Deficiency Records for Alhambra Rehab and Healthcare
Updated as of January 01, 2022
This is not the most recent data for Alhambra Rehab and Healthcare. For the most recent information, click here.
A list of the most recent deficiencies for Alhambra Rehab and Healthcare. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-16 | 2021-08-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-16 | 2021-08-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-16 | 2021-08-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-16 | 2021-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-11-17 | 2020-12-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-08-14 | 2020-08-24 | Y |
| 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 | 2020-08-14 | 2020-08-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-07-17 | 2020-07-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-07-17 | 2020-07-31 | Y |
| 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 | 2020-07-17 | 2020-07-31 | Y |
| 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 | 2020-07-17 | 2020-07-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-18 | 2020-07-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-13 | 2020-02-11 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-13 | 2019-12-01 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-11-13 | 2019-12-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-11-13 | 2019-12-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-11-13 | 2019-12-01 | 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 | 2019-11-13 | 2019-12-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-13 | 2019-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-13 | 2019-12-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-13 | 2019-12-01 | 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 | 2019-11-15 | 2019-11-21 | 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 | 2019-11-15 | 2019-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-15 | 2019-11-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-15 | 2019-11-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-15 | 2019-11-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-16 | 2019-09-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-16 | 2019-09-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-03 | 2019-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-30 | 2019-05-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-03 | 2019-05-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-03 | 2019-05-30 | Y |
| 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 | 2019-05-03 | 2019-05-30 | Y |
| 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 | 2019-04-25 | 2019-05-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-14 | 2019-03-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-03-14 | 2019-03-29 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-02-22 | 2019-02-26 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-10-05 | 2018-11-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-10-05 | 2018-11-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-10-05 | 2018-11-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-10-05 | 2018-11-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-05 | 2018-11-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-10-05 | 2018-11-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-10 | 2018-10-31 | 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 | 2018-10-10 | 2018-10-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-10 | 2018-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-10 | 2018-10-31 | 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 | 2018-10-10 | 2018-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-10 | 2018-10-31 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-10-10 | 2018-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-10 | 2018-10-31 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-10-10 | 2018-10-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-12-13 | 2018-03-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-12-13 | 2018-01-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-13 | 2018-01-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-12-13 | 2018-01-11 | 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 | 2017-12-18 | 2018-01-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2017-12-18 | 2018-01-10 | 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 | 2017-12-18 | 2018-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-18 | 2018-01-10 | N |
