ALHAMBRA, CA - A federal inspection conducted in June 2024 at Alhambra Healthcare & Wellness Centre identified multiple deficiencies in wound care management, bowel and bladder programs, respiratory care services, and medication management that affected resident health and safety.
Wound Care Management Failures Lead to Pressure Injury Progression
One of the most significant findings during the inspection involved the facility's failure to provide appropriate treatment for a resident who developed a Stage 2 pressure injury. The resident, initially admitted with muscle weakness and osteoporosis, had been identified as at risk for developing pressure injuries according to assessments conducted in March and June 2024 using the Braden Scale, a standardized tool for evaluating pressure injury risk.
According to the inspection narrative, the resident initially presented with moisture-associated skin damage (MASD) on the sacrum area, which subsequently progressed to a Stage 2 pressure injury by June 21, 2024. A Stage 2 pressure injury represents a significant escalation in severity, characterized by broken skin that may appear as an abrasion, blister, or shallow crater.
The facility's treatment nurse confirmed that despite this progression, the physician was not notified of the pressure injury development, resulting in no wound treatment orders being issued. Additionally, no Change of Condition form was completed to document the wound's advancement from MASD to a Stage 2 pressure injury.
Why Pressure Injury Management Matters
Pressure injuries represent one of the most preventable complications in long-term care settings. When skin is subjected to prolonged pressure, blood flow to the affected area becomes restricted, depriving tissue of oxygen and nutrients. Without prompt intervention, these injuries can progress rapidly through increasingly severe stages, potentially leading to deep tissue damage, infection, and in severe cases, life-threatening complications such as sepsis.
The progression from moisture-associated skin damage to a Stage 2 pressure injury indicates that the skin barrier had been compromised, creating an entry point for bacteria. At this stage, residents face increased risk of infection, prolonged healing times, and significant discomfort. Early physician notification and implementation of appropriate wound care protocols are essential to prevent further deterioration.
According to industry standards, facilities should have comprehensive protocols in place that include daily skin inspections, prompt physician notification of any changes in wound status, and immediate implementation of pressure relief measures. The facility's own policy required staff to observe and report signs of active pressure injury daily and notify the physician when changes occur in skin integrity conditions.
Bowel and Bladder Program Implementation Gaps
The inspection revealed that three residents who had been assessed as good candidates for scheduled toileting programs never received physician orders to implement these interventions, despite multiple assessments indicating they would benefit from such programs.
The bowel and bladder screening tool identified these residents as appropriate candidates for scheduled toileting interventions on multiple occasions throughout 2023 and 2024. Scheduled toileting involves establishing regular times to assist residents with bathroom use, typically before or after meals, based on individual patterns and needs.
One resident who required substantial assistance with bathing and dressing was assessed as a good candidate for the program in August 2023, November 2023, February 2024, and May 2024. Despite these repeated assessments, no toileting schedule order was obtained from the physician, and the program was never implemented.
The Importance of Continence Management Programs
Maintaining bowel and bladder function represents a critical quality of life issue for nursing home residents. When continence can be preserved or restored through scheduled toileting programs, residents experience numerous benefits including reduced risk of urinary tract infections, prevention of skin breakdown from prolonged exposure to moisture, improved self-esteem, and maintenance of dignity.
For cognitively impaired residents who may not recognize or communicate the need to use the bathroom, scheduled toileting provides regular opportunities to maintain continence. Without such programs, these residents face increased likelihood of developing incontinence, which can lead to a cascade of complications including skin breakdown, increased fall risk when attempting to reach the bathroom independently, and social withdrawal.
The facility's own policy emphasized that scheduled toileting programs were appropriate for residents who are caregiver dependent and cognitively impaired, and stated the program's purpose was to restore as much bowel and bladder function as possible, prevent skin breakdown, and restore resident dignity and self-respect. The Assistant Director of Nursing confirmed that implementing scheduled toileting helps residents improve incontinence status, practice independence, and promote dignity.
Respiratory Care Service Deficiencies
Inspectors identified multiple respiratory care violations affecting four residents who required supplemental oxygen and other respiratory interventions. The findings revealed both infection control concerns and failures to follow physician orders.
One resident with congestive heart failure had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula for shortness of breath. During observation, the resident was found sitting in a wheelchair without the nasal cannula in use, with the tubing hanging at the back of the wheelchair exposed to environmental contaminants. The tubing was not stored in a clean plastic bag as required by facility protocols.
Another resident's oxygen nasal cannula was found wrapped around the bed's side rail, exposed and not properly stored. These practices created potential for bacterial contamination of equipment that delivers air directly into residents' respiratory systems.
Additionally, one resident's oxygen equipment and humidifier water container were not labeled with dates indicating when they were first opened or last changed. Facility policy required this equipment to be changed every seven days and properly dated to prevent bacterial growth in the water used to humidify oxygen.
Perhaps most concerning, a resident with Parkinson's disease and chronic obstructive pulmonary disease who had physician orders for suctioning as needed had no suction equipment readily available at the bedside. This same resident's nebulizer tubing was found on the floor rather than properly stored.
Respiratory Care Standards and Infection Risk
Oxygen therapy equipment requires meticulous attention to cleanliness and proper storage because it provides a direct pathway to the lungs. Contaminated oxygen delivery devices can introduce bacteria, fungi, or viruses into the respiratory system, potentially causing pneumonia or exacerbating existing respiratory conditions.
Humidifier water containers represent particular infection risks because standing water provides an ideal environment for bacterial growth, including potentially deadly organisms such as Pseudomonas aeruginosa. Industry standards require regular equipment changes, proper labeling, and use of sterile water to minimize these risks.
For residents with chronic respiratory conditions requiring supplemental oxygen, inconsistent delivery of prescribed oxygen can result in hypoxia (low oxygen levels in body tissues), which may cause shortness of breath, confusion, rapid heart rate, and in severe cases, organ damage. The facility's Assistant Director of Nursing confirmed that failure to provide oxygen according to physician orders could result in the resident developing shortness of breath and hypoxia.
Medication Management Concerns
The inspection documented that one resident's gabapentin, a medication prescribed for diabetic nerve pain, was completely out of stock when the nurse attempted to administer the morning dose. The nursing staff confirmed the resident missed the scheduled dose because previous shifts had failed to reorder the medication when supplies ran low.
Gabapentin requires consistent dosing to maintain therapeutic blood levels and effectively manage neuropathic pain. According to facility policy, nurses should reorder medications three to four days in advance when only four to seven doses remain in stock to ensure continuous availability.
Consequences of Medication Interruptions
For residents taking gabapentin for diabetic neuropathy, missing doses can result in breakthrough pain that may take days to control once medication is resumed. Diabetic neuropathy causes burning, tingling, or shooting pain in the extremities that can significantly impact quality of life, sleep, mobility, and overall function.
Beyond the immediate discomfort, inconsistent gabapentin dosing can lead to decreased medication effectiveness over time. The nursing staff acknowledged that gabapentin would not be effective if not taken consistently as scheduled, and that the resident could experience nerve pain due to the missed dose.
Additional Issues Identified
The inspection revealed several other deficiencies that raised concerns about facility operations:
Medication Storage Violations: Unused insulin pens for two residents requiring diabetes management were stored in medication carts at room temperature rather than being refrigerated as required by manufacturer specifications. Improper insulin storage can cause the medication to lose potency or become toxic, potentially leading to uncontrolled blood sugar levels and serious health complications.
Food Safety Concerns: Kitchen inspections found improperly sealed containers of rice and brown sugar that could allow pest contamination, as well as a can opener with dried food residue, gunk, and rust that had not been properly cleaned between uses. These conditions created potential for foodborne illness transmission to residents.
Infection Control Lapses: A nursing assistant was observed performing incontinence care for a resident, then touching the call light, blanket, bed rail, and bed remote with contaminated gloves without changing them. This practice significantly increased infection transmission risk. Additionally, the facility had not implemented water testing protocols to validate their water management program's effectiveness in controlling Legionella and other waterborne pathogens, despite housing a vulnerable population at increased risk for Legionnaires' disease.
The inspection findings at Alhambra Healthcare & Wellness Centre highlight the critical importance of following established protocols for wound care, continence management, respiratory services, and medication administration in long-term care settings. When facilities fail to implement physician-ordered interventions or follow their own policies, residents face increased risk of complications, infections, and diminished quality of life.
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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