Alhambra Healthcare & Wellness Centre, Lp
ALHAMBRA HEALTHCARE & WELLNESS CENTRE, LP in ALHAMBRA, CA — inspection on June 28, 2024.
Found 15 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a concurrent observation and interview in Resident 5's room at 6/25/2024 at 2:06 PM, Resident 5 was observed with both arms contracted (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) and both legs contracted. DON stated the call light should not be on the floor and it should be within the reach of Resident 5. DON also stated the resident's call light should have been a padded alarm and not the call light with a button due to the resident's condition and the resident's ability to use the call light.
A review of the facility's Policy and Procedure (P&P) titled Communication - Call System, revised 1/1/2012, indicated call cords will be placed within the resident's reach in the resident's room.
A review of the facility's P&P titled Resident Rights - Accommodation of Needs, revised 1/1/2012, indicated the facility staff interacts with the residents in a way that accommodates the physical limitations of the residents.
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Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801
indicated upon admission, the admission staff or designee will obtain a copy of a resident's advance
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plans were utilized to ensure facility staff provided continuity of care for the residents and was used
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.
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Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801
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.
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Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801
During concurrent observation in Resident 10's room and interview on 6/26/2024 at 7:45 AM with the
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.
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Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801
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.
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Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801
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Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801
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: *The humidifier and tubing should be changed no more than every 7 days and labeled with the date of the change. *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.
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Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801
pharmacy so it would be available for the next medication nurse to give, and Resident 54 would not
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.
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Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801
Based on observation, interview, and record review the facility failed to follow its Medication Storage
- Refrigerate Residents 48's unused Novolin R Flex Pen (form of insulin, a naturally occurring
- Refrigerate Residents 59's unused Basaglar Kwik Pen (is a long-acting insulin that helps lower high
hormone, used to control blood sugar in patients with diabetes).
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
- During a concurrent observation of Medication Cart 3 in Station 2 and interview with Licensed
- During a concurrent observation of Medication Cart 3 in Station 2 and interview with LVN 4 on
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.
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.
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Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801
During an observation in the facility's kitchen on 6/25/2024 at 7:49 PM, the following were observed:
- A clear plastic container of rice storage was not sealed properly.
- A clear plastic container of brown sugar was not sealed.
- 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.
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 according to the manufacturer's guidelines.
The can opener will be sanitized between uses.
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Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801
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Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801
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.
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.
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Form Approved OMB
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
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.
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Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.