Alhambra Healthcare: Pressure Injury Care Failures - CA
Federal inspectors found Alhambra Healthcare & Wellness Centre violated care planning requirements for Resident 26, whose pressure injury on the sacrum area was observed by staff during the week of June 17-21, 2024, but never addressed in the resident's care plan.
Certified Nursing Assistant 3 told inspectors she first noticed the pressure injury during that week. Treatment Nurse 1 explained the wound initially started as moisture-associated skin damage from prolonged exposure to urine or other bodily fluids, but progressed to a stage 2 pressure injury by June 21.
"The skin breaks open; it can look like an abrasion, blister, or a shallow crater of the skin," the inspection report defines stage 2 injuries.
Despite the worsening condition, Treatment Nurse 1 confirmed there were no treatment orders for Resident 26's pressure injury. The Director of Nursing admitted the facility had no care plan addressing the wound that had progressed to stage 2.
Resident 26 was admitted with muscle weakness and osteoporosis. A March assessment showed the resident was at risk for developing pressure injuries using the standardized Braden Scale. By June, the resident required substantial assistance with bathing and footwear, and partial assistance with oral hygiene, toileting, and dressing.
The facility's own policy requires comprehensive care plans within seven days of assessment completion and mandates updates when new problems arise or conditions change. The skin integrity policy specifically requires reviewing and updating care plans as necessary.
Assistant Director of Nursing told inspectors care plans ensure staff provide continuity of care and guide them on residents' specific needs. "The care plan was used to monitor the plan of care for the resident for health improvements or decline," the ADON stated.
Feeding Assistance Failures
Inspectors also found the facility failed to provide ordered one-on-one feeding assistance to two residents, putting them at risk for weight loss, aspiration, and dehydration.
Resident 643, admitted with a displaced hip fracture and swallowing difficulties, had doctor's orders for one-on-one feeding assistance with all meals starting April 5, 2024. The resident had severe cognitive impairment and was dependent on staff for transfers, dressing, and personal hygiene.
On June 26, inspectors observed Resident 643 sitting up in bed at 8:03 AM with her breakfast tray untouched on the bedside table. At 12:30 PM, a certified nursing assistant set up the resident's lunch tray and left the room. Ten minutes later, the resident was still alone with untouched food. At 12:56 PM, the food remained untouched.
When the Assistant Director of Nursing reviewed the facility's feeding assistance list, Resident 643's name was missing despite the doctor's order.
"She did not know why the resident was missed and did not make it onto the list," inspectors wrote.
The ADON explained that when residents with feeding assistance orders don't receive help, "it placed the resident at risk for weight loss and aspiration since the resident is not getting the proper nutrition and calories that they would from the tray and are also at risk for dehydration and weakness."
Speech Therapist 1 told inspectors Resident 643 needed one-on-one support to increase food intake and ensure safety, including making sure the resident wore dentures, chewed slowly, and stayed upright during meals. The resident's cognition was impaired, with some days requiring more support than others.
"Resident 643 does not really eat but does a lot better when the resident is assisted with feeding," the Director of Rehabilitation confirmed.
Second Feeding Violation
Resident 10 faced similar problems with feeding assistance. Admitted in January 2023 with anemia, malnutrition, and end-stage heart failure, the resident had severe cognitive impairment and required supervision during eating according to the care plan.
Licensed Vocational Nurse 7 told inspectors on June 26 that Resident 10 was feeding herself with "food all over Resident 10's mouth and clothes."
The resident's September order required "assisted feeding" for safety to prevent aspiration and choking. The care plan specified the resident needed supervision from staff during eating and assistance with personal hygiene.
Certified Nursing Assistant 7 acknowledged he should stay with the resident while eating and provide a protective bib. He admitted having "food crumbs and/or stains all over Resident 10's mouth and cloth was not acceptable."
Declining Mobility Without Updated Care
A third violation involved Resident 5, whose care plan wasn't revised despite significant mobility decline. Admitted with muscle weakness and osteoarthritis, the resident initially had one impaired upper extremity and normal lower extremities according to October 2023 therapy evaluations.
By March 2024, therapy evaluations showed all four extremities were impaired. The resident's June assessment indicated complete dependence for all activities of daily living, including eating, hygiene, toileting, bathing, and dressing.
When inspectors observed Resident 5 on June 25, the resident was "lying in bed with contracted arms and legs."
The Assistant Director of Nursing admitted the care plan should be revised since the resident was no longer in the restorative nursing program and mobility had declined. The Director of Rehabilitation said the resident's declining mobility required recommendations for splinting on the left arm and both legs to prevent contractures, which occur when muscles and joints tighten and shorten, causing deformity.
Despite the dramatic functional decline documented in therapy evaluations and assessments, the facility failed to update the care plan. The facility's policy requires care plan revisions for new problems, condition changes, and behavioral changes.
The violations occurred during a June 28, 2024 inspection at the 415 South Garfield facility. All three violations were classified as causing minimal harm or potential for actual harm to few residents.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ALHAMBRA HEALTHCARE & WELLNESS CENTRE, LP in ALHAMBRA, CA was cited for violations during a health inspection on June 28, 2024.
Certified Nursing Assistant 3 told inspectors she first noticed the pressure injury during that week.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.