Health inspection·January 5, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few edges. Also, there were staff observed at 12:30 p.m. while passing meal trays in the area, who tripped slightly on the slightly raised corners of the flooring. On 01/05/2023 at 7:43 a.m., Staff A, CNA was observed to scuff her feet on the floor in the areas where it was slightly sunken. She was holding a meal tray and tripped slightly when walking through the area. She confirmed this happened at times but tried to remember the area was not even when walking on it. On 01/05/2023 at 12:40 p.m., an interview with the Maintenance Director and the Nursing Home Administrator (NHA) both revealed about three months ago (approximately 10/2022), the front lobby restroom toilets started to back up and they, along with outside services, worked to correct the problem. The NHA and Maintenance Director both revealed the problem expanded to other resident room bathrooms to include the low 100's. The Maintenance Director said they had an outside service investigate the problem and they suggested to put in vent plates in the main hallway in between resident rooms 103/105. He revealed they put in the vent plates and the problem still existed. The NHA said once the problem persisted, he along with Maintenance Department, tried to do an in house fix with the flooring that would not stay affixed to the ground. He revealed they tried various heavy duty double tapes, and heavy duty vinyl/plastics glue which did not work. He said around 12/29/2022, he received a outside service quote in order to correct the floor problem. The NHA revealed he provided the quote to the facility's corporate office and it was just finally approved as of 1/5/2023, which was during the state annual inspection. The NHA said he had no documentation to support continued monitoring of the floor area in question and that the flooring had been little by little becoming more unsecured to the floor, and causing scuffing and/or trip hazards. 2. On 01/03/2023 at 12:10 p.m., during a lunch meal observation in the main dining room, the room was observed with seven tables, and twelve residents seated at them in preparation for lunch. During the meal observation, there was a long section in the side of the room approximately thirty feet. This section had four sets of double glassed doors. The set of doors on the far left or (East) side of the room, and located near the television, were observed with heavy dust/debris build up on the doors, the plastic shutter blinds, the wall corners, and the windows themselves. Photographic evidence was taken. On 01/05/2023 at 12:45 p.m., an interview with the Housekeeping Director revealed he along with up to three other housekeeping staff were responsible for the general cleaning maintenance of the building to include residents spaces, specifically rooms, bathrooms, dining rooms, etc. The Housekeeping Director revealed the general cleaning of the main dining room was after each meal service which included wiping and sanitizing the tables, sweeping and mopping the entire floor, and cleaning and wiping high touch surfaces to include furniture, and window shutters. He also indicated his staff should be wiping down high touch surfaces as need and in between meal services if need be. The Housekeeping Director confirmed the large amount of dust and debris on the window shutters in the main dining room and indicated that those shutters should have been cleaned more often. On 01/05/2023 at 1:00 p.m. the Director of Nursing provided the Housekeeping Aide job description with a last revisit dated of 01/01/2015. The job description revealed; The primary and purpose of this position is to perform the day-to-day activities of the Environmental/Housekeeping Department in accordance with current, federal, state local standards, guidelines and regulations governing our facility, and may be directed by the Environmental Services Director and/or Administrator, to assure that our Facility is maintained in a clean, safe, and comfortable manner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 2 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Duties and Responsibilities include but not limited to: Level of Harm - Minimal harm or potential for actual harm Administrative Functions - Ensure that work and cleaning schedules are followed as closely as practical. Residents Affected - Few Safety and Sanitation - Ensure that assigned work areas are maintained on a clean, safe, comfortable, and attractive manner. - Report all hazardous conditions or equipment to your supervisor. Housekeeping Services - Perform day-to-day housekeeping functions as assigned. - Clean and polish furnishings, fixtures, ledges, room heating or cooling units, etc., in resident rooms, recreational areas, etc. daily as instructed. - Clean windows and mirrors in resident rooms, recreational areas, bathrooms, and entrance or exit ways. - Remove dirt, dust, grease, film, etc. from surfaces using proper cleaning or disinfecting solutions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 3 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure care planning with problem areas, goals, and interventions was developed for three (Residents #108, #3, and #10), of twenty residents related to contracture management, splint/bracing management, and PTSD/Trauma behavior management. Findings included: 1. On 12/3/2023 at 10:20 p.m. and 1:45 p.m., Resident #108 was observed in his room and seated in a wheelchair next to his bed. The call light was placed within his reach and he was dressed for the day. He appeared pleasant and had no immediate concerns. He was not presenting with any behaviors, pain or discomfort at the time of the visit and agreed to be interviewed. He was observed with a hard plastic splint on his left forearm up to his elbow that was held on with two expanding stretch fabric strips. He indicated he was right handed and had a contracture in his left arm due to a stroke in the past, and used the splint to manage his contracture. He said he put the splint on himself. Staff did not help him with it. The dresser positioned behind him was observed with two other types of arm/hand splints. He could not explain their use and said he used the one he had on. He confirmed the splint was not uncomfortable and took it off when he got uncomfortable. Resident #108 was not sure if staff were still helping him with contracture management to help reduce the risk for further decline of his left arm and hand. He said he was helped by therapy but they were no longer assisting him. On 12/04/2023 at 7:30 a.m., Resident #108 was observed in his room, lying in bed, and with the call light placed on his right side (dominant side and side without contracture). He was awake and not presenting with any behaviors, pain or discomfort. He was observed wearing his left arm splint. He said he would take it off shortly when he got his breakfast. He was asked about the other two splints that were placed on his dresser. He did not know why they were there. He was also not aware if the staff assisted him with the placing on and taking off the splint and did not believe they washed the splint either. At 8:07 a.m., Resident #108 was observed receiving his breakfast meal tray from staff. The staff set up the tray and positioned the plate in a manner where he could easily reach it with his right hand. His left splint/brace was observed lying on the over the bed table. He said the staff did not take off the splint but he was able to do it himself, but with great effort. On 12/04/2023 at 8:27 a.m., an interview was conducted with the Rehab Director, Staff D, related to Resident #108. He said Physical Therapy (PT)/Occupational Therapy (OT) did not currently have the resident on case load and would print out the discharge assessment for both PT/OT related to the resident. The Rehab Director confirmed the resident had developed a contracture on his left elbow and they had him on contracture management. He confirmed direct care staff were responsible for assisting him with his splint/brace daily. However, he believed the resident could don and doff it himself. The Rehab Director was not sure if the resident was care planned with interventions and goals with use of the splint/brace or care planned for contracture management. On 01/04/2023 at 9:24 a.m. an interview with the Minimum Data Set (MDS)/Care Plan Coordinator, Staff E revealed she was aware and knew Resident #108 to include his care and services. Staff E was asked about the resident's splint on the left arm/elbow. She confirmed he utilized the splint as tolerated. She said direct care staff should assist with the splint but the resident also put the device on and took it off himself. She was not sure who monitored his daily use of the splint/brace. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 4 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm confirmed they had not developed care plan problem areas or care interventions related to the left elbow splint/brace. She confirmed the Care Planning/MDS department to include herself, had just realized there was no care planning for the splint and would make one with problem areas, goals, and interventions. The MDS/Care Plan Coordinator confirmed the resident was not currently on a restorative nursing program for contracture/range of motion management. Residents Affected - Few On 01/04/2023 at 9:30 a.m., an interview with Staff F, Certified Nursing Assistant (CNA) revealed she knew Resident #108 was assigned to him at times. She confirmed he utilized a left arm splint/brace. She confirmed there were no care plan interventions related to the CNAs' responsibility to maintain and clean the splint/brace. She did not know who was responsible for monitoring the brace/splint use, skin issues, or how long he wore it during the shift. Staff F was asked about the other two splints that were placed on the resident's his dresser. She did not know what the splints were for and said they had been in the room over two to three weeks. A review of Resident #108's medical record revealed he was admitted to the facility on [DATE]. A review of the advance directives revealed Resident #108 was his own responsible party. A review of the diagnosis sheet revealed diagnoses to include: Cerebral Infarction, Rhabdomyolysis, Dysphagia, Muscle weakness, and Depression. There were no diagnoses listed to include contractures upon his admission. A review of the current Physician's Order Sheet (POS) dated for the month of 1/2023 revealed orders to include but not limited to: 1. Apply splint/brace (Left elbow extension splint), during daytime as tolerated and monitor skin integrity when applying and removing, every day and evening shift, with an order date of 12/19/2022; 2. Apply splint/brace L[eft] WHFO (Wrist, hand, finger orthosis) at night as tolerated, monitor skin integrity when applying and removing, every day and evening shift with an order date of 12/19/2022; 3. May participate in restorative program as needed and tolerated with an order dated of 6/27/2022. Review of the Minimum Data Set (MDS) most recent Quarterly assessment, dated 12/30/22022 revealed, Cognition/Brief Interview Mental Score or BIMS score - 15 of 15, which indicated intact cognition; Activities of Daily Living (ADL) - Bed Mobility at Extensive assistance with one person, Eating at Independent with One person assistance, Personal Hygiene at Extensive assistance with one person assistance; The ADL Functional Limitation Range of Motion section was not checked for limited ROM and indicated no limitation. Review of the Monthly Summary dated 11/06/2022 revealed Needs assistance with Personal Hygiene, Bed Mobility and Independent with Eating. Review of the Monthly Summary dated 12/06/2922 also revealed Needs assistance with Personal Hygiene, Bed Mobility and Independent with Eating. Review of the nurse progress notes dated, revealed: - 10/12/2022 09:52 (9:52 a.m.) - Care area review IDT - Eats independently, Resident is currently on adaptive eating equipment (Divided Plate). Wears a universal cuff to help with meals - 10/18/2022 07:58 (7:58 a.m.) - ITD met. Resident currently on adaptive equipment (divided plate). Wears a universal cuff to help with meals and has limited mobility/contractures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 5 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - 10/24/2022 21:18 (9:18 p.m.) MD progress note - Developed weakness in left arm and left leg was admitted to hospital and dx.(diagnosis) Cerebrovascular Accident (CVA). PT also with mild cognitive impairment dx. Encephalopathy. Pt stabilized and admitted to Skilled Nursing Facility (SNF). Continue with functional treatment (tx). CVA with Left side Hemi. Review of the Treatment Administration Record (TAR) dated for the month of 1/2023 revealed: Apply splint/brace (L elbow extension splint) during daytime as tolerated, monitor skin integrity when applying and removing, Every day and evening shift with original order date 12/19/2022. This was initiated as completed each shift. (Signed and initialed each day night and day shift all days in 1/2023). Also, apply splint/brace (L WHFO) at night as tolerated and day and night original order 12/19/2022 and (signed and initialed each day night and day shift days in 1/2023) Review of the 12/2022 TAR revealed the following: - Apply splint/brace (L elbow extension) during daytime as tolerated and monitor skin integrity when applying and removing every day and evening shift. Original order date 12/19/2022. It was documented by nursing each shift that skin was monitored. - Apply splint/brace (L WHFO) at night as tolerated and monitor skin integrity when applying and removing. Every day and evening shift. Original order date 12/19/2022. It was documented each shift the skin was monitored by nursing. A Multi-disciplinary Rehab Screening assessment dated [DATE] revealed - Change in condition to include: Change in ambulation/function mobility status, Change in Active Range of Motion (AROM)/Passive Range of Motion (PROM) or contracture status, Change in ability to feed self. A ROM Functional Limitation screen dated 06/28/2022 revealed - Upper extremity function (SHOULDER) ROM Left checked as Slight Limitation ROM; Right checked as No limitation; Upper extremity function (ELBOW) range of motion (ROM) Left checked as Minimal Limitation ROM; Right checked as No limitation. Comments - Left elbow PROM limited. A ROM/Function limitation screen dated 10/05/2022 revealed - Upper extremities (SHOULDER) ROM Left checked as Minimal Limitation in ROM; Right checked as No limitations (ELBOW) ROM Left checked as Minimal Limitation ROM; Right checked as No limitation A review of the Physical Therapy Discharge summary dated [DATE], revealed in the comments summary notes - E-Stim (Electrical muscle stimulation) applied to Left Lower Extremities (LLE) Quads in order to increase ROM, decrease muscle spasms, stimulate innervated muscles to cause a muscular contraction to strengthen and assist in functional activities. Pt and caregiver education on safety precautions and use of assistive devices in order to facility improved functional abilities. A review of the Occupational Therapy Discharge summary dated [DATE] revealed in the comments section - Pt will increase Left elbow extension to 120 degrees, will tolerate Left elbow extension splint and L WHFO for 8 hours in order to initiate wear schedule outside of therapy services, and to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 6 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few include: L WHFO 4 hours, Left elbow splint up to 2 hours. Interventions to include Left Upper Extremities (LUE) PROM in preparation for splinting and contracture prevention/management. The Care Planning policy and procedure dated 2001 revealed; Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The implementation section of the policy revealed; 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). #5. The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan. The Assistive Devices policy and procedure dated 2001 revealed; Our facility maintains and supervises the use of assistive devices and equipment for residents. The implementation section of the policy revealed; #3. Recommendations for the use of device and equipment are based on the comprehensive assessment and documented in the resident care plan. #6. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. a. Appropriateness for resident condition - the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. b. Personal fit - the equipment or device is set only according to its intended purpose and is measured to fit the resident's size and weight. c. Device condition - devices and equipment are maintained on schedule and according to manufacturer's instruction. d. Staff practices - staff are required to demonstrate competency on the use of devices and equipment and are available to assist and supervise residents as needed. The Resident Mobility and Range of Motion policy and procedure dated 2001 revealed; 1. Residents will not experience an avoidable reduction in range of motion (ROM), 2. Residents with limited Range of Motion will receive treatment and services to increase and/or prevent a further decrease in ROM, 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The implementation section of the policy revealed the following pertinent areas: #4 The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. #5 The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. #6 Interventions include therapies, the provision of necessary equipment, and/or exercise and will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 7 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 be based on professional standards of practice and be consistent with state laws and practices acts. Level of Harm - Minimal harm or potential for actual harm #7 The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident and representative will be included in determining these goals and objectives. Residents Affected - Few #8 Documentation of the resident's progress towards the goals and objectives will include attempts to address changes or decline I the resident's condition or needs. 3. A review of Resident #10's Psychiatric Periodic Evaluation, dated 12/1/22, indicated a diagnosis of Post-Traumatic Stress Disorder (PTSD). A review of the resident's care plan revealed there was no care plan in place for Trauma/PTSD. A review of admission records indicated Resident #10 was initially admitted [DATE] with a re-admission on [DATE] with diagnoses including alcohol abuse and recurrent depressive disorders. PTSD was not listed as a diagnosis in the resident's electronic medical record. A review of Resident #10's Minimum Data Set (MDS,) dated 12/6/22, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating he is cognitively intact. Section I, Active Diagnoses, in the MDS did not indicate a diagnosis of PTSD. A review of Resident #10's progress notes revealed a Physician Note on 1/20/22 stating the resident was being seen for an acute follow-up psychiatric visit per request for evaluation of nightmares. The note stated the resident reported having the same nightmare over and over for years, it consisted of him riding in a large bus that was traveling over a bend in the road and the bus fell off the bed and crashed. The nightmares woke the resident up and were frightening. The resident admitted to having past trauma and stated at the age of 15 he watched a car hit his mother which resulted in her death. He stated he vividly remembered the day he observed this. He reported he was working at an ice cream shop and his mother was crossing the street in a yellow coat. He reported frequently reliving this event throughout his life sometimes causing him anxiousness. He also reported hypervigilance to the physician. On 1/4/23 at 3:54 p.m. an interview was conducted with the Director of Nursing (DON.) She stated a new diagnosis can be entered into the medical record by the DON, the Assistant Director of Nursing (ADON,) the MDS Coordinator, or the physician. She stated if a resident had a new diagnosis it was discussed in morning meetings and would be added to the electronic medical record. On 1/4/23 at 5:22 p.m. an interview was conducted with Staff T, Registered Nurse (RN). When asked if Resident #10 had PTSD, she stated, Not that I know of. She stated the resident had depression but took medication for that and he was fine. A telephone interview was conducted with Staff S, Licensed Practical Nurse (LPN) on 1/5/23 at 8:11 a.m. Staff S confirmed he was regularly assigned to Resident #10 on night shift. He stated he had not witnessed the resident having nightmares. When asked if the resident had PTSD, he stated he knew the resident was in the military and served time in prison. Staff S said, I don't know what impact that had on him. He said the resident did get extremely agitated over wanting cigarettes. An interview was conducted with the DON and ADON on 1/5/23 at 8:44 a.m. When discussing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 8 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident having falls, the ADON stated the resident was initially having falls related to nightmares. She said they had psychiatry see the resident. The ADON said the resident had PTSD from seeing his mom get killed. She also stated he spent 18 years in prison. She stated the psychiatrist adjusted the resident's medication. The DON stated after the medication was adjusted the resident went a long stretch with no falls. When asked why Resident #10 did not have a diagnosis or care plan related to PTSD, she stated, that is a good question. The DON was observed reviewing the resident's electronic medical record. The DON confirmed there was no PTSD diagnosis in the system. The ADON and DON confirmed they had known about the resident's PTSD. An interview was conducted with the MDS Coordinator on 1/5/23 at 9:29 a.m. She stated if the resident had a new diagnosis the doctor or nurse should let her know, then she would put the diagnosis and care plan in the system. She stated she did not know Resident #10 had a PTSD diagnosis. She confirmed there was no diagnosis or care plan related to Trauma/PTSD in the resident's medical record. She stated she was adding it immediately and would review everyone in the facility. A follow up interview was conducted with the DON on 1/5/23 at 9:37 a.m. The DON stated Resident #10's PTSD diagnosis, and nightmares were discussed several times at morning meetings. She stated the MDS Coordinator was present and should have known. The DON stated there were no notes for these meetings. On 1/5/23 at 11:45 a.m. an interview was conducted with Resident #10. The resident confirmed he did have nightmares. He repeated his recount of the nightmares as the physician previously noted. He stated they have improved with medication changes. A facility policy titled Care Planning-Interdisciplinary Team, dated September 2013, was reviewed. The policy stated the following: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individual comprehensive care plan for each resident. 2. Evaluation of the electronic medical record (EMR) for Resident #3 revealed she was initially admitted to the facility on [DATE] with diagnoses including, but not limited to post-traumatic stress disorder (PTSD). An interview was conducted with Resident #3 on 01/03/2023 at 9:24 a.m. She was observed sitting in her wheelchair by the nurse's station, dressed for the day and with a blanket covering her lap. Resident #3 had a pleasant demeanor and was without behaviors or signs/symptoms of PTSD. A review of Resident #3's EMR Minimum Data Set (MDS) quarterly assessment dated [DATE] provided that Resident #3 had a brief interview for mental status (BIMS) conducted, with a total score of 15 indicating intact cognition. The MDS for Resident #3 included a patient health questionnaire (PHQ-9) with a total score of 9, indicating mild depression. The MDS for Resident #3 also documented active diagnoses that included PTSD. Behavior documentation was included in the MDS and stated that Resident #3 was without indicators of psychosis, had no behavioral symptoms (physical/verbal/other), and no rejection of care behaviors. Review of a Psychiatric Periodic Evaluation dated 09/15/2022 within Resident #3's EMR provided documentation from the medical provider that Resident #3 asserts that she has been having a lot of good days lately, but she still tends to focus on the negative memories of her past at times. The medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 9 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm provider also documented that other than reliving the past verbal and emotional abuse issues from her past she has not had any other PTSD sxs [signs/symptoms] such as nightmares or hypervigilance. Review of an OBRA (omnibus budget reconciliation act) Social Service Evaluation dated 12/12/22, stated Resident #3 was followed by psychiatric services on a regular basis for depression and PTSD. Residents Affected - Few Active physician orders for Resident #3 were reviewed in the EMR and included orders for Alprazolam (Xanax) 0.25 mg every 24 hours as needed for anxiety, Alprazolam 1 mg once daily for anxiety, and Guanfacine Hydrochloride (HCl) 2 mg once daily related to hypertension, among other active orders. However, upon review of a Psychiatric Periodic Evaluation dated 12/15/2022, the medical provider indicated in Resident #3's care plan Guanfacine 2 mg P.O. [by mouth] nightly for PTSD. Additionally on that visit, Resident #3 was stated to have a stable mood on her current medication regime, and she had denied any recent PTSD symptoms. Review of active care plans for Resident #3 as of 01/03/2023 provided a care plan with a focus of alteration in thought process related to periods of forgetfulness, age-related cognitive decline, with psych diagnoses of PTSD and bipolar disorder. Active interventions on this care plan included addressing Resident #3 by her preferred name, introducing self when speaking to resident, administering medications as ordered and observing for effectiveness and side effects, encouraging and allowing Resident #3 to make decisions regarding daily cares and educating on unsafe choices as needed, orienting Resident #3 to time or place as needed, providing occupation therapy and speech language pathology screens as needed, continuing psychiatric consultation as ordered, and observing for changes in Resident #3's cognitive function and notifying the physician if noted. Review of active care plans for Resident #3 as of 01/03/2023 did not reveal a plan of care dedicated exclusively to providing trauma-based care for Resident #3's active diagnoses of post-traumatic stress disorder. An interview was conducted with Resident #3 on 01/04/2023 at 12:02 p.m. Resident #3 was observed in her room lying in bed watching television. She stated she was waiting for lunch, and was observed to have a pleasant mood and demeanor. She was without any behaviors or observable symptoms of PTSD. An interview was conducted on 01/05/2023 at 11:46 a.m. with Staff G, Licensed Practical Nurse (LPN), regarding Resident #3's diagnosis of PTSD. Staff G stated that she was unaware of the resident's PTSD diagnosis and she had never seen the resident display any behaviors associated with PTSD. Upon re-review of active care plans for Resident #3 on 01/05/2023, a care plan was observed to have been initiated on 01/05/2023 with a focus of providing care for Resident #3's PTSD diagnosis related to childhood trauma and interventions were included that focused on providing trauma informed care. An interview was conducted on 01/05/2023 at 12:50 p.m. with Staff E, MDS/Care Plan Coordinator, and Staff H, Regional MDS Consultant. Staff E stated Resident #3's PTSD diagnosis was related to childhood trauma and flashbacks of verbal abuse from her mother. Staff E stated Resident #3 did not talk much about her flashbacks and typically did not have behaviors associated with PTSD. Staff E stated she thought the PTSD care plan initiated on 01/05/2023 had already been in place previously. Staff H stated the PTSD care plan was a fairly new care plan pathway and they did not become aware of the care plan option until around the time of the recent hurricanes in 2022. Staff E stated she was responsible for reviewing care plans on a daily basis related to provider's orders and then also quarterly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 10 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 for all residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 11 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure activities of daily living (ADLs) related to showers and hair care were provided for one (Resident #17) of three residents reviewed. Residents Affected - Few Findings included: During a facility tour on 01/04/23 at 12:22 p.m., an interview was conducted with Resident #17. She stated she felt neglected. The resident said, look at my hair, it's like a lump of a nest. They haven't tried to assist me, no one has attempted to comb or brush my hair since I have been here. Resident #17 stated her hair was matted because they left her hair uncombed for a long time. The resident stated she had one shower that she could remember. She stated one of the CNAs told her she should cut her hair. Resident #17 said, I said No, they can take the time to comb it. It is not fair to me. I am dependent on staff for care. The resident stated she had not refused to shower. She stated there was one incident, the only one time she received a shower. The CNA was not comfortable with the lift. The resident stated they argued, and it made her mad. Resident #17 stated since the incident, no one had offered her a shower. Resident #17 stated she received a bed bath here and there. Resident #17 was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. A Minimum Data Set (MDS) dated [DATE], section C, showed a brief interview for mental status (BIMS) of 13, indicating intact cognition. Section G showed Resident #17 was dependent on staff for ADLs, including personal hygiene, toilet use and dressing. The resident was totally dependent on staff for bathing/showers, requiring two staff physical assist. Review of Resident #17's Certified Nurses' Aide (CNA) task log, under bathing task showed from 12/06/22 to 1/4/23 the resident received one shower documented on 12/24/22. The record showed three bed baths were offered during a 30-day period. A care plan for Resident #17 dated 10/13/22, showed Resident #17 had a self-care deficit with dressing, grooming, bathing related to generalized weakness and chronic pain. The resident participated with ADLs with cues from staff. Interventions included to gather and set up supplies for care, cue/encourage resident to participate in ADLs tasks, allow resident ample time to attempt/complete ADL task, provide hands on assistance with dressing, grooming, bathing, staff to anticipate resident's needs with ADLs decline in ADL function, and report to physician as indicated. An interview was conducted with Resident #17 on 01/03/23 at 10:10 a.m. Resident #17 was observed in her room lying in bed, facing the wall, her hair was noted uncombed, matted, and tangled in a clamp. The resident appeared disheveled and untidy. Resident #17 did not respond to the interview. On 01/03/23 at 12:42 p.m., Resident #17 was observed in her room during lunch. The resident was asked if she had received assistance with showers/bath. Resident #17 said, what assistance? The resident stated she had not received assistance with her hair. On 01/04/23 at 12:25 p.m., an interview was conducted with Staff I, CNA. She stated Resident #17 was dependent on staff for all care, and she did not get out of bed often. Staff I stated the resident did not typically refuse care, but you had to ask her what she needed. Staff I stated they count on her to initiate her care needs. Staff I stated the resident was alert and oriented, and made her needs known. Staff I stated she thought the resident received showers as scheduled. She stated she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 12 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 not given her a shower or bath. Level of Harm - Minimal harm or potential for actual harm On 01/04/23 at 12:32 p.m., an interview was conducted with Staff N, CNA. Staff N stated she worked with Resident #17 often and the resident was dependent on staff. Staff N stated the resident stayed in bed all the time, per her preference. Staff N stated they assisted the resident as needed. She stated she did not necessarily refuse care, but sometimes she was not compliant. Staff N stated she washed the resident off as needed, especially after changing her. Staff N stated she had not given Resident #17 a shower lately. Residents Affected - Few On 01/04/23 at 12:34 p.m., an interview was conducted with Staff J, LPN. She stated the resident kept to herself and was not aware that she was refusing any care today. She stated the resident did refuse showers sometimes. She was scheduled to shower three times a week . Staff J showed the surveyor a shower schedule confirming Resident #17 should be showering three times a week if she wished, on Tuesdays, Thursdays, and Saturdays. Staff J stated on the day of scheduled shower, the CNA went to the room and offered the resident a shower/bath. If the resident refused a full bath or shower, but accepted a bed bath, they provided it. If the resident was refusing showers/baths, it would be noted in the CNA task log. Staff J said, No they do not document elsewhere. If you can't find it in the resident's EMR, then it is not there. Staff J stated Resident #17 came in with her hair put up in a bun and she just noticed last week that it was completely matted. Staff J stated she then asked the resident if she would like it combed. Staff J stated the resident said she preferred to go to a salon because it was already matted. Staff J stated the resident was upset because a CNA said they would cut it off. Staff J stated she did not know if they could take the resident to a salon, but social services would have to figure that out. An interview was conducted with the Director of Nursing (DON) on 01/04/23 at 3:25 p.m. The DON stated the resident refused showers which should be documented. She stated the CNAs should be documenting refusals and not document N/A (not applicable). The DON said, Not applicable should not be an option. She either showered or she did not. The DON stated she had initiated education for the CNAs who were documenting N/A and would have a discussion with the resident. The DON stated she discussed the resident's refusal to shower in October. The DON stated she did not remember specifically discussing Resident #17's hair and could not recall why the issue of her matted hair had not surfaced. The DON confirmed if a resident was refusing care, it should be documented. The DON stated the care plan should reflect the resident refused care, and appropriate interventions should be in place. The DON reviewed the CNA task log and saw only one documented shower. She stated, I get what you are saying, it does not look good. A follow-up was conducted on 01/04/23 at 03:42 p.m., with the Regional Clinical Nurse. She reviewed the shower task log and said, Yes, it makes sense she should be getting more showers or there should be more refusals documented. She stated it did make sense to care plan the refusals if there was a pattern. She reviewed the behavior log for the resident and confirmed there were no documented behaviors or shower/bath refusals. She stated she spoke to the resident and observed her hair was matted. She said, Oh, that's not good. I saw her hair. I can't believe it got that bad. Regional Clinical Nurse stated she spoke with Resident #17, and she expressed her preference to receive bed baths in the evenings. The Regional Clinical Nurse confirmed she would expect the resident's wishes to shower or receive a bath to be honored. Review of a facility policy, revised March 2018, showed residents will be provided with care treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 13 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete nutrition grooming and personal and oral hygiene. Residents will be provided with care treatment and services to ensure that their activities of daily living do not diminish unless the circumstance of their clinical condition demonstrates that diminishing ADLs are unavoidable. If residents with cognitive impairment or dementia resist care staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. A residents' ability to perform ADL's will be measured using clinical tools, including the MDS. [Total dependence] means full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire seven-day look back. Interventions to improve or minimize resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated, and revised as appropriate. Event ID: Facility ID: 105712 If continuation sheet Page 14 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility did not ensure follow through on services related to a power wheelchair were conducted in a timely manner for one (Resident #3) of two sampled residents. Residents Affected - Few Findings included: An interview was conducted with Resident #3 on 01/03/2023 at 9:24 a.m The resident was observed dressed for the day in plain clothes with a blanket over her lap and positioned by the nursing station. Resident #3 stated she had returned from a radiation appointment that morning and when transported back to the facility she was placed by the nurse's station. Resident #3 stated that she would kill for a cup of coffee and that she had asked for a cup and was told by an aide that there was some in her room. Resident #3 stated that she was unable to wheel herself to her room and was waiting for a staff member to assist her. Resident #3 stated she had asked an aide to move her to her room but at the time the aide needed to provide assistance to a different resident. Resident #3 stated she had been a CNA for many years and understood that sometimes staff could be busy. A review of Resident #3's medical record provided an initial admission date of 6/25/2019 with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, post-traumatic stress disorder, anxiety disorder, and neuromuscular dysfunction of bladder. A quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #3 had a Brief Interview for Mental Status (BIMS) conducted, with a total score of 15 which indicated intact cognition. The MDS indicated Resident #3 required extensive assistance and a one-person physical assist for bed mobility, dressing, and toilet use, total dependence and two+ persons physical assistance for transfers, and independent with set-up help only for eating. On 01/03/2023 at 9:50 a.m., Resident #3 was observed sitting by the nurses' station in her wheelchair and stated she was still waiting to be assisted back to her room. On 01/03/2023 at 10:10 a.m., Resident #3 was observed sitting by the nurses' station in her wheelchair and stated she was still waiting to be assisted back to her room. An interview was conducted on 01/03/2023 at 10:28 a.m. with Resident #3 by the unit nurse's station. At which time, she stated she had not yet received coffee. She stated she spoke with the Dietary Manager just a few minutes prior and asked him for a cup, and he stated that he would have someone bring it to her. Resident #3 stated the Dietary Manager again passed by her several minutes later and stated he was surprised she still had not received a cup of coffee. Resident #3 then stated she would like to see about getting her morning appointments changed to a later time so she would be able to have coffee before leaving in the morning. On 01/03/2023 at 10:30 a.m., the Dietary Manager was observed walking down the hall with a covered cup of coffee and stated it was for Resident #3. An interview was conducted with Resident #3 on 01/04/2023 at 8:56 a.m The resident was observed dressed for the day and was up in her wheelchair by the nurse's station. Resident #3 stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 15 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few received breakfast that morning before leaving the facility for her daily radiation appointment and had also had a hot cup of coffee. Resident #3 stated she was down to receive an early breakfast before her appointments and this does occur. A review of active physician orders dated as of 01/04/2023 included, but were not limited to, Monday-Friday (daily) cancer center appointments for 28 radiation visits. Resident #3 was ordered to be sent with an information packet, Hoyer sling, and in need of any early breakfast tray as well as sending a bagged snack. An interview was conducted on 01/04/2023 at 12:02 p.m. with Resident #3 in her room. The resident was observed lying in bed with personal belongings in reach and she was watching television. She stated she had had her power wheelchair, which was in the facility positioned in the hall outside of the resident's room, for five or six years. She stated the power wheelchair was unusable because it had a low battery, the tilt back was broken, and she slid down in the chair which put her at risk of sliding out of the chair. She stated she would like to order a lap belt to aide in holding her in the chair, but per the Therapy Director, she would have to be able to operate the lap belt herself so that it would not be considered a restraint. Resident #3 stated she was completely paralyzed on her left side, including both her upper and lower extremities, but had use of her right arm with some decreased strength. She stated her posture had also become a problem and was the reason she slid out of the power wheelchair. She stated she was provided her current wheelchair, a manual wheelchair with a tilted back, possibly two months ago. Resident #3 called the manual wheelchair a torture chamber and stated that it was very uncomfortable for her to use. Resident #3 stated that since having to use the manual wheelchair she had become totally dependent on staff and others to help her get around and participate in activities like smoking or taking a leave of absence from the facility. Resident #3 stated that she was not currently working with therapy services but would like to get on the restorative therapy case load to help improve her posture. She stated she believed a social worker at the facility sent an application for a new electric wheelchair, but she was denied and was currently waiting to find out more about the status of fixing her unusable power wheelchair by way of having a friend complete the needed repairs. Review of a physician progress note dated 12/19/2022 stated Resident #3 had limited range of motion in the left upper and lower extremities with contracture on the left leg more than the right affecting her ability to flex and extend both hips. The resident was noted with left upper extremity weakness with significant difficulties with range of motion against gravity, and her range of motion was significantly impaired passively as well as actively in both legs with left hip external rotation and left knee flexion contracture. Review of a physician progress note dated 12/8/2022 stated Resident #3 required assistance to be moved in a regular wheelchair. The note indicated she had physical debility with a history of cerebrovascular accident (CVA) with left-sided weakness, both upper and lower extremity contractures and poor posture. Resident #3 was care planned to continue physical therapy (PT), occupational therapy (OT), and restorative therapy as needed and tolerated. The physician progress note stated Resident #3 used an electric wheelchair for mobility but was now unable because of poor posture and sliding down from the power wheelchair. Resident #3 was indicated to benefit from a new power wheelchair that tilted and paperwork for the power wheelchair was sent by social work to be approved. On 01/04/2023 at 5:15 p.m., an interview was conducted with the Director of Nursing (DON) regarding Resident #3's power wheelchair and Resident #3's concern over loss of independence related to having to utilize a manual wheelchair. The DON stated in 2022 the resident was evaluated on two or three (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 16 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few separate occasions for safe use of her electric wheelchair, and she was deemed unsafe to utilize the mobility device. A review of medical documentation from 09/02/2022 entitled Seating/Mobility evaluation revealed that Resident #3 was referred for a power mobility assessment for positioning and drive system. Resident #3's goal at the time was to spend time up in the wheelchair to perform ADLs, while caregiver goals were to maximize Resident #3's safety and independence during ADL routine. Resident #3's current seating/mobility device was described as a right hand drive power wheelchair with a standard form wheelchair cushion and a standard wheelchair back. The reason provided for the updated evaluation was to accommodate Resident #3's postural changes. The Clinical Criteria section of the evaluation indicated Resident #3's environment supported the use of a power wheelchair and the resident had sufficient function/abilities to use the recommended equipment. The final recommendation of the evaluation was a power wheelchair with a tilt/recline positioning system. A review of Resident #3's medical record provided documentation of a physical medicine and rehabilitation follow up note dated 09/12/2022. The physician documented that a tilt in space motorized wheelchair may help Resident #3 to stay safer seated in her wheelchair without sliding down to floor due to inability to control bilateral hip flexion. The physician stated that such a device would allow Resident #3 to maintain a safer posture in her wheelchair, perform ADLs safer, and provide much needed independence to move around. A review of documentation uploaded into Resident #3's medical record provided a prescription dated 9/15/2022 for a power wheelchair with right hand joystick drive, power reclining and tilt-in-space features with custom pressure relieving cushion and trunk (lateral) support with adjustable footrest for a diagnosis of postural instability, left-sided hemiparesis and hemiplegia due to CVA. An interview was conducted on 01/05/2023 at 10:40 a.m. with the Therapy Director regarding Resident #3's evaluation and current mobility situation. Per the Therapy Director, Resident #3 had participated in therapy programs on a number of occasions in order to minimize contractures and improve quality of life. The Therapy Director stated Resident #3 would participate in therapy programs until she reached maximum potential, and then would be provided education for strengthening exercises that she should perform on her own. The resident often lacked follow through with these recommendations resulting in changes to her postural stability leading to her no longer being able to maintain posture while in the currently available power wheelchair. The Therapy Director reported he had met with the facility physician, the physiatrist/pain management provider, and Social Services, and had done a mobility evaluation in September 2022 which led to the prescription for the new power wheelchair device being obtained. The Therapy Director indicated that to his knowledge the only way Resident #3 can obtain a new power wheelchair is through Medicaid, and the Social Services Director sent all information to Medicaid. The Therapy Director stated that in the meantime, the safest available and equivalent option for Resident #3 is the standard manual wheelchair with reclined back. An interview was conducted on 01/05/2023 at 10:55 a.m. with the Social Services Director (SSD). He said all documentation regarding Resident #3's power wheelchair was sent to a durable medical equipment (DME) company, but the power wheelchair was not covered under Resident #3's insurance plan as she resided in a skilled nursing facility setting. The SSD indicated Resident #3's postural positioning was not appropriate to use her current power wheelchair and this information, along with the denial for a new chair, was provided back to the facility team. The SSD stated he discussed a self-pay option with the resident, with a new chair having an average cost of $5,000. The SSD also stated he recently spoke with Resident #3 about renting a power wheelchair and provided her with names and phone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 17 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few numbers for rental companies. The SSD described the normal process would be for therapy to make an assessment of the resident and recommend the appropriate equipment, and then social services would attempt to facilitate acquiring the recommended device. The SSD stated if they were unable to acquire the equipment, then the resident was notified which had happened. The SSD stated he probably did not have any documentation of these encounters with the DME company or the resident and his normal practice was to shred documentation after three to four months. The SSD stated he would not have scanned the documents into Resident #3's electronic medical record. On 01/05/2023 at 2:25 p.m., an interview was held with the Nursing Home Administrator who stated Resident #3 would be evaluated the following day by Occupational Therapy for assessment of safe positioning in a new chair. The Nursing Home Administrator stated this should have been completed sooner and education would be provided to the Social Services Director regarding responding to resident needs in a timely manner. A review of Resident #3's electronic medical record did not reveal any documentation from social services regarding follow up or resolution of the power wheelchair issue, nor was there documentation of information provided to Resident #3 regarding her power wheelchair situation from September through December 2022. Review of the job description for the facilities Social Services Director provided that administrative functions of the Social Services Director include, but are not limited to: plan, develop, organize, implement, evaluate, and direct the social services programs of the facility; develop and implement policies and procedures for the identification of medically related social and emotional needs of the resident; participate in community planning related to the interests of the facility and the services and needs of the resident; participate in discharge planning, development and implementation of social care plans and resident assessments; perform administrative requirements, such as completing necessary forms, reports, etc., and submitting such to the Administrator, as required; provide information to resident and families as to Medicare and Medicaid, and other financial assistance programs available to the resident; provide consultation to members of facility staff, community agencies, etc., in efforts to solve the needs and problems of the resident through the development of social services programs; maintain a quality working relationship with the medical profession and other health related facilities and organizations; coordinate social service activities with other departments, as necessary; assume the authority, responsibility, and accountability of directing the Social Service Department; and assure that social service progress notes are informative and descriptive of the services provided and of the resident's response to the service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 18 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure behavior monitoring was in place for one (Resident #10) of five residents on psychotropic medication reviewed for unnecessary medication. Findings included: A review of the admission records for Resident #10 indicated he was initially admitted on [DATE] and a re-admitted on [DATE] with diagnoses including recurrent depressive disorders. A review of physician orders revealed the following: Duloxetine HCL Dr sprinkle 40 mg. One time a day for depression. Date 11/29/22 A care plan review showed a care plan in place for the potential for adverse side effects related to the use of psychotropic medication. The interventions included observe for effectiveness of psychotropic medications, observe for adverse side effects related to psychotropic medication use, and observe for changes in mood/behavior. A review of Resident #10's electronic Medication Administration Record (eMAR) did not show any behavior or side effect monitoring in place for the resident's use of Duloxetine. On 1/3/23 a request was made to the Director of Nursing (DON) to provide documentation of behavior monitoring for Resident #10. An interview was conducted with the Regional Nurse Consultant on 1/4/23 at 5:33 p.m. She was observed reviewing Resident #10's medical record and was unable to find any indication behavior monitoring was in place. On 1/4/23 at 5:45 p.m. an interview was conducted with the DON. She provided behavior monitoring for Resident #10's previous stay in November 2022. The DON stated behavior monitoring was not done in December and it must have been missed when he was readmitted on [DATE]. She confirmed the behavior monitoring should have been in place. A review of Resident #10's Behavior Monitoring Flow Sheet for January 2023 indicated an order for behavior and side effect monitoring related to Duloxetine use was put in place on the night shift on 1/3/23. A facility policy titled Antipsychotic Medication Use, dated December 2016, was reviewed. The policy stated the following: 8. Diagnosis alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others, AND: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 19 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 (1) the symptoms are identified as being due to mania or psychosis or Level of Harm - Minimal harm or potential for actual harm (2) behavioral interventions have been attempted and included in the plan of care, except in an emergency. Residents Affected - Few 16. Staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. 17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation b. Cardiovascular: orthostatic hypotension, arrhythmias c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain d. Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia, or tardive dyskinesia, stroke or TIA. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 20 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 [NAME] 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. She stated she would call the nurse who was using the cart. At 4:20 p.m., Staff Q, Licensed Practical Nurse (LPN) walked to the unlocked medication cart. Staff Q stated she walked away from the cart because she had to go put orders in the computer. She said she is new to Long-Term Care and still trying to figure things out. She said she had worked in the facility for over a year. She confirmed she had training and knew she should lock the medication cart when not using it. (Photographic evidence obtained.) On 1/5/23 at 9:00 a.m. an audit was completed of the East Medication Storage room with the Director of Nursing (DON.) The DON stated over-the-counter medication was kept in Central Supply, not in the medication storage room. Central Supply was observed to have a locked, ventilated cabinet with medication inside. A random review of medication revealed 1 bottle of CO Q-10 that expired on 9/22, 2 bottles of Vitamin E 1000 IU that expired on 6/22, 2 bottles of Vitamin E 400 IU that expired on 9/22 and one that expired on 6/22, and 1 bottle of Docusate Calcium that expired on 9/22 and 10 that expired on 12/22. The DON stated the Central Supply Clerk should be checking the medications and cleaning them out every month. She stated there should not be expired medication in the cabinet. The DON mentioned that medications get delivered to the Supply Clerk's office. An interview was conducted with the Regional Nurse Consultant on 1/5/23 at 9:24 a.m. She stated medications should be cleaned out monthly and no expired medications should be in the storage area. On 1/5/23 at 11:30 a.m. a follow-up interview was conducted with the DON. She confirmed medications were delivered and sometimes kept in the Supply Clerk's office. The DON was observed walking in the Supply Clerk's office. The office was located on the East Hall and the door was unlocked. No one was in the office at that time. Two bottles of Sodium Chloride tablets were on the desk, 1 bottle of Vitamin B Complex, 1 bottle of Vitamin E, 1 bottle of Fiber tablets, and 1 bottle of Aspirin were sitting on top of a filing cabinet. A prescription bottle was observed to be sitting on the front of the desk. The bottle contained Humulin R 500 units/ml for Resident #208. The prescription was dated 8/30/21 and the vial of insulin expired 11/22. The DON stated she didn't know why the insulin was in there and stated there should not be any prescription medications in the office. A review of admission records revealed Resident #208 was admitted to the facility on [DATE] and was discharged on 9/11/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 21 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many A review of orders revealed an order for Humulin R U-500 Solution. Inject 100 units subcutaneously three times a day related to Type II Diabetes Mellitus. Order date 8/30/21. A telephone interview was conducted with the facility's Consultant Pharmacist on 1/5/23 at 12:30 p.m. The pharmacist stated expired medications or medications from discharged residents should be returned to the pharmacy. He stated this was the only facility he had seen that did not keep over-the-counter medication in the medication storage room. He stated he did not audit the supply room but did ensure the medications were locked and sealed. Regarding prescription insulin being in the Supply Clerk's office he stated, prescription medication should not be stored in there at all. On 1/5/23 at 12:45 p.m. the Regional Nurse Consultant was observed entering the Supply Clerk's office. The door was unlocked, no one was in the office, and three residents were sitting within 10 feet of the door. The Regional Consultant confirmed the presence of expired medication in the office. She said she didn't know why it was there and confirmed no prescription medication should be in the office. On 1/5/23 at 12:55 an interview was conducted with Staff R, Supply Clerk. She stated when over-the-counter medication was expired, she put it in her office to remind her to reorder it. She stated she forgot the insulin was on her desk. Staff R confirmed she was not a nurse. She said she had the insulin in her office because it needed a particular needle that she was trying to find. She stated she was having a hard time finding it, then the resident was discharged , and she forgot about it. A facility provided job description for Central Supply Clerk was reviewed. The job description stated the following: Administrative Functions -Organize storage, issue and delivery of supplies and equipment in accordance with established policies and procedures. -Ensure inventory is updated as required, when receiving and issuing supplies and equipment. -Ensure storage instructions are followed. Safety and Sanitation -Maintain supply and storage rooms in a safe, clean, and orderly condition. A facility policy titled Storage of Medications was reviewed. The policy stated the following: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked area, under proper temperature, light and humidity controls. Only persons authorized to order, store, manage and prepare and administer medications have access to locked medications. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Over the Counter medications or supplies handled by authorized facility personnel are discontinued, outdated, or deteriorated drugs or biologicals are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 22 of 23 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 returned to the dispensing pharmacy, or source or destroy. Level of Harm - Minimal harm or potential for actual harm 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 23 of 23