Other·February 24, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during an entity reported incident investigation of an abbreviated standard survey. Entity Reported Incident #: CA00513848Substantiated with one regulatory violation. Representing the Department of Public Health: Health Facilities Evaluator Nurse # 33668 The inspection was limited to the entity reported incident and does not represent the findings of a full inspection of the facility.

F223 SS=G FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.12(a)(1)

F223 02/17/2017 483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. 483.12(a) The facility must(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ESPO11 Facility ID: CA950000101 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055760 (X3) DATE SURVEY COMPLETED 02/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALHAMBRA HEALTHCARE & WELLNESS CENTRE, LP 415 S Garfield Ave Alhambra, CA 91801 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was not physically abused by a staff member. On 12/9/16, Resident 1 reported to the facility she was abused by someone in the shower. This deficient practice resulted in Resident 1 sustaining a bruise lip and a bruise and skin tear on her left arm. Findings: A review of Resident 1's medical record "Face Sheet" indicated the resident was admitted to the facility on 10/22/15 with diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and dementia (loss of brain function). A review of a Minimum Data Set (MDS, a resident assessment and care screening tool), dated 10/27/16, indicated Resident 1 had clear speech and was usually understood. Resident 1 displayed some memory problems, did not display any disorganized thinking, altered level of consciousness, hallucinations (seeing or hearing things in the absence of any real external stimuli) or delusions (misconceptions or beliefs, that are firmly held, contrary to reality). According to Section G, functional status, Resident 1 needed extensive assistance (staff provide weight-bearing support) for transferring and bathing. According to Section E, Behaviors, Resident 1 did not have any physical, verbal or other behavioral symptoms not directed towards FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ESPO11 Facility ID: CA950000101 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055760 (X3) DATE SURVEY COMPLETED 02/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALHAMBRA HEALTHCARE & WELLNESS CENTRE, LP 415 S Garfield Ave Alhambra, CA 91801 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE others. A review of Resident 1's Interdisciplinary Team Conferences (IDT) from 2/5/16 to 10/20/16, there was no documentation of Resident 1 being combative, resisting care or assaultive behaviors. A review of Resident 1's weekly summary from 10/31/16 to 12/11/16 there was no documentation of Resident 1 being combative, resisting care or assaultive behaviors. A review of Resident 1's Alzheimer's/dementia care plan dated 10/22/16 there was no documentation of Resident 1 being combative, resisting care or displaying assaultive behaviors. A review of Resident 1's, Incident and Accident Report Form, dated 12/9/16 at 9:45 a.m., indicated Resident 1 had a swollen upper lip 2 x 3 centimeters (cm) and a left upper arm skin tear 1 x 1 x 0.1 cm. The report indicated Resident 1 stating a girl hit her inside the room. On 12/9/16 at 12 p.m. a police officer arrived to the facility. On 12/9/16 at 1:45 p.m. Resident 1 was able to identify CNA 1 as the girl that hit her and CNA 1 was asked to leave the facility. A record review of Resident 1's physician's orders dated 12/9/16 at 10:50 a.m., indicated to cleanse skin tear to left upper arm with normal saline (salt water), pat dry, apply triple antibiotic ointment, and cover with dry dressing every day for 14 days. Monitor upper lip for any skin breakdown, swelling, bleeding and complain of pain. During an interview, on 12/28/16 at 10 a.m., with Resident 1 and the social service designee acting as interpreter, Resident 1 stated she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ESPO11 Facility ID: CA950000101 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055760 (X3) DATE SURVEY COMPLETED 02/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALHAMBRA HEALTHCARE & WELLNESS CENTRE, LP 415 S Garfield Ave Alhambra, CA 91801 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE remembered being hit by a fist by two women and one was wearing a dress. During an interview, on 12/28/16 at 10:20 a.m., with the administrator (ADM) she stated Resident 1 first reported the alleged abuse to the activity assistant (AA) on 12/9/16 at 9:45 a.m. The ADM stated Resident 1 was unable to tell them who hit her, but stated it happened in the shower. CNA 1 was assigned to her that day and gave Resident 1 a shower that morning. The ADM stated CNA 1 denied hitting Resident 1. CNA 1 did mention Resident 1 was very combative that morning during the shower. The ADM stated on the afternoon of 12/9/16 there was visible swelling of Resident 1's upper lip. Resident 1 also had a bruise and skin tear on her left upper arm that was not present the previous day (12/8/16). The ADM stated due to the Resident 1's statement and the visible injuries, Resident 1's family did not feel it was safe for their family member to be around CNA 1. The ADM stated they terminated CNA 1 effective 12/12/16. During an interview, on 12/29/16 at 9:52 a.m., with family member (FM 1) she stated she visited Resident 1 on 12/9/16 at 11:15 am. FM 1 stated "I saw my mom and her lip was swollen. I asked her what happened to her lip and she said someone hit her. I asked who and she couldn't tell me. I knew it was my mom's shower day because she takes showers on Tuesday and Fridays. I asked who her nurse was that day and they told me CNA 1. I asked to speak to CNA 1. I asked her what happened to my mom's lip and she said she didn't know. She did say my mom was not cooperative in the shower that morning. I asked the other CNA that feed her breakfast if her lip was swollen at breakfast and she said no. I think it happened in the shower or when they were transferring my mom. LVN 1 stripped her in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ESPO11 Facility ID: CA950000101 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055760 (X3) DATE SURVEY COMPLETED 02/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALHAMBRA HEALTHCARE & WELLNESS CENTRE, LP 415 S Garfield Ave Alhambra, CA 91801 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE front of me to check her body and there was a bruise on her left arm with blood. You could tell it was a fresh because there was blood too." According to the facility's policy and procedure titled, "Abuse-Prevention Program," dated 11/2016 indicated the facility is to ensure the health, safety, and comfort of residents by preventing abuse and mistreatment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ESPO11 Facility ID: CA950000101 If continuation sheet 5 of 5