Alhambra Healthcare & Rehabilitation Center

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Tag F0686 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · from a complaint inspection · Deficient, Provider has date of correction Apr 3, 2026

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.

Tag F0726 · CMS scope and severity F (no actual harm, potential for more than minimal harm; widespread) · from a complaint inspection · Deficient, Provider has date of correction Apr 3, 2026

Provide and implement an infection prevention and control program.

Tag F0880 · CMS scope and severity E (no actual harm, potential for more than minimal harm; pattern) · from a complaint inspection · Deficient, Provider has date of correction Apr 3, 2026

Provide care and assistance to perform activities of daily living for any resident who is unable.

Tag F0677 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · from a complaint inspection · Deficient, Provider has date of correction Jan 3, 2026

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Tag F0755 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · from a complaint inspection · Deficient, Provider has date of correction Jan 3, 2026

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Tag F0921 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · from a complaint inspection · Deficient, Provider has date of correction Jan 3, 2026

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Tag F0925 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · from a complaint inspection · Deficient, Provider has date of correction Jan 3, 2026

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Tag F0559 · CMS scope and severity E (no actual harm, potential for more than minimal harm; pattern) · from a complaint inspection · Deficient, Provider has date of correction Nov 17, 2025

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.

Tag F0761 · CMS scope and severity E (no actual harm, potential for more than minimal harm; pattern) · from a complaint inspection · Deficient, Provider has date of correction Aug 21, 2025

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.

Tag F0584 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Apr 25, 2025

PASARR screening for Mental disorders or Intellectual Disabilities

Tag F0645 · CMS scope and severity E (no actual harm, potential for more than minimal harm; pattern) · Deficient, Provider has date of correction Apr 25, 2025

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Tag F0657 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Apr 25, 2025

Provide care or services that was trauma informed and/or culturally competent.

Tag F0699 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Apr 25, 2025

Post nurse staffing information every day.

Tag F0732 · CMS scope and severity F (no actual harm, potential for more than minimal harm; widespread) · Deficient, Provider has date of correction Apr 25, 2025

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Tag F0812 · CMS scope and severity F (no actual harm, potential for more than minimal harm; widespread) · Deficient, Provider has date of correction Apr 25, 2025

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.

Tag F0584 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Feb 5, 2023

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Tag F0656 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Feb 5, 2023

Provide care and assistance to perform activities of daily living for any resident who is unable.

Tag F0677 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Feb 5, 2023

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Tag F0745 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Feb 5, 2023

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.

Tag F0758 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Feb 5, 2023

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.

Tag F0761 · CMS scope and severity F (no actual harm, potential for more than minimal harm; widespread) · Deficient, Provider has date of correction Feb 5, 2023

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.

Tag F0584 · CMS scope and severity E (no actual harm, potential for more than minimal harm; pattern) · Deficient, Provider has date of correction Aug 12, 2021

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.

Tag F0585 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Aug 12, 2021

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Tag F0812 · CMS scope and severity F (no actual harm, potential for more than minimal harm; widespread) · Deficient, Provider has date of correction Oct 15, 2021

Have a plan that describes the process for conducting QAPI and QAA activities.

Tag F0865 · CMS scope and severity F (no actual harm, potential for more than minimal harm; widespread) · Deficient, Provider has date of correction Oct 15, 2021

Address subsistence needs for staff and patients.

Tag E0015 · CMS scope and severity F (no actual harm, potential for more than minimal harm; widespread) · Deficient, Provider has date of correction Apr 30, 2025

Meet other general requirements.

Tag K0200 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Apr 30, 2025

Provide properly protected cooking facilities.

Tag K0324 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Apr 30, 2025

Have properly installed hallway dispensers for alcohol-based hand rub.

Tag K0325 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Apr 30, 2025

Have approved installation, maintenance and testing program for fire alarm systems.

Tag K0345 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Apr 30, 2025

Inspect, test, and maintain automatic sprinkler systems.

Tag K0353 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Apr 30, 2025

Have simulated fire drills held at unexpected times.

Tag K0712 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Apr 30, 2025

Have generator or other power source capable of supplying service within 10 seconds.

Tag K0918 · CMS scope and severity F (no actual harm, potential for more than minimal harm; widespread) · Deficient, Provider has date of correction Apr 30, 2025

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Tag K0929 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Apr 30, 2025

Have approved installation, maintenance and testing program for fire alarm systems.

Tag K0345 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Jan 24, 2023

Inspect, test, and maintain automatic sprinkler systems.

Tag K0353 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Jan 24, 2023

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Tag K0521 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Jan 24, 2023

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Tag K0761 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Jan 24, 2023

Have generator or other power source capable of supplying service within 10 seconds.

Tag K0918 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Jan 24, 2023

Have approved installation, maintenance and testing program for fire alarm systems.

Tag K0345 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Aug 13, 2021

Inspect, test, and maintain automatic sprinkler systems.

Tag K0353 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Aug 13, 2021

Install corridor and hallway doors that block smoke.

Tag K0363 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Aug 13, 2021

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Tag K0372 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Aug 13, 2021

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Tag K0741 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Aug 13, 2021

Have generator or other power source capable of supplying service within 10 seconds.

Tag K0918 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Aug 13, 2021

Have proper medical gas storage and administration areas.

Tag K0923 · CMS scope and severity D (no actual harm, potential for more than minimal harm; isolated) · Deficient, Provider has date of correction Aug 13, 2021