One resident was moved four times during their stay at the facility. Another changed rooms twice in five days. A third was transferred without any documentation that staff told them it was happening.
The violations center on a basic resident right: advance notice before room changes. Federal regulations require nursing homes to notify residents and their families before moving them, but Alhambra's records showed no such notifications for multiple room transfers in September.
Resident #2 experienced the most disruption, changing rooms on September 29, September 19, and September 15. Staff documented only one of those moves in the resident's progress notes. The Director of Nursing later confirmed this resident had actually changed rooms four times total during their stay.
"I see one progress note about one of the room changes," the Director of Nursing told inspectors on October 15. "It appears Resident #2 was moved the first time because we needed a private isolation room. I would expect to find a note in the progress notes documenting the other room changes."
Resident #3 changed rooms twice within five days, moving on September 24 and September 19. Staff failed to document notification for either transfer.
Resident #4 was moved on September 30 with no record that anyone told them about the change beforehand.
The pattern revealed a breakdown in basic communication protocols. The Director of Nursing explained that the Social Services Director typically handles family notifications while nursing staff complete the physical room transfers. But when inspectors arrived, the Social Services Director was out of the building and unreachable.
"Residents, and their representatives are supposed to be notified of a room change each time," the Director of Nursing acknowledged. "Normally the SSD will document notification of the room change in the progress notes."
The nursing director said room changes happen for various reasons. Some are by resident request for personal preferences. Others are initiated by the facility for operational needs, like the isolation room requirement that prompted Resident #2's first move.
But regardless of the reason, the law requires advance notice. The facility's own policy, revised in December 2016, acknowledges residents' rights to "be informed about his or her rights and responsibilities" and to "exercise his or her rights without interference, coercion, discrimination or reprisal from the facility."
Room assignments carry particular significance in nursing homes, where residents often spend their final years. A room becomes home. Roommate relationships develop. Personal belongings are arranged in familiar patterns. Moving someone without notice disrupts these connections and can cause confusion, especially for residents with dementia.
The inspection found no evidence that any of the three residents or their families were consulted before the moves or received written explanations afterward. Progress notes, which should document all significant events in a resident's care, contained no mention of the notifications that should have preceded most of the room changes.
When confronted with the missing documentation, the Director of Nursing didn't dispute the violations. She confirmed each resident had changed rooms as the census records showed and acknowledged that notification should have been documented in every case.
The facility's policy manual contains detailed language about treating residents "with kindness, respect, and dignity" and ensuring "a dignified existence." But the room change violations suggest a gap between written policies and daily practice.
For Resident #2, who endured four room changes, the lack of proper notification meant repeated disruptions without explanation. The resident went from room to room, including a stint in isolation, while staff failed to maintain basic records about whether anyone bothered to explain what was happening.
The violations affected multiple residents over a concentrated time period, suggesting systemic problems rather than isolated oversights. Three residents experienced undocumented room changes within a 15-day span in September, pointing to broader breakdowns in communication protocols.
Federal inspectors classified the violations as causing "minimal harm or potential for actual harm" but noted they affected "some" residents. The finding indicates ongoing compliance problems that could affect other residents beyond those specifically documented in the complaint investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alhambra Healthcare & Rehabilitation Center from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
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