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Deficiency Records for Alhambra Healthcare and Wellness Centre, LP
A list of the most recent deficiencies for Alhambra Healthcare and Wellness Centre, LP. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Alhambra Healthcare and Wellness Centre, LP. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-28 | 2024-07-28 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-06-28 | 2024-07-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-28 | 2024-07-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-06-28 | 2024-07-28 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-06-28 | 2024-07-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-28 | 2024-07-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-06-28 | 2024-07-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-28 | 2024-07-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-28 | 2024-07-28 | N |
| 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 locked, compartments for controlled drugs. | Health | 2024-06-28 | 2024-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-28 | 2024-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-28 | 2024-07-28 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-06-28 | 2024-07-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-07-01 | 2024-07-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-01 | 2024-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-01 | 2024-07-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-07-01 | 2024-07-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-01 | 2024-07-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-01 | 2024-07-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-07-01 | 2024-07-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-29 | 2024-06-21 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-04-19 | 2024-05-07 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-04-19 | 2024-05-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-05 | 2024-05-05 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-05 | 2024-05-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-21 | 2024-01-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-21 | 2024-01-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-12 | 2023-07-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-24 | 2022-11-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-02 | 2022-10-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-02 | 2022-10-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-18 | 2022-04-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-18 | 2022-04-26 | Y |
| 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 locked, compartments for controlled drugs. | Health | 2022-02-18 | 2022-04-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-06 | 2021-12-23 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-11 | 2021-08-04 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-06-11 | 2021-08-04 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-06-11 | 2021-08-04 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-06-11 | 2021-08-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-11 | 2021-08-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-11 | 2021-08-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-11 | 2021-08-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-11 | 2021-08-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-11 | 2021-08-04 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-06-11 | 2021-07-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-11 | 2021-07-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-11 | 2021-07-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-11 | 2021-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-11 | 2021-07-28 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-11 | 2021-07-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-11 | 2021-07-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-06-11 | 2021-07-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-11 | 2021-07-28 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-06-11 | 2021-07-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-11 | 2021-07-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-06-11 | 2021-07-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-11 | 2021-07-28 | N |
| 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 locked, compartments for controlled drugs. | Health | 2021-06-11 | 2021-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-11 | 2021-07-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-11 | 2021-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-11 | 2021-07-28 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2021-06-11 | 2021-07-28 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-06-11 | 2021-07-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-01 | 2019-08-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-01 | 2019-08-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-01 | 2019-08-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-01 | 2019-08-01 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-07-01 | 2019-07-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-01 | 2019-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-01 | 2019-07-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-01 | 2019-07-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-01 | 2019-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-01 | 2019-07-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-01 | 2019-07-26 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-07-01 | 2019-07-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-01 | 2019-07-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-01 | 2019-07-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-01 | 2019-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-01 | 2019-07-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-01 | 2019-07-26 | N |
| Keep all essential equipment working safely. | Health | 2019-07-01 | 2019-07-26 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-07-01 | 2019-07-26 | N |
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