Alhambra Rehab & Healthcare

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 14, 2021

  Based on observation, interview and record review, the Facility failed to provide supervision and implement effective fall prevention measures for 1 of 3 residents (R1) reviewed for incident/accidents in the sample of 5. This failure resulted in R1 sustaining 3 falls within 4 days, and ultimately sustaining a right [CONDITION(S)] requiring hospitalization and surgical repair. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents that R1 is moderately cognitively impaired and requires extensive assist of one staff to transfer, ambulate, and use the toilet. […]

• No harm, potential for more than minimal, widespreadF727Aug 2, 2024

  Based on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 38 residents living in the Facility. Findings Include: The Facility's July 2024 RN (Registered Nurse) and LPN (Licensed Practical Nurse) schedule documents the Facility did not have a RN on 7/9/24, 7/19/24, 7/24/24, 7/27/24, or 7/28/24. The Facility provided time cards documenting V6, Registered Nurse (RN) and Minimum Data Set (MDS) Coordinator, worked on 7/9/24, 7/19/24, and 7/24/24, and V2, Director of Nursing (DON) worked on 7/27/24. […]

• No harm, potential for more than minimal, widespreadF761Aug 2, 2024

  Based on observation, interview, and record review, the Facility failed to properly store and medications and discard expired medications. This has the potential to affect all 38 residents living in the Facility. Findings include: On 7/31/24 at 8:35 AM, the medication cart on A Hall was inspected with V3, Licensed Practical Nurse (LPN). The cart contained one opened bottle of over the counter liquid protein that was not dated upon opening and one opened bottle of over the counter cough syrup that was not dated upon opening. V3, LPN, stated the liquid protein had a label, but it must have worn off. She stated none of the residents use the cough syrup, so she will just throw it away. On 7/31/24 at 8:40 AM, the medication room on A Hall was inspected with V3, LPN. […]

• No harm, potential for more than minimal, widespreadF880Aug 2, 2024

  A. Based on Observation, Interview, and Record Review, the facility failed to establish and maintain a system of surveillance to identify communicable diseases or infection. This has the potential to affect all 38 residents in the facility. Findings include: On 8/1/2024 Facility Infection Control log documents on 7/21/2023 R196 Urinary Infection. No culture done. On 8/1/2024 Facility Infection Control log documents on 10/10/2023 R195 Urinary infection. No culture done. R195's Physician Order Sheets dated 10/2024 has no documentation of culture and sensitivity. R195's Physician Order Sheets dated 10/10/2023 documents Bactrim DS 800MG-160MG Tablet: Administer 1 tablet by mouth at 8am and 8pm everyday x 7 days related to UTI, Urinary Tract Infection. […]

• No harm, potential for more than minimal, widespreadF755Aug 19, 2022

  Based on interview, observation and record review, the facility failed to secure medications appropriately and count controlled substances to ensure accurate reconciliation and accountability of those medications. This failure has the potential to affect all 39 residents residing in the facility. Findings include: 1. On 8/17/22 at 11:45 AM, V6, Registered Nurse (RN), was observed during medication administration. V6 had the medication cart sitting in the hallway outside of the dining room. V6 left the medication cart to administer medications in a resident room, left the medication cart unlocked and out of V6's view. At 12:00 PM, V6, returned to where the medication cart was located. 2. On 8/17/22 at 1:05 PM, the medication storage refrigerator was checked. […]