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Complaint Investigation

Alhambra Healthcare & Rehabilitation Center

Inspection Date: October 15, 2025
Total Violations 1
Facility ID 105712
Location SAINT PETERSBURG, FL
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Inspection Findings

F-Tag F0559

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

before a change is made.

Based on record review and interviews, the facility failed to document room change notifications for three residents (#2, #3, and #4) of three residents sampled.Findings included: 1.) Review of Resident #2's census revealed Resident #2 changed rooms on 9/29/2025, 9/19/2025 and 9/15/2025. Review of Resident #2's progress notes revealed no documentation of notification of the room changes were located for 9/19/2025 and 9/15/2025. 2.) Review of Resident #3's census revealed Resident #3 changed rooms on 09/24/2025 and 09/19/2025. Review of Resident #3's progress notes revealed no documentation of notification of the room changes for 09/24/2025 and 09/19/2025. 3.) Review of Resident #4's census revealed Resident #4 changed rooms on 09/30/2025. Review of Resident #4's progress notes revealed no documentation of notification of the room changes for 09/30/2025. During an interview on 10/15/2025 at 12:46 P. M., the Director of Nursing (DON) stated the Social Services Director (SSD) was out of the building and was not reachable. The DON stated the SSD notifies the family of any room changes and nursing staff completes the room transfers. The DON stated resident room changes are performed for different reasons,

they can be for personal preferences or by request of the facility. The DON stated residents, and their representatives are supposed to be notified of a room change each time. The DON stated normally the SSD will document notification of the room change in the progress notes. The DON reviewed Resident #2's census and confirmed Resident #2 changed rooms 4 times during her stay. The DON said, I see one progress note about one of the room changes. It appears Resident #2 was moved the first time because we needed a private isolation room. I would expect to find a note in the progress notes documenting the other room changes. During an interview with the DON on 10/15/2025 at 02:30 P. M., the DON looked at the Census for Resident #3. The DON stated the resident had a room change and according to progress notes,

the notification of the room change was not documented. The DON also looked at Resident #4's census and stated Resident #4 had changed rooms within the last thirty days and notification and the reason why, was not documented in progress notes. A policy titled Standards and Guidelines: Residents Rights, and revised 12/2016 showed: Standard: Employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation:Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility;j. be informed about his or her rights and responsibilities.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

📋 Inspection Summary

ALHAMBRA HEALTHCARE & REHABILITATION CENTER in SAINT PETERSBURG, FL inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAINT PETERSBURG, FL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ALHAMBRA HEALTHCARE & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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