Deficiency Records for Alhambra Healthcare and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Alhambra Healthcare and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-05 | 2023-05-02 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-05 | 2023-02-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-05 | 2023-02-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-05 | 2023-02-05 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-01-05 | 2023-02-05 | 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 | 2023-01-05 | 2023-02-05 | 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 | 2023-01-05 | 2023-02-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-04 | 2023-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-04 | 2023-01-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-04 | 2023-01-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-04 | 2023-01-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-04 | 2023-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-10-15 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-07-15 | 2021-10-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-13 | 2021-08-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-13 | 2021-08-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-13 | 2021-08-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-13 | 2021-08-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-13 | 2021-08-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-13 | 2021-08-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-13 | 2021-08-13 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-15 | 2021-08-12 | 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 | 2021-07-15 | 2021-08-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-15 | 2021-08-12 | Y |
| 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 | 2019-10-24 | 2019-11-24 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-10-24 | 2019-11-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-24 | 2019-11-24 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-10-24 | 2019-11-24 | 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 | 2019-10-24 | 2019-11-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-24 | 2019-11-24 | N |
| Meet other general requirements. | Fire Safety | 2019-10-22 | 2019-11-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-22 | 2019-11-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-22 | 2019-11-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-22 | 2019-11-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-22 | 2019-11-24 | N |
