination, communication between departments, and quality oversight. When assessment information doesn't translate into timely interventions, when care plans don't reflect current conditions, and when physician orders aren't reliably implemented, residents face increased risks for preventable complications.
The facility's policies outlined appropriate standards for comprehensive care planning, skin integrity management, and accommodation of individual needs. However, the inspection findings demonstrated gaps between written policies and actual implementation, suggesting opportunities for improved staff training, monitoring systems, and accountability measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alhambra Healthcare & Wellness Centre, Lp from 2024-06-28 including all violations, facility responses, and corrective action plans.
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