Alhambra Healthcare & Rehabilitation Center

Based on record review and interviews, the facility failed to document room change notifications for three residents (#2, #3, and #4) of three residents sampled.

Findings included: 1.) Review of Resident #2's census revealed Resident #2 changed rooms on 9/29/2025, 9/19/2025 and 9/15/2025.

Review of Resident #2's progress notes revealed no documentation of notification of the room changes were located for 9/19/2025 and 9/15/2025. 2.) Review of Resident #3's census revealed Resident #3 changed rooms on 09/24/2025 and 09/19/2025.

Review of Resident #3's progress notes revealed no documentation of notification of the room changes for 09/24/2025 and 09/19/2025. 3.) Review of Resident #4's census revealed Resident #4 changed rooms on 09/30/2025.

Review of Resident #4's progress notes revealed no documentation of notification of the room changes for 09/30/2025.

During an interview on 10/15/2025 at 12:46 P. M., the Director of Nursing (DON) stated the Social Services Director (SSD) was out of the building and was not reachable.

The DON stated the SSD notifies the family of any room changes and nursing staff completes the room transfers.

The DON stated resident room changes are performed for different reasons, they can be for personal preferences or by request of the facility.

The DON stated residents, and their representatives are supposed to be notified of a room change each time.

The DON stated normally the SSD will document notification of the room change in the progress notes.

The DON reviewed Resident #2's census and confirmed Resident #2 changed rooms 4 times during her stay.

The DON said, I see one progress note about one of the room changes. It appears Resident #2 was moved the first time because we needed a private isolation room. I would expect to find a note in the progress notes documenting the other room changes.

During an interview with the DON on 10/15/2025 at 02:30 P. M., the DON looked at the Census for Resident #3.

The DON stated the resident had a room change and according to progress notes, the notification of the room change was not documented.

The DON also looked at Resident #4's census and stated Resident #4 had changed rooms within the last thirty days and notification and the reason why, was not documented in progress notes. A policy titled Standards and Guidelines: Residents Rights, and revised 12/2016 showed: Standard: Employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation:Federal and state laws guarantee certain basic rights to all residents of this facility.

These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility;j. be informed about his or her rights and responsibilities.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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