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Deficiency Records for Alhambra Post Acute
A list of the most recent deficiencies for Alhambra Post Acute. 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 Post Acute. 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? |
|---|---|---|---|---|
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-05-03 | 2024-05-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-16 | 2024-05-02 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-01 | 2024-01-19 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-12-01 | 2024-01-19 | 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 | 2023-12-01 | 2024-01-19 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-12-01 | 2024-01-19 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-12-01 | 2024-01-19 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-12-01 | 2024-01-19 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-12-01 | 2024-01-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-01 | 2024-01-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-01 | 2024-01-19 | 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 | 2023-12-01 | 2024-01-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-01 | 2024-01-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-01 | 2024-01-19 | 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 | 2023-12-01 | 2024-01-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-01 | 2024-01-19 | 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 | 2023-12-01 | 2024-01-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-01 | 2024-01-19 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-12-01 | 2024-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2024-01-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-01 | 2024-01-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-12-01 | 2024-01-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-06 | 2023-12-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-12-06 | 2023-12-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-12-06 | 2023-12-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-06 | 2023-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-06 | 2023-12-15 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-11-07 | 2023-11-09 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-03-15 | 2022-04-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-15 | 2022-04-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-15 | 2022-04-27 | N |
| Have a properly installed and maintained dumbwaiter or escalator. | Fire Safety | 2022-03-15 | 2022-04-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-15 | 2022-04-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-11 | 2022-04-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-11 | 2022-04-11 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-03-11 | 2022-04-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-11 | 2022-04-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-11 | 2022-04-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-11 | 2022-04-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-11 | 2022-04-11 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-03-11 | 2022-04-11 | 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 | 2022-03-11 | 2022-04-11 | 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 | 2022-03-11 | 2022-04-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-11 | 2022-04-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-11 | 2022-04-11 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-11 | 2022-04-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-11 | 2022-04-11 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-11 | 2022-04-11 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-11 | 2022-04-11 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-03-11 | 2022-04-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-03 | 2022-03-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-21 | 2020-03-10 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-02-21 | 2020-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-21 | 2020-03-10 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-12-04 | 2019-12-31 | N |
| Use approved construction type or materials. | Fire Safety | 2019-12-04 | 2019-12-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-04 | 2019-12-31 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-02-21 | Not Fixed | N |
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