Health inspection·March 26, 2025

F 0584 Photographic Evidence Obtained 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 2 of 16 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 03/26/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Some Review of Resident #6's admission Record showed an admit date of 11/13/2023 with a diagnosis of PTSD. Diagnoses of dissociative identity disorder and borderline personality disorder were added on 6/25/2024 and a diagnosis of major depressive disorder was added on 10/16/2024. Review of Resident #6's Level I PASRR screen completed on 11/13/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, question 2. C. Adaption to change: The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system, was checked no. Review of Resident #6's Psychology Subsequent Note dated 3/5/2025 revealed under Assessments and Plan, Resident #6 had a treatment objective to learn to adjust to living in the facility by building resiliency skills and engaging in enjoyable activities. Review of Resident #6's record did not reveal a Level II PASRR screen. 4. Review of Resident #13's admission Record showed an admit date of 11/16/2021. Diagnoses included bipolar disorder and major depressive disorder, added 8/15/2024; and dementia, added 2/4/2022. Review of Resident #13's Level I PASRR screen completed on 11/9/2024 showed in Section A. Mental Illness (MI) or suspected MI, bipolar disorder, depressive disorder, and unspecified dementia, unspecified severity, were checked. Section II showed, Question #5: Does the individual have a primary diagnosis of Dementia? The response was checked Yes. Section II: Other Indications for PASRR Screen Decision-Making also showed, A Level II PASRR evaluation must be completed if the individual has a primary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness, Intellectual Disability, or both. A Level II PASRR may only be terminated by the Level II PASRR evaluator. The facility did not complete a Level II PASRR screen for Resident #13. 5. Review of Resident #2's admission Record showed an admit date of 12/2/2020. Diagnoses included anxiety disorder, added 11/21/2024; major depressive disorder, added 10/16/2024; and schizoaffective disorder, added 9/9/2021. Review of Resident #2's Level I PASRR screen completed on 11/9/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, question 2. C. Adaption to change: The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system, was checked no. Review of Resident #6's Psychology Subsequent Note dated 2/26/2025 revealed Resident #2 has been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 3 of 16 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 03/26/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some being seen for major depressive disorder, with a follow up scheduled for the following week due to the resident not feeling well. Review of Resident #2's record did not reveal a Level II PASRR screen. During an interview on 3/26/2025 at 1:14 PM, the Social Services Director (SSD) and the Director of Nursing (DON) confirmed being responsible for completing the PASRR screens. The SSD and DON confirmed according to the directions on the Decision-Making Screen, a Level II PASRR evaluation is needed if the resident has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness, Intellectual Disability, or both. The SSD and DON continued to state they have never really thought of the questions being indicated for them to complete, and confirmed, in reading the questions in Section II, they should be completing the questions if the residents are being treated or have the characteristics on a continuing or intermittent basis. The SSD and DON confirmed in the examples above the sections should have been marked yes and then a Level II evaluation would have been indicated. Review of the facility's policy and procedures titled Preadmission Screening and Resident Review (PASRR) with a revision date of March 2019 showed: Policy Statement: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations. Policy Interpretation and Implementation: 1. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The hospital or facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level Il (evaluation and determination) screening process. (1) The social worker or designee is responsible for making referrals to the appropriate state designated authority. c. Upon completion of the Level Il evaluation, the state PASARR representative determines if the individual has a physical or men I condition, what specialized or rehabilitative services he or she needs, and whether placement in facility is appropriate. d. The state PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the state PASARR representative, the potential resident and his or her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 4 of 16 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 03/26/2025 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 0645 representative are notified. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of policy and procedures, and interviews, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASRR) screening was completed for five residents (#48, #29, #6, #13, and #2) of 15 residents sampled. Residents Affected - Some Findings included: 1. A review of Resident #48's admission Record showed an admit date of 8/21/2023 with diagnoses of Post-Traumatic Stress Disorder (PTSD), unspecified dementia, alcohol abuse, and cocaine abuse. The diagnosis of major depressive disorder was added on 9/26/2024. A review of Resident #48's Level I PASRR screen completed on 11/13/2024 showed in Section A. Mental Illness (MI) or suspected MI, depressive disorder, substance abuse, and PTSD were checked. Section II showed, Question #5: Does the individual have a primary diagnosis of Dementia? The response was checked Yes. Section II: Other Indications for PASRR Screen Decision-Making also showed, A Level II PASRR evaluation must be completed if the individual has a primary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness, Intellectual Disability, or both. A Level II PASRR may only be terminated by the Level II PASRR evaluator. The facility did not complete a Level II PASRR screen for Resident #48. 2. A review of Resident #29's admission Record showed an admit date of 4/24/2024 with diagnoses of paranoid schizophrenia, unspecified psychosis not due to a substance or known physiological condition, and PTSD. A diagnosis of major depressive disorder was added on 8/15/2024. A review of Resident #29's Level I PASRR screen completed on 1/20/2025 showed in Section A. Mental Illness (MI) or suspected MI, depressive disorder, schizophrenia, and unspecified psychosis not due to a substance or known physiological condition and PTSD, checked. A review of Resident #29's most recent psychiatric progress note with a service date of 2/27/2025 showed the rationale behind diagnoses for schizophrenia as, the history of this patient shows that the patient has chronic inconsistent psychosis. These symptoms cause significant distress and functional impairment to the patient. The patient has had a history of psychosis for more than one month, causing emotional and behavioral disturbance for six months or more. A Level II PASRR screen was not completed for Resident #29 for his severe chronic serious mental illness of schizophrenia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 5 of 16 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 03/26/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to develop an individualized plan of care to include goals and interventions for two residents (#11 and #9) of forty two residents sampled. Findings included: 1. On [DATE] at 11:09 a.m., Resident #11 was observed reading a book while sitting in a wheelchair. An interview was attempted, however, she did not respond and continued to read her book. Her roommate stated Resident #11 is, Always reading, hard of hearing, and doesn't wear her hearing aids. A review of Resident #11's admission Record revealed an original admission date of [DATE] and a re-admission date of [DATE]. Further review of the admission record revealed the following diagnoses to include: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, generalized anxiety, and post-traumatic stress disorder. A review of Resident #11's psychiatry notes, dated [DATE], [DATE], and [DATE], revealed the following, . History of Present Illness: This is a [AGE] years old patient with a past psychiatric history of depression, anxiety, dementia, insomnia and PTSD. PTSD (Post Traumatic Stress Disorder): The history suggests that this patient suffered from significant trauma resulting into nightmares, flashbacks, and hypervigilance in the past. These symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one months and have occurred without any substance abuse or organic brain pathology . Care Plan for PTSD diagnosis: Trauma: history of abuse from father (Both physical and sexual) as a child. Further review of psychiatry notes, dated [DATE], revealed the following, . PTSD Section: Twin died, mistreated by family (provided by facility) No triggers noted. Due to cognitive impairments associated with dementia the patient is unable to elaborate on current symptoms or provide detailed history. However, staff and caregivers report no observable PTSD symptoms, such as nightmares, hypervigilance, flashbacks, or avoidance behaviors. Care Plan for PTSD diagnosis: Trauma: history of abuse from father (Both physical and sexual) as a child. Triggers: Approach . Corrected/Confirmed Diagnosis: Added PTSD dx [diagnosis] and care plan in the chart: As pt [patient] has active symptoms of PTSD such as flashbacks, nightmares, hypervigilance, causing distress, I added PTSD dx. The trauma is Twin died, mistreated by family (provided by facility). The current triggers are not reported. A review of Resident #11's care plan, revised on [DATE], revealed the following: [Resident name] has risk or actual diagnosis of PTSD and has potential for re-traumatization R/T [related to] Childhood trauma: twin died, felt unloved by family. A review of goals revealed the following, Resident will remain free from episodes of re-traumatization AEB [as evidenced by]: (personalize) through the next review. Revision on: [DATE]. Target Date: [DATE]. Resident will remain free from episodes of re-traumatization AEB no flashbacks or upsetting dreams through the next review Target Date: [DATE], Resident will have minimal triggers of re-traumatization thru the next review. Target Date: [DATE], Resident will have minimal negative changes in thinking and mood through the next review Target Date: [DATE]. A review of interventions include the following, . Establish a relationship (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 6 of 16 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 03/26/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of trust with the resident, Date Initiated: [DATE], Created on: [DATE], . Provide calming and reassuring environment, Date Initiated: [DATE], Created on: [DATE], . Use calm approach. Explain action during cares. Date Initiated: [DATE], Created on: [DATE], . Avoid positioning yourself between the resident and the door Date Initiated: [DATE], Created on: [DATE] ., Provide female caregivers ONLY to assist with cares per resident/responsible party preference. Date Initiated: [DATE], Created on: [DATE]. Provide male caregivers ONLY to assist with cares per resident/responsible party preference. Date Initiated: [DATE], Created on: [DATE] . On [DATE] at 9:18 a.m., an interview was conducted with Staff C, Certified Nursing Assistant (CNA) who stated she looked at the care card to view a resident's diagnoses. Staff C, CNA stated she would go into the resident's electronic medical record or speak with the nurse to determine what their needs are. She stated she's not sure where to view in their chart how to approach a resident related to triggers for someone diagnosed with PTSD. She stated she thinks the care card or [NAME] would have that. She stated, The care card tells you everything about the resident. Staff C, CNA confirmed she hasn't had training or education related to PTSD. Regarding Resident #11, she stated she worked with the resident often. Staff C, CNA stated she didn't know the resident had PTSD and could not identify her triggers. On [DATE] at 9:56 a.m., an interview was conducted with the Social Services Director (SSD). He stated for residents with PTSD they, Determine the root cause and psych follows them. He stated for the diagnosis of PTSD, there is a care plan in place. The SSD stated the care plan included how to approach the person, their environment, avoid putting yourself in front of them and between the door, medication management as needed, observing for changes in behaviors, and psychiatry/psychology (psych) services as needed. He stated for sexual abuse or assault they determine if the resident feels comfortable with a male or female staff. The SSD stated the care plan, Has prefilled boxes to check off, however, they could be filled in. He stated he hasn't had to put individualized triggers for any PTSD care plans. Regarding Resident #11, the SSD stated he knows the resident has PTSD. He stated the resident told him her trauma stemmed from the loss of her twin, and she felt her family didn't love her. He stated he reviewed Resident #11's psych notes and confirmed the psych provider attended monthly interdisciplinary team meetings. The SSD stated he printed and looked at every psych note. He confirmed he had not seen the psych notes which included documentation related to physical and sexual abuse. The SSD confirmed Resident #11's care plan should include interventions related to approach and determining her preferences for care. 2. Review of the admission Record for Resident #9 revealed an admission date of [DATE] and a readmission on [DATE] with diagnoses to include hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease; end stage renal disease (ESRD); and dependence on renal dialysis. Review of the Minimum Data Set (MDS) from admission dated [DATE] revealed Resident #9 was on hemodialysis. Review of Resident #9's Order Summary Report dated [DATE] revealed the following orders: - [DATE]: Check dialysis access site for signs of infection (warmth, redness, tenderness or edema) when performing routine care at regular intervals every shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 7 of 16 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 03/26/2025 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 0657 - [DATE]: Dialysis center to maintain dressing changes to dialysis access site. Level of Harm - Minimal harm or potential for actual harm - [DATE]: If there is major bleeding from the access site, apply pressure to insertion site, contact emergency services and dialysis center period verify any clamps are closed on lumens if not an AV shunt. This is a medical emergency. Do not leave the resident alone until EMS (Emergency Medical Services) arrives. As needed for major bleeding. Residents Affected - Few - [DATE]: Mild bleeding from the access site (post dialysis) can't be expected. For mild bleeding, reinforce pressure dressing. Contact the dialysis center or physician for further instructions. As needed for mild bleeding. - [DATE]: Remove pressure dressing after return from dialysis (enter dialysis days Monday Wednesday and Friday) per dialysis orders. In the evening every Monday, Wednesday, Friday. - [DATE]: Dialysis access site: (Left Upper Arm). Type of Access: Fistula. every shift - [DATE]: Dialysis Monday, Wednesday, Fridays; Pick up time: 11:30 am Center Address [listed address, phone, transportation company] every day shift every Monday, Wednesday, Friday. - [DATE]: Do not use the dialysis access site arm to take blood pressure, blood sample, administer IV (intravenous) fluids, or give injections. Left arm, every shift. - [DATE]: Palpate the dialysis fistula access site to feel the Thrill use stethoscope to hear the Bruit of blood flow through the access site. Left upper arm, every shift for fistula monitoring left upper arm. Review of Resident #9's care plan revealed a Focus area, Resident has potential for complications related to hemodialysis for treatment of ESRD. Shunt site is located: (Specify shunt location), Receives dialysis on: (Mon., Wed., Fri), Receives dialysis at: (insert dialysis center name, address, phone number), Date Initiated: [DATE], Revision on: [DATE]. Goal showed: Resident will remain free from avoidable complications related to hemodialysis thru the next review date. Target Date: [DATE]. During an interview on [DATE] at 11:45 a.m. the Minimum Data Set (MDS) Coordinator confirmed being responsible for updating and completing the care plans. The MDS Coordinator reviewed Resident #9's care plan for dialysis and stated I must have missed updating the information. The information should be updated and individualized as needed. During an interview on [DATE] at 9:28 a.m., the Director of Nursing (DON) stated in general staff are educated to, Look for behaviors and report behaviors to the nurse, the nurse reports to the doctor, and CNAs are educated on a, Need to know basis and it wouldn't be appropriate for them to go through diagnoses for each resident. The DON stated she was unaware of Resident 11's triggers but knew Resident #11 had PTSD. The DON confirmed PTSD triggers should be on the care plan and knowing the resident's and their triggers would assist the staff in knowing how to approach individuals. The DON confirmed care plans should be individualized and updated as needed. Review of the facility's policies and procedures dated revised [DATE] and titled Care Plans, Comprehensive Person-Centered revealed the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 8 of 16 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 03/26/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas/conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma-informed. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. Assessments of residents are ongoing and care plans are revised as information about the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 9 of 16 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 03/26/2025 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 0657 residents and the residents' conditions change. Level of Harm - Minimal harm or potential for actual harm 11. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; Residents Affected - Few b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 10 of 16 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 03/26/2025 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to identify specific triggers related to post traumatic stress disorder (PTSD) and develop an individualized plan of care to prevent re-traumatization for one resident (#11) of one residents reviewed for PTSD. Residents Affected - Few Findings included: On [DATE] at 11:09 a.m., Resident #11 was observed reading a book while sitting in a wheelchair. An interview was attempted, however, she did not respond and continued to read her book. Her roommate stated Resident #11 is, Always reading, hard of hearing, and doesn't wear her hearing aids. A review of Resident #11's admission Record revealed an original admission date of [DATE] and a re-admission date of [DATE]. Further review of the admission record revealed the following diagnoses to include: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, generalized anxiety, and post-traumatic stress disorder. A review of Resident #11's care plan, revised on [DATE], revealed the following: [Resident name] has risk or actual diagnosis of PTSD and has potential for re-traumatization R/T [related to] Childhood trauma: twin died, felt unloved by family. A review of goals revealed the following, Resident will remain free from episodes of re-traumatization AEB [as evidenced by]: (personalize) through the next review. Revision on: [DATE]. Target Date: [DATE]. Resident will remain free from episodes of re-traumatization AEB no flashbacks or upsetting dreams through the next review Target Date: [DATE], Resident will have minimal triggers of re-traumatization thru the next review. Target Date: [DATE], Resident will have minimal negative changes in thinking and mood through the next review Target Date: [DATE]. A review of interventions include the following, . Establish a relationship of trust with the resident, Date Initiated: [DATE], Created on: [DATE], . Provide calming and reassuring environment, Date Initiated: [DATE], Created on: [DATE], . Use calm approach. Explain action during cares. Date Initiated: [DATE], Created on: [DATE], . Avoid positioning yourself between the resident and the door Date Initiated: [DATE], Created on: [DATE] ., Provide female caregivers ONLY to assist with cares per resident/responsible party preference. Date Initiated: [DATE], Created on: [DATE]. Provide male caregivers ONLY to assist with cares per resident/responsible party preference. Date Initiated: [DATE], Created on: [DATE] . On [DATE] at 9:18 a.m., an interview was conducted with Staff C, Certified Nursing Assistant (CNA) who stated she looked at the care card to view a resident's diagnoses. Staff C, CNA stated she would go into the resident's electronic medical record or speak with the nurse to determine what their needs are. She stated she's not sure where to view in their chart how to approach a resident related to triggers for someone diagnosed with PTSD. She stated she thinks the care card or [NAME] would have that. She stated, The care card tells you everything about the resident. Staff C, CNA confirmed she hasn't had training or education related to PTSD. Regarding Resident #11, she stated she worked with the resident often. Staff C, CNA stated she didn't know the resident had PTSD and could not identify her triggers. On [DATE] at 9:28 a.m., an interview with the Director of Nursing (DON) revealed staff are educated, To look for behaviors. She stated she expected CNAs to report behaviors to the nurse, then the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 11 of 16 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 03/26/2025 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurse would report to the provider. She stated CNAs are educated on a, Need to know basis. The DON stated it wouldn't be appropriate to specify diagnoses to staff for each resident. She stated if a resident was displaying behaviors, she'd tell staff to, Watch for certain behaviors and keep them on enhanced monitoring. The DON stated she doesn't know about Resident #11's triggers. She stated she knows the resident has PTSD. The DON stated she knows Resident #11's PTSD comes from, Military. The DON confirmed PTSD triggers should be on the care plan as she expected nurses to look there. She stated staff, Learn the residents and their triggers to identify how to approach. She stated Resident #11 doesn't have behaviors or outbursts, Only if she had a UTI [urinary tract infection]. The DON stated staff are provided general education about behaviors and behaviors being charted. On [DATE] at 9:56 a.m., an interview was conducted with the Social Services Director (SSD). He stated for residents with PTSD they, Determine the root cause and psych follows them. He stated for the diagnosis of PTSD, there is a care plan in place. The SSD stated the care plan included how to approach the person, their environment, avoid putting yourself in front of them and between the door, medication management as needed, observing for changes in behaviors, and psychiatry/psychology (psych) services as needed. He stated for sexual abuse or assault they determine if the resident feels comfortable with a male or female staff. The SSD stated the care plan, Has prefilled boxes to check off, however, they could be filled in. He stated he hasn't had to put individualized triggers for any PTSD care plans. Regarding Resident #11, the SSD stated he knows the resident has PTSD. He stated the resident told him her trauma stemmed from the loss of her twin, and she felt her family didn't love her. He stated he reviewed Resident #11's psych notes and confirmed the psych provider attended monthly interdisciplinary team meetings. The SSD stated he printed and looked at every psych note. He confirmed he had not seen the psych notes which included documentation related to physical and sexual abuse. The SSD confirmed Resident #11's care plan should include interventions related to approach and determining her preferences for care. A review of the facility's policy titled Trauma Informed Care revised [DATE] revealed the following: Purpose: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. Preparation: 1. All staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting . General Guidelines: . 2. Trauma-informed care is culturally sensitive and person-centered. 3. Caregivers are taught strategies to help eliminate, mitigate, or sensitively address a resident's triggers . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 12 of 16 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 03/26/2025 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and record review, the facility did not ensure up-to-date staffing information was posted on one day (3/24/25) of three days observed. Residents Affected - Many Findings included: Upon entering the facility on 3/24/25 at 9:00 AM, an observation was made of a posting titled, Daily Staffing Projection, dated 3/22/25 with census of 60. On 3/24/25 at 10:12 AM, the staffing posting was still not updated. Review of the facility's policy and procedure dated 11/19/2019 titled Nursing Services - Nurse Staffing Information showed: INTENT: It is the policy of the facility to make staffing information readily available in a readable format to residents and visitors at any given time. POLICY: 1. The facility will post the following information on a daily basis: a. Facility name. b. The current date. c. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses. ii. Licensed practical nurses or licensed vocational nurses (as defined under State law). iii. Certified nurse aides. d. Resident census. 2. The facility will post the nurse staffing data on a daily basis at the beginning of each shift. 3. Data must be posted as follows: a. Clear and readable format. b. In a prominent place readily accessible to residents and visitors. 4. The facility will, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. 5. The facility will maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 13 of 16 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 03/26/2025 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 0732 Photographic Evidence Obtained Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 14 of 16 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 03/26/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and interviews, the facility did not follow professional standards for food service safety as evidenced by food not maintained for safe consumption and improper labeling and dating of food items in the main kitchen and dining room. Findings included: On 3/24/25 at 9:56 a.m., an initial tour of the facility's kitchen was conducted with the facility's Certified Dietary Manager (CDM). An observation of the dish machine area, that was in use by Staff E, Cook, revealed pliers with a red handle on the machine's base. Further observations on the top area of the dish machine revealed light brown colored crumbs and other food particles. An observation of the dish machine hood revealed multiple dark brown and black spots along the top and sides. The multiple spots observed appeared to be signs of rust. On 3/24/25 at 10:03 a.m., an observation of the walk-in cooler, conducted with the CDM, revealed strips of bacon in a clear storage bag with an open date of 3/17/25, but no use by date. The CDM identified the food as, Vegan bacon, and stated the staff should have kept the original package label to determine the expiration date. She proceeded to remove the vegan bacon strips. Observations of the right side of the walk-in cooler revealed a box of two large lettuce heads with leaves that were separated. The separated leaves had areas that were yellow, brown, and black in color. She proceeded to remove the separated lettuce leaves, while the other two lettuce heads were left in the box. Further observations of the right side of the walk-in cooler revealed a box of potatoes that had multiple blue, gray, and white spores/bio growth. The CDM proceeded to remove the box of potatoes. At 10:11 a.m., an interview with the CDM revealed the Kitchen Manager should be reviewing the walk-in cooler for proper storage of food and beverage items, to include labeling and dating. On 3/24/25 at 10:11 a.m., an observation of the reach-in refrigerator, identified as #2, was conducted with the CDM. Observations of reach-in #2 revealed a shallow pan containing lemons and limes that had multiple gray and black spots. The CDM was observed removing the pan with the lemons and limes. Further observations of reach-in #2 revealed a stick of butter was not properly sealed and the top part was exposed to the air. On 3/24/25 at 10:32 a.m., an observation of the refrigerator/freezer in the dining room area was conducted with the facility's Director of Nursing (DON). She stated the refrigerator/freezer was for resident's food. An observation of the refrigerator revealed a food item with a resident's name, but no date or other labeling. The DON could not confirm how long the food had been there. An observation of the freezer revealed two individual ice cream packages. The DON confirmed the ice cream was not provided by the facility. The DON confirmed the two ice cream items did not have a resident's name. On 3/25/25 at 12:48 p.m., an interview was conducted with the facility's Kitchen Manager. The Kitchen Manager stated the pliers observed on 3/24/25 on the dish machine base were potentially there since last week. He stated the dish machine pipe was being fixed by maintenance last week and the maintenance staff member was using those pliers. Regarding observations of the top part of the dish machine, he stated it's part of the cleaning schedule. He stated the staff member that used the dish machine is responsible for cleaning that area and, It should have been cleaned. Regarding the dish machine hood, the Kitchen Manager stated he's not sure when it's been cleaned as it's not part of the cleaning schedule. He stated, It's been overlooked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 15 of 16 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 03/26/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 3/25/25 at 1:06 p.m., interviews were conducted with the Kitchen Manager and CDM. The Kitchen Manager stated all staff are responsible for proper storage, labeling, and dating and he conducted daily monitoring of storage, labeling, and dating. He stated the dietary staff's monthly meeting, conducted on 2/21/25 and 3/17/25, included topics such as labeling/dating and expectations for personal items. A review of the sign-in sheet revealed all staff attended. He stated he talked about storage, labeling, and dating every month. The Kitchen Manager stated reviews of the refrigerator/freezer in the dining room is on the cleaning list for dietary staff. He stated Certified Nursing Assistants (CNA's) are expected to label and date food/beverage items. The CDM stated items should be discarded if it's in there for more than 3 days or if items are not labeled or dated. She stated dietary staff are expected to review the refrigerator/freezer in the dining room at least once a day, as they have to put beverages in there. The Kitchen Manager stated he reviewed the refrigerator/freezer in the dining room once a day. A review of the facility's policy titled Labeling and Dating dated 8/12/23 revealed the following, Leftovers and opened foods shall be clearly labeled with date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use. (i.e. salad dressings, pickles, etc.). Further review of the policy, under Procedure, revealed the following, 1. 7 day shelf life including date of preparation -label includes: a. Name of food item, b. Discard date (to be discarded at end of 7th day) . 2. 30 day shelf life, usually applies to items that are shelf stable until opened label includes: a. Name of food item if not clearly identified on container b. Discard date (i.e. opened 4/20, discard 5/30) . A review of the facility's policy titled Food Storage revealed the following, All food stock and food products are stored in a safe and sanitary manner. All food stock is dated and used on a first in, first out basis. A review of the facility's policy titled FIFO (First In First Out) revealed the following under Procedure, 1. Date all food items upon receipt. (If item has vendor delivery date label, further dating is not required unless individual cans, boxes, etc. are removed from the dated packaging) . 5. Food products are used by the expiration date, if not, food items are discarded. Photographic Evidence Obtained FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105712 If continuation sheet Page 16 of 16