Alhambra, CA

Alhambra Hospital Med Ctr Dp/Snf

4-star overall rating with 4-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

100 S Raymond Ave, Alhambra, CA

(626) 570-1606

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Ahmc Healthcare

Operator or chain grouping

Approved since

2008-04-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

2.71

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.62

Licensed practical nurse staffing · state 1.22 · national 0.87

Aide hours / resident day

2.87

Nurse aide staffing · state 2.64 · national 2.35

Total nurse hours

7.20

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

4.34

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

6.90

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

2.42

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

1.17

CMS adjusted RN staffing hours

Adjusted total hours

3.10

CMS adjusted total nurse staffing hours

Case-mix index

3.18

Higher values indicate more complex resident acuity

RN turnover

27%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

23%

Annual nurse turnover · state 38% · national 46%

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 4 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 45
Staff flu vaccination coverage	48%	42% 6 pts better	Numerator 24 · Denominator 50
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.0%	98.5% 0.5 pts better	93.4% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.0%	98.2% 2.2 pts worse	95.5% 0.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	1.6% 1.6 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	6.8% 6.8 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	2.0%	4.1% 2.1 pts better	5.4% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 4.0% · Q4 0.0% · 4Q avg 2.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	0.0%	13.7% 13.7 pts better	19.6% 19.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who received an antipsychotic medication	0.0%	14.2% 14.2 pts better	16.7% 16.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.4% 0.4 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents with a catheter inserted and left in their bladder	10.1%	1.0% 9.1 pts worse	1.0% 9.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 13.3% · Q3 8.7% · Q4 5.8% · 4Q avg 10.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.0%	1.2% 1.8 pts worse	1.7% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.2% · Q3 0.0% · Q4 4.0% · 4Q avg 3.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	0.0%	10.9% 10.9 pts better	19.8% 19.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0%
Percentage of long-stay residents with pressure ulcers	10.7%	4.7% 6 pts worse	5.1% 5.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.1% · Q3 12.3% · Q4 14.0% · 4Q avg 10.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-03 · Fire 2025-07-03

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2024-06-30 · Fire 2024-06-30

13 health deficiencies

Top issue: Resident Rights (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-07-14 · Fire 2023-07-14

5 health deficiencies

Top issue: Infection Control (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-07-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-18

D · Potential for more than minimal harm 2023-07-14

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2023-08-02

D · Potential for more than minimal harm 2023-07-14

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-08-02

D · Potential for more than minimal harm 2023-07-14

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-02

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-07-03

F693 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-07-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-07-03

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-07-03

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-07-03

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-07-03

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-07-03

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-07-03

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-07-18

E · Potential for more than minimal harm 2024-06-30

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-07-05

E · Potential for more than minimal harm 2024-06-30

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2024-07-05

E · Potential for more than minimal harm 2024-06-30

F693 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-07-03

E · Potential for more than minimal harm 2024-06-30

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-07-03

E · Potential for more than minimal harm 2024-06-30

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-07-17

E · Potential for more than minimal harm 2024-06-30

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2024-07-03