Alhambra Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Alhambra Healthcare & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF726Mar 3, 2026

  Based on observations, interviews, and record review, the facility failed to ensure Licensed Practical Nurses (LPN) were board certified to administer intravenous (IV) infusion of medications for three residents (#1, #3, and #4) out of five residents sampled for medication administration. Findings included: https://www.fha.org/common/Uploaded%20files/FHA/Health%20Care%20Issues/Growing%20the%20Health%20Care%20Workforce/Issue%20Brief%20on%20Licensed%20Practical%20Nurse%20Scope%20of%20Practice.pdf showed the following:Approved Programs for IV CertificationsThe Board of Nursing (Board) specifies the requirements for LPNs to practice infusion therapy (IVs), pursuant to the Rule 64B9-12.005, Florida Administrative Code, Competency and Knowledge Requirements Necessary to Qualify the LPN to… […]

• No harm, potential for more than minimal, widespreadF732Mar 26, 2025

  Based on observation and record review, the facility did not ensure up-to-date staffing information was posted on one day (3/24/25) of three days observed. Findings included: Upon entering the facility on 3/24/25 at 9:00 AM, an observation was made of a posting titled, Daily Staffing Projection, dated 3/22/25 with census of 60. On 3/24/25 at 10:12 AM, the staffing posting was still not updated. Review of the facility's policy and procedure dated 11/19/2019 titled Nursing Services - Nurse Staffing Information showed: INTENT: It is the policy of the facility to make staffing information readily available in a readable format to residents and visitors at any given time. POLICY: 1. The facility will post the following information on a daily basis: a. Facility name. b. The current date. c. […]

• No harm, potential for more than minimal, widespreadF812Mar 26, 2025

  Based on observations and interviews, the facility did not follow professional standards for food service safety as evidenced by food not maintained for safe consumption and improper labeling and dating of food items in the main kitchen and dining room. Findings included: On 3/24/25 at 9:56 a.m., an initial tour of the facility's kitchen was conducted with the facility's Certified Dietary Manager (CDM). An observation of the dish machine area, that was in use by Staff E, Cook, revealed pliers with a red handle on the machine's base. Further observations on the top area of the dish machine revealed light brown colored crumbs and other food particles. An observation of the dish machine hood revealed multiple dark brown and black spots along the top and sides. […]

• No harm, potential for more than minimal, widespreadF761Jan 5, 2023

  Based on observations, interviews, and policy reviews, the facility failed to properly store and secure medications in two of three medication carts, one medication stock room, one of three medication refrigerators, and for one (Resident #208) of one resident reviewed. Findings include: An observation was made on 1/4/23 at 4:11 p.m. of an unlocked medication cart on the West Back Unit. Two nurses were standing five feet away from the medication cart. At 4:15 p.m. both nurses had walked out of the hall and the cart remained unlocked. There were no nurses in sight of the cart and the medication cart was sitting in one of the main resident hallways. After four minutes had passed, a nurse on the opposite hall asked if there was a problem. She was notified the medication cart was unlocked. […]

• No harm, potential for more than minimal, widespreadF812Jul 15, 2021

  Based on observation, interview, and record review the facility failed to ensure sanitizer solution used to clean food and non-food contact surfaces in the kitchen, which serviced two of two hallways, was at manufacturing concentration levels of 200-400 parts per million (ppm) to ensure equipment was sanitized prior to storage. Findings included: During a comprehensive kitchen tour on 07/15/21 at 10:00 a.m., with the Kitchen Manager and the Certified Dietary Manager (CDM), Staff H, Cook was observed standing at the 3-compartment sink in the process of cleaning dishes. The Kitchen Manager revealed the food-contact sanitizing solution used in the 3-compartment sink was quaternary [MEDICATION(S)]. […]