Alhambra Healthcare & Wellness Centre, Lp

F-F656) Residents Affected - Few Based on interview and record review the facility failed to ensure one (1) of two (2) sampled residents (Resident 26) was given appropriate treatment for a Stage 2 (the skin breaks open; it can look like an abrasion, blister, or a shallow crater of the skin) Pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin).

This deficient practice resulted in Resident 26's pressure injury progressing from a Moisture-Associated Skin Damage (MASD, inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine stool, sweat, wound drainage, saliva, or mucus) wound, to a stage 2 pressure injury.

Findings:

A review of Resident 26's Admission Record indicated the resident was a admitted to the facility on [DATE REDACTED] with the diagnoses of muscle weakness and osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bones changes)

A review of Resident 26's History and Physical (H&P), dated 6/13/2023, indicated resident had the capacity to understand and make decisions.

A review of Resident 26's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 6/8/2024, indicated resident was severely impaired in cognitive (the functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making. MDS also indicated resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene, toileting hygiene, lower body dressing and personal hygiene. Resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self and putting on/taking off footwear.

A review of Resident 26's Braden Scale (tool used to indicate risk for developing pressure injuries), dated 3/8/2024, indicated resident was at risk of developing pressure injuries.

A review of Resident 26's Braden Scale, dated 6/8/2024, indicated resident was at risk of developing pressure injuries.

During an interview on 6/26/2024 at 10:08 AM, Treatment Nurse 1 (TN 1) stated Resident 26 initially had MASD on the sacrum area which has now developed into a stage 2 pressure injury since 6/21/2024. TN 1 stated the doctor was not notified of Resident 26's pressure injury, therefore there was no wound treatment orders to care for Resident 26's stage 2 pressure injury. TN 1 also stated there was no Change of Condition (COC; a sudden deviation from the resident's baseline in physical, cognitive, behavioral, or functional domains) form completed for Resident 26's progression of wound to a stage 2 pressure injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During a concurrent interview and record review of Resident 26's Physician Orders with the Assistant Director of Nursing (ADON), on 6/26/24 at 4:09 PM, the ADON stated Resident 26 physician order did not Level of Harm - Minimal harm or indicate Resident 26 having a pressure injury. The ADON stated there was no order for Resident 26 to have potential for actual harm a wound consult, therefore Resident 26 had not seen the wound doctor after Resident 26's wound progressed to a stage 2 pressure injury. The ADON stated since Resident 26 had not seen the wound Residents Affected - Few doctor, resident 26's wound could become worse.

During a concurrent interview and record review of Resident 26's Care Plans with DON on 6/27/2024 at 11:01 AM, DON stated Resident 26 did not have a care plan indicating any pressure injuries.

A review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 8/24/2023, indicated the comprehensive care plan will also be reviewed and revised at the following times such as onset of new problems and change of condition.

A review of the facility's P&P titled, Pressure Injury Prevention, revised 3/30/2023, indicated staff will observe and report any signs of active pressure injury daily.

A review of the facility's P&P titled, Skin Integrity Management, revised 10/26/2024, indicated the physician will be notified when there is a change in the condition of the pressure injury or skin integrity condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42223

Residents Affected - Some Based on observation, interview, and record review, the facility failed to implement a toileting schedule (timed voiding) for three (3) of 3 sampled residents (Resident 40, 16, and 82), who were assessed as candidates on the bowel and bladder (B&B) program screener (an assessment of the bowel and bladder to see if residents are candidates to join a scheduled toileting) as indicated on the facility policy and procedure.

This deficient practice has the potential for Residents 40, 16, and 82 to become incontinent (loss of bowel and bladder control).

Findings:

1. A review of Resident 40's Admission Record indicated resident was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with the diagnoses of muscle weakness and hypertension (high blood pressure).

A review of Resident 40's History and Physical (H&P), dated 5/17/2024, indicated resident did not have the capacity to understand and make decisions.

A review of Resident 40's Minimum Data Set (MDS, a standardized screening and assessment tool), dated 6/12/2024, indicated resident was severely impaired in cognitive (the functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making. MDS also indicated Resident 40 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating, oral hygiene, upper body dressing, lower body dressing and putting on/taking off footwear. MDS indicated Resident 40 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two (2) or more helpers is required for the resident to complete the activity) with toileting hygiene and shower/bathe self. MDS indicated Resident 40 was occasionally incontinent with urinary continence and always continent with bowel continence.

A review of Resident 40's B&B Program Screener, dated 8/7/2023, indicated resident was a good candidate for retraining.

A review of Resident 40's B&B Program Screener, dated 11/5/2023, indicated resident was a good candidate for retraining.

A review of Resident 40's B&B Program Screener, dated 2/3/2024, indicated resident was a good candidate for retraining.

A review of Resident 40's B&B Program Screener, dated 5/5/2024, indicated resident was a good candidate for retraining.

During an interview on 6/26/2024 at 9:57 AM, Certified Nursing Assistant 3 (CNA 3) stated the resident will call for assistance when she wants to urinate but not when she has a bowel movement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 During a concurrent interview and record review with Licensed Vocational Nurse 6 (LVN 6) on 6/27/2024 at 8:42 AM, LVN 6 stated after the B&B screening was conducted and indicated that the resident was a Level of Harm - Minimal harm or candidate, an order for scheduled toileting (scheduled restroom breaks per physician order; ex: before meals potential for actual harm or after meals) would be obtained. LVN 6 stated Resident 40 did not have an order for toileting schedule.

Residents Affected - Some During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 6/27/2024 at 8:53 AM, the ADON stated Resident 40 was identified as candidate for scheduled toileting based on the B&B screener program. The ADON also stated since Resident 40 did not have an order for scheduled toileting, Resident 40's incontinence may not improve.

2. A review of Resident 16's Admission Record, dated 5/29/2024, indicated resident was admitted to the facility on [DATE REDACTED] with the diagnoses of muscle weakness and hypertension.

A review of Resident 16's H&P, dated 5/30/2024, indicated the resident did not have the capacity to understand and make decisions.

A review of Resident 16's MDS, dated [DATE REDACTED], indicated the resident was moderately impaired with cognitive skills for daily decision making. MDS also indicated rResident 16 required partial/moderate assistance with eating, oral hygiene, and personal hygiene. Resident 16 was dependent in toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. MDS indicated resident was not rated for urinary incontinence and was always incontinent for bowel continence.

A review of Resident 16's B&B Program Screener, dated 5/29/2024, indicated resident was a good candidate for scheduled toileting.

During a concurrent interview and record review with the Director of Nursing (DON) on 6/27/2024 at 11:08 AM, the DON stated Resident 16 was a good candidate for the toileting program. The DON stated Resident did not have a physician's order indicating Resident 16 was on scheduled toileting. The DON also stated scheduled toileting aids in restoring bowel and bladder continence (the ability to control movements of the bowels and bladder) and would be beneficial for Resident 16.

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3. A review of Resident 82's Admission Record indicated the resident was initially admitted to the facility on [DATE REDACTED] and with diagnoses of type 2 diabetes (DM2 - condition that results in too much sugar circulating in

the blood) and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body's needs).

A review of Resident 82's H&P, dated 5/24/2024, indicated the resident does not have the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 A review of Resident 82's MDS, dated [DATE REDACTED], indicated the resident was moderately impaired with cognitive skills for daily decision making, and needed substantial/maximal assistance (helper does more than half the Level of Harm - Minimal harm or effort) with toilet transfers (ability to get on and off a toilet or commode) and was dependent (helper does all potential for actual harm of the effort) with toileting hygiene (the ability to maintain perineal [an area between the thighs that marks the approximate lower boundary of the pelvis] adjust clothes before and after voiding or having a bowel Residents Affected - Some movement) and dressing (how a resident puts on, fastens and takes off all items of clothing). MDS also indicated that resident was frequently incontinent (unable to restrain natural discharges or evacuations of urine or feces - two [2] or more episodes of bowel incontinence but at least one continent bowel movement) and was not on the toileting program to manage their bowel incontinence.

During an interview on 6/26/2024 at 10 AM with Resident 82, Resident 82 stated that he is incontinent (unable to restrain natural discharges or evacuations of urine or feces) and needs help with changing since

he is unable to get up out of bed and walk or get out of bed on his own.

A review of Resident 82's B&B Program Screener, dated 5/29/2024 and 6/18/2024, indicated the B&B Program Screener dated 5/29/2024 indicated a score of seven (7) which indicated that the resident was a candidate for scheduled toileting and the B&B Program Screener Dated 6/18/2024 indicated a score of 14 which indicated the resident was a candidate for scheduled toileting.

During a concurrent review of Resident 82's electronic medical record (EMR, an electronic version of a patient's medical history), dated 5/29/2024 to 6/27/2024 and interview with the ADON on 6/27/2024 at 11:59 AM, ADON stated there was no care plan for the resident being on a scheduled toileting program. ADON stated that there was no care plan implemented for resident to be on a scheduled toileting program.

During an interview on 6/27/2024 at 11:59 AM with ADON, ADON stated that a toileting schedule is when the licensed nurse assesses what times to schedule to either take or assist a resident to the restroom, offer bedside commode (portable toilet) or bed pan (a receptacle used by a bedridden resident as a toilet). ADON also stated that although Resident 82 has a Foley catheter (brand name for urinary indwelling catheter which is a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage), the resident could still be on scheduled toileting program for bowel movement but currently is not on one. ADON further stated that if Resident 82 was assessed to be a candidate, then the resident should be on a scheduled toileting program since it helps residents improve incontinence status, practice independence, and promote dignity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 A review of the facility's Policy and Procedure (P&P) titled, Bowel and Bladder Training/Toileting Program, revised 8/21/2020, indicated its purpose was to provide for residents who are incontinent of bowel and/or Level of Harm - Minimal harm or bladder appropriate treatment and services to minimize urinary tract infections (UTI, an infection in any part potential for actual harm of the urinary system) and to restore as much bowel and/or bladder function as possible to prevent skin breakdown and irrigation, improve resident morale and restore resident dignity and self-respect. The P&P Residents Affected - Some also indicated, Interventions identified by the licensed nurses and/or the Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose to set goals, make decisions and share resources and responsibilities) will be care planned and communicated to the corresponding professional and to the facility staff for implementation. It also indicated each resident who is incontinent of bowel and/or bladder is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal bladder and/ or bowel functions as possible. The policy also indicated scheduled toileting program is appropriate for residents who are caregiver dependent, cognitively impaired and cannot gain control of their bowel and bladder function.

A review of the facility's P&P titled Resident Rights - Quality of life, dated 3/2017, indicated facility staff treats cognitively impaired residents with dignity and sensitivity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45099 potential for actual harm Based on observation, interview, and record review, the facility failed to provide the necessary respiratory Residents Affected - Some care services for four (4) of 4 sampled residents (Resident 2, 49, 63, and 641) in accordance with the facility's policy and procedure.

1. For Resident 2, the facility failed to ensure the oxygen via nasal cannula (a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) was administered according to physician's order. This deficient practice had the potential for Resident 2 not being able to receive the benefits of the supplemental oxygen ordered if the oxygen tubing is not in an optimal working condition.

2. For Resident 2 and 49, the facility failed to ensure the nasal cannula was placed in a clean plastic bag when not in use. This deficient practice had the potential for the residents to develop a respiratory infection.

3. Resident 641's oxygen nasal cannula (NC; a device that delivers extra oxygen through a tube and into your nose) and water container for humidified oxygen (warmed and moistened oxygen) was not labeled with date of first use (opened) or changed.

4. Resident 63 who had an order for suctioning (clearing the airway of a patient) as needed had no suction canister (temporary storage container for secretions or fluids removed from the body) and yaunker (an oral suctioning tool used in medical procedures and is typically a firm plastic suction tip with a large opening surrounded by a bulbous [round] head and is designed to allow effective suction without damaging the surrounding tissue) readily available at his bedside and the resident's nebulizer (a machine that turns liquid medication into a mist that can be breathed directly into the lungs) treatment NC was found on the floor.

Findings:

1. A review of Resident 2's Admission Record indicated Resident 2 was admitted on [DATE REDACTED] and readmitted

on [DATE REDACTED] with congestive heart failure (CHF, a serious condition in which the heart doesn't pump blood as efficiently as it should).

A review of Resident 2's History and Physical (H&P), dated 4/5/2024, indicated Resident 2 was able to make decisions for herself.

A review of Resident 2's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 5/6/2024, indicated Resident 2 had moderate cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 2 required substantial assistance (helper does more than half the effort) with toileting, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with upper body dressing and required supervision (helper provides verbal cues) with eating and oral hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 A review of the Physician's Order, dated 5/14/2024, timed at 1:02 PM indicated to administer oxygen at 2 L/minute (Liter per minute - unit of flow rate) via nasal cannula (a medical device used to provide Level of Harm - Minimal harm or supplemental oxygen therapy to people who have lower oxygen levels) continuous for shortness of breath potential for actual harm (SOB, frightening sensation of being unable to breath normally or feeling suffocated).

Residents Affected - Some During a concurrent observation and interview in Resident 2's room on 6/25/2024 at 3:13 PM, Resident 2 was sitting on the wheelchair with her nasal cannula at the back of the wheelchair hanging close to the oxygen tank exposed and not in use. Certified Nursing Assistant 1 (CNA 1) stated and confirmed Resident 2's nasal cannula was at the back of the resident's wheelchair and stated there should be a plastic bag to place Resident 2's nasal cannula to avoid contamination.

During an observation on 6/27/2024 at 1:36 PM, the Licensed Vocational Nurse 1 (LVN 1) stated Resident 2's nasal cannula should be placed in a bag to prevent from touching any surface and avoid from getting contaminated.

During an interview on 6/27/2024 at 4:41pm, LVN 2 stated Resident 2 should be using her oxygen nasal cannula while on the wheelchair to help with her breathing. LVN 2 stated Resident 2 could get SOB if the oxygen was not in use.

During an interview on 6/27/2024 at 4:48 PM, the Assistant Director of Nursing (ADON) stated Resident 2 could develop SOB and hypoxia (low levels of oxygen in the body tissues) if the oxygen via nasal cannula was not provided according to the physician's order. The ADON also stated Resident 2's nasal cannula should be placed in a bag if not being used to prevent contamination.

2. A review of Resident 49's Admission Record indicated Resident 49 was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED] with atherosclerotic (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of the artery) heart disease.

A review of the Physician's Order, dated 10/31/2022, timed at 6:32 PM indicated to administer oxygen at 2 L/minute via nasal cannula to keep oxygen saturation over 92 % prn for SOB as needed.

A review of Resident 49's H&P, dated 8/24/2023, indicated Resident 49 has the capacity to understand and make decisions.

A review of Resident 49's MDS, dated [DATE REDACTED], indicated Resident 49 had moderate cognitive skills for daily decision making. The MDS also indicated Resident 49 required set up (helper sets up or cleans up) with eating, oral, toileting, and personal hygiene shower, upper and lower body dressing, and putting on/taking off footwear.

During a concurrent observation and interview in Resident 49's room on 6/25/2024 at 11:15 AM, Resident 49 was in bed with his nasal cannula wrapped on the left bedside rail (made from plastic or metal and have hooks and other attachments to attach them to the bed frame) exposed and not inside the plastic bag and not placed by the oxygen concentrator (a medical device that gives extra oxygen by taking and filtering air from the surroundings). LVN 1 stated and confirmed Resident 49's nasal cannula was wrapped on the left bedside rail and stated Resident 49's nasal cannula should be placed inside a plastic bag and should not be touching anything unclean to avoid contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 During an interview on 6/27/2024 at 4:13 PM, LVN 3 stated Resident 49's stated the nasal cannula should be placed in the plastic bag and oxygen tubing dated with date of first use. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/28/2024 at 11:42 AM, the ADON stated Resident 49's nasal cannula should not be left hanging by the side rails and was exposed to germs of the side rails and it is not acceptable. ADON also Residents Affected - Some stated, the nasal cannula should be placed in a clean plastic bag when not in use.

A review of the facility's policy and procedure titled, Oxygen Therapy, revised November 2017, indicated that

the oxygen was to be administered under safe and sanitary conditions to meet resident needs. The policy also indicated that licensed nursing staff will administer oxygen as prescribed. The policy further indicated to administer oxygen per physician's order.

48395

3. A review of Resident 641's Admission Record, indicated the resident was initially admitted to the facility on [DATE REDACTED] with diagnoses of hypertensive urgency (an acute [sudden] severe elevation in blood pressure without signs or symptoms of end-organ damage [damage occurring in major organs fed by the circulatory system - heart, kidneys, brain, eyes - which can sustain damage due to uncontrolled hypertension]) and pneumonia (an infection of one or both of the lungs caused by bacteria, viruses or fungi).

A review of Resident 641's H&P, dated 6/25/2024, indicated the resident does not have the capacity to understand and make decisions.

A review of Resident 641's Order Summary Report dated 6/18/2024, indicated for Resident 641 to have oxygen at 2 liters (L; a unit of measurement) via (by) NC continuously every shift for shortness of breath (SOB).

During an observation on 6/25/2024 at 9:05 AM in Resident 641's room, Resident 641's oxygen NC tubing and water container for her humidified oxygen was not labeled with date opened or changed.

During a concurrent observation and interview on 6/25/2024 at 9:13 AM with Physical Therapist 1 (PT 1) in Resident 641's room, Resident 641's oxygen NC and water for her humidified oxygen was observed with no label of date opened or changed. PT 1 stated that the resident's oxygen NC tubing and water container for her humidified oxygen was not labeled with date it was open or changed.

During a concurrent observation and interview on 6/25/2024 at 9:20 AM with Certified Nursing Assistant 2 (CNA 2) in Resident 641's room, Resident 641's oxygen NC and water for her humidified oxygen was observed with no label of date it was opened or changed. CNA 2 stated that the resident's oxygen NC tubing and water container for her humidified oxygen was not dated.

4. A review of Resident 63's Admission Record, indicated the resident was initially admitted to the facility on [DATE REDACTED] with diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness and difficulty with balance and coordination) and chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation (the worsening of a disease or an increase in its symptoms).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 A review of Resident 63's H&P, dated 5/17/2023, H&P indicated the resident does not have the capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm A review of Resident 63's MDS, dated [DATE REDACTED], indicated the resident had severe impairment (difficulty with or unable to make decisions, learn, remember things) with their cognitive (ability to think, remember, and Residents Affected - Some reason) ability for daily decision making, and was dependent (helper does all of the effort) with transfers (how resident moves to and from bed, chair, wheelchair), dressing (how a resident puts on, fastens and takes off all items of clothing), personal hygiene & eating.

A review of Resident 63's Order Summary Report dated 6/28/2024, indicated on 5/25/2023 it was ordered that the resident may suction excessive secretions (fluid produced by the glands that line the nose, mouth, throat and windpipe) as needed. It also indicated an order for the resident to have Ipratropium-Albuterol Solution (a medication used to help control the symptoms of lung diseases] 0.2-2.5 (3) milligrams (mg; a unit of measurement) per 3 milliliters (ml; a unit of measurement) via inhalation orally every 4 hours as needed for wheezing.

During a concurrent observation and interview on 6/25/2024 at 8:37 AM with Licensed Vocational Nurse 4 (LVN 4) in Resident 63's room, a suction machine was observed on Resident 63's nightstand with no canister or yaunker set up or attached. LVN 4 stated that there is no yaunker or suction canister set up at the resident's bedside and that there should be always one available in case the resident needs their respiratory secretions suctioned.

During a concurrent observation and interview on 6/27/2024 at 10:36 AM with CNA 4 inside Resident 63's room, Resident 63's nebulizer NC tubing was observed partly in the bag with the main body of the tubing on

the floor. CNA 4 stated that the resident's nebulizer NC tubing is touching the floor.

During a concurrent observation and interview on 6/27/2024 at 10:36 AM with LVN 5 in Resident 63's room, Resident 63's nebulizer NC tubing was observed partly bin the bag with the rest of the tubing touching the floor. LVN 5 stated that the resident's nebulizer NC tubing is touching the floor and that it should not be for infection control purposes.

During an interview on 6/28/2024 at 2:33 PM with Infection Preventionist (IP), IP stated that all oxygen tubing and water containers for humidified oxygen should be labeled with the date it was changed or first use for infection control and so that staff know when the tubing was last changed. IP also stated that all NC tubing either for use with oxygen or nebulizer treatment should be stored in a bag when not in use and should not be touching the floor due to infection control and further stated that when a resident is ordered for suction as needed, it is important that a full set up with the suction machine, canister and yaunker always be present at

the bedside and has been set up because it puts the resident at risk for aspiration if it is not readily available.

During an interview on 6/28/2024 at 4:23 PM with the Director of Nursing (DON), the DON stated that there is no policy for suctioning or for the storage of oxygen and nebulizer tubing to be off the floor and not touching the floor. The DON further stated that it is important that there is a policy to address these subjects so that all staff know how to perform those respiratory interventions properly.

A review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, revised November 2017, the P&P indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 *The humidifier and tubing should be changed no more than every 7 days and labeled with the date of the change. Level of Harm - Minimal harm or potential for actual harm *Humidifier equipment will be maintained and/or changed per manufacturer's guidelines or no more than every 7 days. They will be dated each time they are changed. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45099

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure one (1) of 5 (five) sampled residents (Resident 54) had sufficient supply of gabapentin (nerve pain medication) to administer in accordance with the physician's order and facility's policy and procedure.

These deficient practices resulted to a delay in the administration of the medication and had the potential to create medication - related adverse consequences such as unrelieved nerve pains to Resident 54.

Findings:

A review of Resident 54's Admission Record indicated Resident 54 was admitted on [DATE REDACTED] with type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar by either the body does not produce enough insulin, or it resists insulin) with diabetic neuropathy (nerve damage caused by diabetes which can affect nerves that supply feeling and movement in the arms and legs).

A review of the Physician's Order, dated 11/14/2022, timed at 3:57 PM indicated to administer gabapentin capsule 100 milligram (mg, a unit of measurement) by mouth two (2) times a day for neuropathy.

A review of Resident 54's History and Physical (H&P), dated 11/14/2023, indicated Resident 54 had the capacity to understand and make decisions.

A review of Resident 54's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 5/15/2024, indicated Resident 54 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 54 required supervision (helper provides verbal cues) with shower, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated Resident 54 required set up (helper sets up or cleans up) with toileting hygiene and upper body dressing.

During a medication pass observation on 6/27/2024 at 9:21 AM, the Licensed Vocational Nurse 4 (LVN 4) stated Resident 54 did not have any supply of gabapentin 100 mg in the medication cart to administer to the resident.

During an interview on 6/27/2024 at 11:56 AM, LVN 4 stated when the medication is between six (6) to seven (7) left in stock, the licensed nurse should have called the pharmacy to order refill. LVN 4 also stated

the nurse in charge of passing the medications for Resident 54 needed to be more attentive to how much gabapentin was left on the resident's stock otherwise there is a possibility for the resident to experience nerve pains due to not receiving the medication as scheduled. LVN 4 further stated Resident 54 missed his morning dose today (6/27/2024) of gabapentin because the staff in charge on previous days failed to order

the refill.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During an interview on 6/27/2024 at 1:37 PM, LVN 1 stated the licensed nurse in charge of Resident 54 was supposed to notify the pharmacy and the resident's physician when there's no available medications to give Level of Harm - Minimal harm or to the resident. LVN 1 also stated when there's only four (4) to 5 left on Resident 54's gabapentin, the license potential for actual harm nurse in charge of the resident should have ordered the refill from the pharmacy so it would be available for

the next medication nurse to give, and Resident 54 would not miss a dose. LVN 1 further stated Resident 54 Residents Affected - Few could start having pain if the gabapentin was not administered as ordered.

During an interview on 6/28/2024 at 11:37 AM, the Assistant Director of Nursing (ADON) stated the charge nurse had to make sure Resident 54's gabapentin was refilled on time before the resident ran out of stock.

The ADON also stated, Resident 54's gabapentin medication would not be effective if not taken consistently as scheduled.

A review of the facility's Policy and Procedure titled, Medication Ordering and Receiving from Pharmacy, updated February 2020, indicated to reorder medications (three or four) days in advance of need to assure

an adequate supply is on hand. The policy also stated the refill order is called in, faxed, or otherwise transmitted to the pharmacy. when ordering

A review of the facility's Policy and Procedure titled, Medication Administration, dated January 1, 2012, indicated its purpose was to ensure the accurate administration of medications for residents in the facility.

The policy also indicated that the medication will be administered as prescribed to ensure compliance with dose guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 47362 Residents Affected - Few Based on observation, interview, and record review the facility failed to follow its Medication Storage policy by failing to:

1. Refrigerate Residents 48's unused Novolin R Flex Pen (form of insulin, a naturally occurring hormone, used to control blood sugar in patients with diabetes).

2. Refrigerate Residents 59's unused Basaglar Kwik Pen (is a long-acting insulin that helps lower high blood sugar levels).

This deficient practice increased the risk for Residents 48 and 59 to receive insulin that had become ineffective or toxic due to improper storage possibly leading to health complications, which may result to harm and hospitalization .

Findings:

1. During a concurrent observation of Medication Cart 3 in Station 2 and interview with Licensed Vocational Nurse (LVN 4) on 6/28/2024 at 2:35 PM, Residents 48's Novolin R Flex Pen was observed in Medication Cart 3. LVN 4 stated a green sticker on Residents 48's Novolin R Flex Pen indicated the medication needs to be refrigerated. LVN 4 also stated Residents 48's unused Novolin R Flex Pen was not and was supposed to be in the refrigerator.

2. During a concurrent observation of Medication Cart 3 in Station 2 and interview with LVN 4 on 6/28/2024 at 2:49 PM, Residents 59's Basaglar Kwik Pen was observed in Medication Cart 3. LVN 4 stated a green sticker on Residents 59's Basaglar Kwik Pen indicated the medication needs to be refrigerated. LVN 4 also stated Residents 59's unused Basaglar Kwik Pen was not and was supposed to be in the refrigerator. LVN 4 stated it was important to follow the proper storage of the medications to maintain its patency or its concentration.

During interview and record review on 6/28/2024 at 3 PM with the assistant director of nursing (ADON), ADON stated unused Novolin R Flex Pen and Basaglar Kwik Pen should be stored in the refrigerator. ADON also stated the green sticker indicating Refrigerate was a reminder to nurses. ADON added Basaglar Kwik Pen box indicated, Store at 36 degrees Fahrenheit to 46 degrees Fahrenheit until time of use. Protect from direct heat and sunlight. Discard unused portion of the Basaglar Kwik Pen 28 days after first opening. ADON stated it was important to keep the potency of the medication and if proper storage was not observed the health of the residents will be compromised.

A review of the facility's Policy and Procedure (P&P) titled, Storage of Medications, dated 8/2019, indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 47362

Residents Affected - Some Based on observation, interview, and record review, the facility failed to follow proper food handling practices

in accordance with its policy and procedure by failing to ensure:

1. A container of rice was sealed properly.

2. A container of brown sugar was sealed properly.

3. A can opener was clean and free of gunk (unpleasantly sticky or messy substance) and rust (a reddish-brown substance that forms on the surface of iron and steel as a result of reacting with air and water).

These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, which can lead to other serious medical complications and hospitalization .

Findings:

During an observation in the facility's kitchen on 6/25/2024 at 7:49 PM, the following were observed:

1. A clear plastic container of rice storage was not sealed properly.

2. A clear plastic container of brown sugar was not sealed.

3. A can opener was dirty with dried food residue, gunk, and rust.

During concurrent observation in the kitchen and interview on 6/25/2024 at 7:49 AM with the Dietary Supervisor (DS), DS stated the clear plastic container of rice, and the container of brown sugar was not properly closed. DS stated the can opener was dirty with dried food residue, gunk, and rust.

During concurrent interview on 6/26/2024 at 3:28 with the DS, DS stated all food containers were supposed to be tightly closed to avoid pest inside the container for infection control. DS stated all lids and containers were supposed to be in good condition and not broken. DS added, the can opener should be washed after every use to keep it clean.

A review of facility Policy & Procedure (P&P) titled, Food Storage and Handling, revised 2/29/2024, indicated to place opened products in storage container with tight fitting lids and to label and date all storage products.

It also indicated to monitor area routinely for pest activity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 A review of facility P&P titled, Can Opener Use and Cleaning, revised 10/1/2024, indicated its purpose is to establish guidelines for the use and cleaning of a can opener. The dietary staff will use the can opener Level of Harm - Minimal harm or according to the manufacturer's guidelines. The can opener will be sanitized between uses. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42223 potential for actual harm Based on observation, interview, and record review, the facility failed to follow infection control practices by Residents Affected - Some failing to:

1. Change gloves while providing incontinence (inability to control bowel and bladder function) care for Resident 40.

This deficient practice had the potential to spread infection to staff and residents.

2. Implement water sample (to collect and deliver for analysis a sample of water representative of the bulk of water being examined) testing to validate the facility's water water management program control measures (actions that can be taken to reduce the potential of exposure to a hazard) initially or on an ongoing basis to ensure the facility's water was free of waterborne (carried or transmitted by water and especially by drinking water) pathogens (any organism that can cause disease) such as legionella (a bacterium which cases legionnaires' disease [a severe form of pneumonia - lung inflammation usually caused by infection]).

This failure had the potential to place the residents in the facility at risk for developing severe respiratory infection (pneumonia).

Findings:

1. A review of Resident 40's Admission Record indicated resident was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with the following diagnoses of muscle weakness and hypertension (high blood pressure).

A review of Resident 40's History and Physical (H&P), dated 5/17/2024, indicated resident did not have the capacity to understand and make decisions.

A review of Resident 40's Minimum Data Set (MDS; a standardized screening and assessment tool), dated 6/12/2024, indicated resident was severely impaired in cognitive (the functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making. MDS also indicated Resident 40 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating, oral hygiene, upper body dressing, lower body dressing and putting on/taking off footwear. MDS indicated resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene and shower/bathe self. MDS indicated Resident 40 was occasionally incontinent with urine and always continent with bowel movement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an observation in Resident 40's room on 6/27/2024 at 9:44 AM, Resident 40's brief (diaper) change was observed. Certified Nursing Assistant 5 (CNA 5) was observed providing perineal care (washing the Level of Harm - Minimal harm or genital and rectal areas of the body). CNA 5's gloves were observed wet. CNA 5 than proceeded touching potential for actual harm Resident 40's call light, blanket, bed rail, and bed remote with gloved hands after performing a brief change for Resident 40. CNA5 did not change gloves prior to touching Resident 40's items and/or devices. Residents Affected - Some

During an interview on 6/27/2024 at 9:59 AM, CNA 5 stated he should have changed his gloves after providing a brief change to Resident 40, and prior to touching Resident 40's items/devices. CNA 5 stated since the gloves were contaminated, Resident 40's call light, blanket, bed rail, and bed remote were also contaminated, which could increase the spread of infection.

During an interview on 6/28/2024 at 11:30 AM, the Infection Preventionist Nurse (IPN) stated after CNA 5 provided a brief change to Resident 40, CNA5 should have removed his gloves and provided hand hygiene prior to touching Resident 40's call light, blanket, bed rail, and bed remote. The IPN stated since CNA 5 continued to touch Resident 40's items/devices with contaminated gloves, the spread of infection to staff and other residents was increased.

A review of the facility's Policy and Procedure (P&P) titled Personal Protective Equipment, revised 1/1/2012, indicated gloves are used only once and are discarded into the appropriate receptable in the room in which

the procedure is being performed. Policy also indicated hands are washed before and after the removing of gloves. Policy stated the procedure is to provide appropriate protective clothing and equipment.

A review of Centers of Disease Control and Prevention (CDC, national public health agency in the United States) undated Glove Removal Job Aid, indicated remove contaminated gloves, dispose contaminated gloves, and wash hands immediately or as soon as possible after the removal of gloves. https://www.cdc. gov/labtraining/docs/job_aids/ready_set_test/Glove_removal_job_aid.docx

48395

During an interview on 6/28/2024 at 8:29 AM with Infection Preventionist (IP), IP stated, For the facility's water management program, we do not test the water for legionella or other waterborne pathogens since there has been no need since we do not have any cases of any residents having legionnaires' disease.

During an interview on 6/28/2024 at 9:15 AM with Maintenance Supervisor (MS), MS stated that they do not test the water for legionella or waterborne pathogens since they have had no issues with anyone at the facility getting sick.

During an interview on 6/28/2024 at 10:55 AM with IP and MS, MS stated they have not tested their water for legionella or waterborne pathogens and do not have any baseline (starting point) testing of the facility's water. IP stated they would only be prompted to call the Medical Director (MD) to ask about testing the facility's water only if there was an issue with their water temperatures being out of range. IP further stated if

they had any issues with waterborne pathogens in their water then there would be an increase in healthcare associated infection (HCAI, infections acquired by residents during their stay in a healthcare setting) pneumonia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 6/28/2024 at 2:20 PM with IP, IP stated that she is not aware of any sampling or testing of the facility's water. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/28/2024 at 3:04 PM with Administrator (ADM), ADM stated that they do not test the facility's water and do not have to unless the facility's hot water temperatures are not within their parameters. Residents Affected - Some ADM added, We have no residents who tested positive with pneumonia and legionella. This is what we consider validation of our control measures for our water management program.

During an interview on 6/28/2024 at 3:23 PM with ADM, ADM stated that the facility does not have any initial or baseline testing of water samples for the facility that indicate the water is negative for legionella or other waterborne pathogens. ADM stated they also do not currently test their residents for legionella.

A review of the facility's policy and procedure (P&P) titled, Water Management, revised 5/25/2023, the P&P indicated:

Following national, state and local guidelines, the team will identify needed control measures based on the risk assessment performed, and how to monitor them. Physical and chemical measures recommended by

the American Association of Heating, Refrigeration and Air-Conditioning Engineers (ASHRAE) that may be applied for the prevention and control of Legionella include, but are not limited to:

o Quarterly measurement of water quality throughout the system to ensure changes that may lead to Legionella growth are not occurring.

A review of the Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey and Certification Group letter titled, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD), dated 6/2/2017, indicated facilities Implement a water management program that considers the ASHRAE industry standard and the Centers for Disease Control (CDC) toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environmental testing for pathogens. It also indicated facilities Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained.

A review of the CDC's toolkit titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/24/2021, indicated, Now that you have a water management program, you need to be sure that it is effective. Your program team should establish procedures to confirm, both initially and on an ongoing basis that the water management program effectively controls the hazardous conditions throughout the building water systems. This step is called validation. Environmental testing for Legionella is useful to validate the effectiveness of control measures. The program team should determine if environmental testing for Legionella should be performed and, if so, how test results will be used to validate

the program. Factors that might make testing for Legionella more important include Being a healthcare facility that provides inpatient services to people who are at increased risk for Legionnaires disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A review of ASHRAE Addendum to ASHRAE Standard [PHONE NUMBER] (defines types of buildings and devices that need a water management program) titled, Legionellosis: Risk Management for Building Water Level of Harm - Minimal harm or Systems, dated 6/23/2018, indicated the Program Team shall establish procedures to confirm, both initially potential for actual harm and on an ongoing basis, that the Program is being implemented as designed. The resulting process is verification. The Program Team shall establish procedures to confirm, both initially and on an ongoing basis, Residents Affected - Some that the Program, when implemented as designed, controls the hazardous conditions throughout the building water systems. The resulting process is validation. The Program Team shall determine whether testing for Legionella shall be performed and if so, how test results will be used to validate the Program. If the Program Team determines that testing is to be performed, the testing approach, including sampling frequency, number of samples, locations, sampling methods, and test methods, shall be specified and documented. The Program Team shall consider include the following as part of the determination of whether to test for Legionella:

b. A health care facility provides in-patient services to at-risk or immunocompromised population.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0911 Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47362

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure one (1) of 47 rooms (map diagram labeled rooms [ROOM NUMBERS], separated by a wall in the middle with two [2] beds on 1 side and three [3] beds on the other side with only 1 door for entry and exit) did not have more than four (4) residents in one shared room.

This deficient practice had the potential to cause the residents in these rooms not to have enough privacy and also had the potential to affect residents' delivery of care.

Findings:

During an observation on 6/25/2024 at 9:10 AM, rooms [ROOM NUMBERS] was observed separated by a wall in the middle, with 2 beds on 1 side and 3 beds on the other side with only 1 door for entry and exit, did not meet the requirement to have no more than four residents to a room. The residents in these rooms were able to ambulate freely and/or maneuver in their walker freely. The Nursing staff had enough space to provide care to these residents with dignity and privacy. There was space for beds, side tables, dressers, and other medical equipment.

A review of the facility's room waiver request, dated 6/25/2024, indicated there was enough space for each resident in the room, nursing and the health and safety of the residents occupying these rooms. The room waiver indicated the two rooms were separated by a brick wall and the entry way to and from rooms [ROOM NUMBERS] was through a common door into the hallway.

During interviews with residents both individually and collectively, the residents did not express any concerns regarding the size of the room.

The Department would be recommending the room waiver for rooms [ROOM NUMBERS] as requested by

the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 055760

F-F686)

Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was initiated for one (1) of 20 sampled residents (Resident 26).

This deficient practice resulted in the delayed care and services for Resident 26's pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin).

Findings:

A review of Resident 26's Admission Record indicated resident was a admitted to the facility on [DATE REDACTED] with

the diagnoses of muscle weakness and osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bones changes)

A review of Resident 26's History and Physical (H&P), dated 6/13/2023, indicated resident had the capacity to understand and make decisions.

A review of Resident 26's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 6/8/2024, indicated resident was severely impaired in cognitive (the functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making. MDS also indicated resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene, toileting hygiene, lower body dressing and personal hygiene. Resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bath self and putting on/taking off footwear.

A review of Resident 26's Braden Scale, dated 3/8/2024, indicated resident was at risk of developing pressure injuries.

During an interview on 6/25/2024 at 9:28 AM, Certified Nursing Assistant 3 (CNA 3) stated she observed Resident 26's pressure injury on the sacrum area during the week of 6/17/2024-6/21/2024.

During an interview on 6/26/2024 at 10:08 AM, Treatment Nurse 1 (TN 1) stated Resident 46 initially had an identified skin wound that started as a Moisture-Associated Skin Damage (MASD; inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine stool, sweat, wound drainage, saliva, or mucus) wound. TN1 stated, currently, Resident 46's wound was now classified as a stage 2 (the skin breaks open; it can look like an abrasion, blister, or a shallow crater of the skin) pressure injury. TN 1 also stated the pressure injury started since 6/21/2024, but there were no orders for treatment of Resident 26's pressure injury.

During an interview on 6/27/2024 at 11:01 AM, DON stated the facility did not have care plan indicating Resident 26's pressure injury which progressed to a stage 2 pressure injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview on 6/27/2024 at 12:32 PM, Assistant Director of Nursing (ADON) stated care plans were utilized to ensure facility staff provided continuity of care for the residents and was used to guide facility staff Level of Harm - Minimal harm or on caring for the residents' specific needs. The ADON stated the care plan was used to monitor the plan of potential for actual harm care for the resident for health improvements or decline.

Residents Affected - Few A review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 8/24/2023, indicated within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. Policy also indicated the Registered Nurse (RN) Supervisor or Charge Nurse will complete the necessary combination of problem specific care plans and the comprehensive care plan will also be reviewed and revised at the following times such as onset of new problems and change of condition.

A review of the facility's P&P titled, Skin Integrity Management, revised 10/26/2023, indicated to review the resident's care plan and update as necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42223

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure resident care plans were revised for one (1) of 20 sampled residents (Resident 5)

This deficient practice had the potential to inadequately care for resident's needs, resulting in a decline in Resident 5's functionality.

Findings:

A review of Resident 5's Admission Record indicated resident was admitted to the facility on [DATE REDACTED] with the following diagnoses of muscle weakness and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time).

A review of Resident 5's History and Physical (H&P), dated 12/11/2022, indicated Resident 40 did not have

the capacity to understand and make decisions.

A review of Resident 5's Occupational Therapy (OT, a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life) titled Occupational Therapy - OT Evaluation & Plan of Treatment, dated 8/30/2023, indicated resident's right upper extremity was impaired and residents left upper extremity was within normal limits.

A review of Resident 5's Physical Therapy (PT, a treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) titled Physical Therapy - PT evaluation & Plan of Treatment, dated 10/27/2023, indicated residents right lower extremity was within normal limits and residents left lower extremity was within normal limits.

A review of Resident 5' s Care Plan with focus on Activities of Daily Living (ADL) self-care performance deficient, revised 1/2/2024, indicated resident required extensive assistance with bed mobility, transfers, ambulation,dressing, eating and hygiene. Care plan also indicated resident required total care with locomotion, toileting and bathing.

A review of Resident 5's OT titled Occupational Therapy - OT Evaluation & Plan of Treatment, dated 3/11/2024, indicated resident's right upper extremity was impaired and residents left upper extremity was impaired.

A review of Resident 5's PT titled Physical Therapy - PT evaluation & Plan of Treatment, dated 3/11/2024, indicated resident's right lower extremity was impaired and left lower extremity was impaired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 A review of Resident 5's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 6/10/2024, indicated resident was severely impaired in cognitive (the functions your brain uses to Level of Harm - Minimal harm or think, pay attention, process information, and remember things) skills for daily decision making. MDS also potential for actual harm indicated resident was dependent (helper does all of the effort. Resident does none of the effort to complete

the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with Residents Affected - Few eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene.

During an observation on 6/25/2024 at 2:06 PM, Resident 5 was observed lying in bed with contracted arms and legs.

During a concurrent interview and record review of Resident 5's Care Plan with focus of limited physical mobility with the Assistant Director of Nursing (ADON) on 6/27/2024 at 12:32 PM, the ADON stated Resident 5's care plan should be revised since the resident was no longer in the Restorative Nursing Assistant (RNA, assists residents with exercise to improve or maintain mobility and independence in the resident) program, and Resident 5's plan of care changed since Resident 5's mobility declined. The ADON also stated care plans need to be revised for the continuity of care of the resident and to monitor if changes were needed if

the resident was improving or worsening.

During a concurrent interview and record review of Resident 5's OT, dated 8/30/2023 and 3/11/2024, and PT, dated 10/27/2024 and 3/11/2024, on 6/28/2024 at 9:38 AM with the Director of Rehabilitation (DOR), the DOR stated Resident 5's mobility was declining, therefore a recommendation would be done for splinting (an external device used to immobilize an injury or joint) to be placed on the left arm, and bilateral lower extremities, to aid in the prevention of contracture (occurs when muscles, tendons, joints, or other tissues tighten or shorten causing a deformity).

A review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 8/24/2023, indicated care plans need to be revised at the onset of new problems, change of condition and to address changes in behavior and care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48395 potential for actual harm Based on observation, interview and record review, the facility failed to ensure two (2) of 20 sampled Residents Affected - Few residents (Residents 643 and 10) were provided one to one (1:1, one staff to one resident) feeding assistance as ordered.

This failure had the potential to put Residents 643 and 10 at risk for weight loss and aspiration (accidentally inhaling a foreign object, food or liquid through the vocal cords into the airway).

Findings:

1. A review of Resident 643's Admission Record, indicated the resident was initially admitted to the facility on [DATE REDACTED] with diagnoses of displaced intertrochanteric (between the trochanters [bony protrusions on the femur - thighbone]) fracture (as partial or complete break in the bone) of the left femur and dysphagia (swallowing difficulties) oropharyngeal phase (starting in the mouth and/or the throat).

A review of Resident 643's History and Physical Examination (H&P), dated 4/4/2024, indicated the resident does not have the capacity to understand and make decisions.

A review of Resident 643's Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 4/11/2024, indicated the resident had severe impairment (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember and reason) skills of daily decision making and was dependent (helper does all of the effort) with transfers (how resident moves to and from bed, chair, wheelchair), dressing (how a resident puts on, fastens and takes off all items of clothing) and personal hygiene and needed substantial/maximal assistance (helper does more than half the effort) with eating.

A review of Resident 643's Order Summary Report dated 6/26/2024, indicated that on 4/5/2024 it was ordered for the resident to have, 1:1 feeding assistance with all meals.

During an observation on 6/26/2024 at 8:03 AM in Resident 643's room, Resident 643 was observed sitting up in bed by herself with her breakfast tray on top of her rolling bedside table placed in front of her with the food untouched.

During an observation on 6/26/2024 at 12:30 PM in Resident 643's room, Certified Nursing Assistant 6 (CNA 6) was observed assisting the resident with setting up her lunch tray in front of her on her rolling bedside table and then left the room.

During a concurrent observation and interview on 6/26/2024 at 12:40 PM with Resident 643 in her room, Resident 643 was observed sitting up in bed with her lunch tray in front of her untouched and no staff member present at her bedside.

During an observation on 6/26/2024 at 12:56 PM in Resident 643's room, Resident 643 was observed sitting up in bed with her lunch tray in front of her with the food on her tray untouched.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 During an observation on 6/26/2024 at 12:59 PM in Resident 643's room, CNA 6 was observed speaking with the resident and then walked out of the room. The food on Resident 643's lunch tray remained of the Level of Harm - Minimal harm or same amount and untouched. potential for actual harm

During a concurrent interview and record review on 6/26/2024 at 4:02 PM with Assistant Director of Nursing Residents Affected - Few (ADON), Resident 643's Order Summary Report dated 6/26/2024 was reviewed. The Order Summary Report indicated an order made on 4/5/2024 for Resident 643 to have, 1:1 feeding assistance with all meals. ADON stated that the resident does have an order for 1:1 feeding assistance with all meals and that the Director of Staff Development (DSD) is the one who coordinates the feeding assistance program and has a list of residents who need feeding assistance.

During a concurrent interview and record review on 6/26/2024 at 4:15 PM with ADON, the list of residents who need 1:1 feeding assistance dated 6/26/2024 was reviewed. The list did not include Resident 643. ADON stated, she did not know why the resident was missed and did not make it onto the list.

During an interview on 6/26/2024 at 4:20 PM with ADON, ADON stated Resident 643 was missed and not included in the list of residents who need feeding assistance.

During an interview on 6/27/2024 at 12:27 PM with ADON, ADON stated when a resident with an order for 1:1 feeding assistance was not assisted, 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.

During an interview on 6/27/2024 at 4:34 PM with Speech Therapist 1 (ST 1) and Director of Rehab (DOR), ST 1 stated Resident 643 needed 1:1 support for feeding to help with increasing the resident's food intake and for resident's safety such as making sure the resident is wearing her dentures, chewing slowly, and is positioned upright during mealtime. ST 1 also stated that Resident 643's cognition is a little impaired and that there are days where she is okay and days when she needs more support. DOR further stated that Resident 643 does not really eat but does a lot better when the resident is assisted with feeding.

A review of the facility's Policy and Procedure (P&P) titled Resident Rights - Accommodation of Needs revised 1/1/2012, indicated The facility's environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well-being. Facility Staff will assist residents in achieving these goals,. The P&P also indicated, Residents' individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.

47362

2. A review of Resident 10's admission record indicated the facility admitted Resident 10 on 1/13/2023 with diagnosis which include anemia(when you have low levels of healthy red blood cells to carry oxygen throughout your body), malnutrition( the state of inadequate intake of food), end stage heart failure(the body can no longer compensate for the lack of blood the heart pumps, and the heart has limited functional recovery) .

A review of Resident 10's H&P Examination dated 1/14/2023 indicated Resident 10 does not have the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 A review of Resident 10's MDS, dated [DATE REDACTED], indicated Resident 10's cognitive skills was severely impaired for daily decision making. The MDS indicated Resident 10 required partial moderate assistance (helper does Level of Harm - Minimal harm or less than half of the effort) on eating, oral hygiene, upper body dressing. The MDS also indicated, Resident potential for actual harm 10 required substantial maximal assistance (helper does more than half of the effort) on toilet hygiene, lower body dressing, putting on/ taking off footwear. Residents Affected - Few

During concurrent observation in Resident 10's room and interview on 6/26/2024 at 7:45 AM with the Licensed Vocational Nurse (LVN 7), LVN 7 stated Resident 10 was feeding herself and food was all over Resident 10's mouth and clothes.

During concurrent interview and record review on 6/27/2024 at 10:58 AM with the assistant director of nursing (ADON), ADON stated Resident 10's Order Summary Report indicated date ordered 9/8/2024 assisted feeding. The ADON stated, it meant Certified Nurse Assistant (can) will assist Resident 10 during feeding for safety precaution to prevent aspiration and choking.

During concurrent interview and record review on 6/27/2024 at 10:58 AM with ADON, ADON stated Resident 10's care plan date initiated 6/29/2022 indicated Resident 10 was at risk for ADL self-care performance deficit related to confusion, fatigue, impaired balance, limited mobility. The care plan interventions indicated

on eating Resident 10 requires supervision from staff with eating and required assistance by staff with personal hygiene.

During interview on 6/27/2024 at 12:08 PM with the CNA 7, CNA 7 stated he put the food of Resident 10 at

the bed side table, but Resident 10 pull it and starts feeding self. CNA 7 also stated he should stay with the resident while eating and provided bib (a cloth or plastic shield tied under the chin to protect the clothes) for safety and dignity of Resident 10. CNA 7 further stated having food crumbs and/ or stains all over Resident 10's mouth and cloth was not acceptable.

A review of the facility's P&P titled, Resident Right- Quality of Life, revised 3/2017, indicated purpose, to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident comprehensive assessment and plan of care. Each resident shall be cared for in a manner that promotes and enhanced the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable wellbeing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 32 055760 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055760 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42223 potential for actual harm (Cross reference