Deficiency Records for Alhambra Healthcare and Wellness Centre, LP
Updated as of April 01, 2024
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? |
---|---|---|---|---|
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 |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-16 | 2018-09-10 | 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 | 2018-07-16 | 2018-09-10 | N |
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-07-16 | 2018-09-10 | 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 | 2018-07-16 | 2018-09-10 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-07-16 | 2018-09-10 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-16 | 2018-09-10 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-16 | 2018-09-10 | 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 | 2018-07-16 | 2018-09-10 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-07-16 | 2018-09-10 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-07-16 | 2018-09-10 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-07-16 | 2018-09-10 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-07-16 | 2018-09-10 | 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 | 2018-07-16 | 2018-09-10 | N |
Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2018-07-16 | 2018-09-10 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-16 | 2018-09-10 | N |
Implement a program that monitors antibiotic use. | Health | 2018-07-16 | 2018-09-10 | 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 | 2018-07-16 | 2018-09-10 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-07-16 | 2018-09-10 | N |
List the names and contact information of those in the facility. | Fire Safety | 2018-07-13 | 2018-08-28 | N |
Conduct testing and exercise requirements. | Fire Safety | 2018-07-13 | 2018-08-28 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2018-07-13 | 2018-08-28 | 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 | 2018-07-13 | 2018-08-28 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-13 | 2018-08-28 | N |
Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2018-07-13 | 2018-08-28 | N |
Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-07-13 | 2018-08-28 | N |