Inspection·October 6, 2021

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #43. The attendees confirmed they had not had a resident council meeting since the former activities director left. They confirmed the last council meeting the facility provided for was in June 2021 and there had been no alternate format in its place. Resident #35 said nobody in the facility said anything about it because they've been so busy. Medical records of the attendees were reviewed for their Brief Interview for Mental Status (BIMS) scores. Resident #41 had a score of 14, Resident #35 had a score of 15, Resident #31 had a score of 9, Resident #47 had a score of 11, and Resident #43 had a score of 12. A score range of 13-15 meant cognitively intact. A score range of 8-12 meant moderate impairment. An interview was conducted with Staff A on 10/6/21 at 3:18 p.m. She said she knew there was a resident council but was never told or assigned to do anything with the council or meetings. She said, I didn't know the process to get it started .I just got told about it today. [NAME] said, I'm just a CNA .I'm just helping out you know . going to the store for them (residents) and bingo and bringing coffee. An interview was conducted with the NHA on 10/06/21 at 3:24 regarding the facility quality assurance and process improvement activities. He reported he had started a process improvement plan related to activities because of concerns identified and brought to his attention during the survey which included the lack of resident council meetings. He said part of the improvement plan would be to ensure that resident council meetings were on the activities calendar and that he would be the designated staff member to assist with facilitating the meetings for the residents. He confirmed that he had never provided Staff A with any training specific to resident council meetings. He said, I told her to manage activities and that I would be posting the calendar .she received training mainly today. Review of facility standard titled Resident Council effective October 2021 revealed: Residents have the right to organize and participate in resident groups in the facility. The council will be provided with a private area to hold the meetings .The purpose of the meeting is to engage and empower the Residents to bring ideas and concerns to improve person centered care in the facility to increase resident satisfaction .The Activities Director or designee will be responsible to: host .organize .take minutes of the meeting . The NHA was interviewed about the standard on 10/05/21 at 4:03 p.m. He confirmed that the October 2021 effective date was probably a revised date. He said the standard had always been in place and confirmed it had not been followed. He said the last time he though it had been followed was July and said he had been spread too thin covering for the activities director in addition to other roles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 2 of 11 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 105713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Health and Rehabilitation Center 3456 21st Ave S Saint Petersburg, FL 33711 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to implement an ongoing resident centered activities program that incorporated the residents' interests for two (Resident #16 and Resident #24) of two sampled residents investigated for activities. Residents Affected - Few Findings included: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses of acute kidney failure, dysphagia, urinary tract infection, adult failure to thrive, neuromuscular dysfunction of bladder, hypertension, hydrocephalus, neoplasm of bladder, convulsions, anxiety, and major depressive disorder. On 10/4/21 at 11:17 a.m., Resident #16 was observed seated in a wheelchair in his room. The resident indicated he had been at the facility for several months due to the unavailability in the Veterans Administration long term care facilities. He was watching a small television in his room. Resident #16 stated that there were not a lot of activities to get involved in at the facility. He stated he would like to get access to books and puzzles because he liked to read and do challenging puzzles. He indicated there were not a lot of books or puzzles in the facility of interest to him. A review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #16, indicated a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognitive responses. A review of the activity assessment completed for Resident #16 on 9/20/21, revealed the resident required physical adaptations, preferred one to one and small group activities, enjoyed watching television, movies, word puzzles, and listening to music. On 10/5/21 at 11:27 a.m., Resident #16 was observed out in the hallways in a wheelchair moving around the facility. He had no signs of distress and was observed in a conversation with another resident. On 10/05/21 at 11:41 a.m., an interview was conducted with the Administrator. The Administrator stated the Activities Director went out with an injury in July and was not able to return. The Administrator stated since July, Staff A, Certified Nurse Aide (CNA) had been filling in. He stated Staff A was not currently at the facility because she was out providing resident transport for appointments. The Administrator stated he had developed the activity calendar and Staff A carried out what was on the calendar. On 10/05/21 at 1:56 p.m., an interview was conducted with the Administrator. The Administrator stated, I haven't done a good job with activities in her absence. The Administrator provided activities calendars for October and September 2021. The Administrator stated he could not access any calendars prior to September because the calendars were in the previous Activity Director's computer, and he did not have access to them. He stated he had hired a new Activity Director that would be starting on November 2nd, 2021. On 10/06/21 at 12:27 p.m., Resident #16 was observed in his room seated in a wheelchair. Resident #16 stated he had gone to look for any books or puzzles available in the facility a while ago, but felt the puzzles were for children and was only able to see five books that were of no interest to him. The resident was sitting by himself watching television. The resident stated no one ever came (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 3 of 11 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 105713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Health and Rehabilitation Center 3456 21st Ave S Saint Petersburg, FL 33711 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 0679 around to the rooms with any other activities. Level of Harm - Minimal harm or potential for actual harm On 10/06/21 at 3:12 p.m., an interview was conducted with Staff A, Certified Nurse Aide (CNA), currently in charge of activities, and Staff B, Registered Nurse (RN) MDS. Staff A stated she had been in charge of activities for about six weeks. Staff A indicated she was not oriented to the position. She stated she was working on orientation with the Administrator, and it had begun today, 10/02/21. Staff A stated she worked Monday through Friday in the role. Staff A indicated the role was not a permanent position for her. Staff B, RN stated the facility had hired a new employee that would start in November for the role of activities director. Staff A indicated she also was responsible for transport of residents to and from appointments as needed. Staff A stated she was responsible to coordinate most of the activities on the activity board. Staff A stated the activities scheduled in the evening do not have anyone assigned to assure they occur. Staff A stated when a resident was unable to come to group activities she would sit in their room, turn the television on, and talk with the resident. She stated sometimes she read the newspaper to them. Staff A indicated she did not have anyone helping her with activities and she was not able to get to all the residents all of the time. Staff A stated she had not been doing any activity assessments for the residents to assess their needs and preferences. Staff B, RN stated an activity assessment was done on admission and yearly that would be included in the MDS assessment, and she was responsible for the assessment. She stated there was also an activity assessment that was done by activities, and no one had been doing that assessment since they lost their last activities director. Staff A stated Resident #16 liked to watch television and sometimes he had come to play bingo. She stated she was not aware of what other interests Resident #16 had. Staff A stated around the time of the onset of Covid all of the books and puzzles were removed because they could not be cleaned and there had been no effort to get new items. Staff A stated there were items to use to play games with residents like bowling, balls, and other activities but she was not aware of where those items were. Staff A and Staff B verified since the last activity director left the facility there had been no real activity program for the residents. Residents Affected - Few 2. A review of the admission Record revealed Resident # 24 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dysphasia, cerebral infraction, atrial fibrillation, chronic respiratory failure, and type 2 diabetes mellitus. On 10/04/2021 at 10: 50 a.m. upon initial tour of facility, Resident #24 was observed laying in bed, no television or radio was observed on or playing in his room. During a follow up visit on 10/04/21 at 1:55 p.m., Resident #24 was observed lying in bed. Observations on 10/05/2021 at 2:00 p.m. and 10/06/21 at 12:18 p.m., did not reveal staffs' interaction with the resident or any form of stimulation (music/television) provided to Resident #24. A review of the most current quarterly Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns, documented a Brief Interview Mental Status (BIMS) 99 indicating that resident's cognitive function was severely impaired. Section D, Mood, D0100 documented 0 which indicated that resident was rarely/never understood. A reviewed of Resident #24's Care Plan, initiated on 06/04/2019, revealed a focus area for Activities: [Resident # 24] requires staff assistance with involvement of activities related to cognitive deficits, little interest in pleasure of doing things, prefers to stay in room. Requires physical assistance to and from activities. Interventions include: Encourage to participates in activities of choice, prefers/would benefit from large group, prefers/would benefit from small group, preferred activity times: Afternoon, referred (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 4 of 11 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 105713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Health and Rehabilitation Center 3456 21st Ave S Saint Petersburg, FL 33711 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 0679 activity times: Morning Level of Harm - Minimal harm or potential for actual harm A reviewed of Resident #24's activity assessment dated [DATE], documented in section A2, preferred activity times: afternoon. Residents Affected - Few Section B. Read: Resident would prefer or benefit from one to one, small groups, in room, and general activities program. Under the subheading Passive Activities, read: Watching TV (televisions), listening to music. On 10/06/21 at 3:23 p.m., an interview was conducted with Staff A, Certified Nursing Assistant (CNA). Staff A stated that she had been overseeing activities for the past six weeks. She stated that in addition for being temporary responsible for activities, she transported residents to doctor's appointment as needed. Staff A stated that Resident #24's CNAs usually got him out of bed in a [reclining] chair and transported him to the restorative room in the mornings. She stated that Resident #24 sat there and watched TV. She stated that, They usually never include the resident in a particular activity, or really do anything else with him. On 10/06/21 at 3:58 p.m., in an interview with Staff D, Certified Nursing Assistant, (CNA), she stated that Resident # 24 was taken to the TV room in a [reclining] chair in the mornings. She stated that there were only two [reclining] chairs available, and the chair that was usually utilized for Resident #24 was currently occupied by another resident. On 10/06/21 at 4:07 p.m., in an interview with the Nursing Home Administrator (NHA) with the Regional Nurse present, the Regional Nurse stated that she thought there were enough chairs in circulation for each resident. The NHA stated that he was not aware of the situation, no one had reported to him that there was a need for additional [reclining] chairs. He stated that he would put in an order/request for additional [reclining] chairs. A review of the policy entitled Activities Overview 1.1.1 effective October 2021 indicated the following: Policy: Activities Department employees will provide activities that include sensitivity and an understanding of each individual resident's needs and requirements including medical, emotional, spiritual, therapeutic, and recreational needs. The activity program will reflect individual needs and provide/promote the following: stimulation or solace physical, cognitive, and/or emotional health enhancement, to the extent practicable, of each resident's physical and mental status resident self-respect by providing activities that support self-expression, social and personal responsibility, and choice. The facility will sponsor activities that promote wellness in the 7 dimensions. This includes programs aimed at: Social wellness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 5 of 11 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 105713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Health and Rehabilitation Center 3456 21st Ave S Saint Petersburg, FL 33711 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 0679 Emotional wellness Level of Harm - Minimal harm or potential for actual harm Environmental wellness Spiritual wellness Residents Affected - Few Physical wellness Life enrichment Intellectual wellness Programs will be designed to meet the resident at their level of functioning. Support activities-for residents who may be severely impaired or unable to tolerate the stimulation of a group Maintenance activities-schedule events that promote the highest level of physical, emotional, cognitive, psychosocial, and spiritual well-being. Empowerment activities-designed to provide self-expression, social and personal responsibility, and a sense of purpose in their daily lives. A qualified activities director who meets one of the following criteria will manage the activities department: 1-Must be a qualified therapeutic recreation specialist or an activities professional who is licensed, certified, or registered as required by State Regulation and is eligible for certification as a therapeutic recreation specialist or as an activity professional by a recognized accrediting body .OR 2-Two years' experience in a social or recreational program within the last five years, one of which was full-time in resident activities program in a health care setting .OR 3-Qualified occupational therapist or occupational therapy assistant .OR 4-Completed a training course approved by the state. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 6 of 11 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 105713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Health and Rehabilitation Center 3456 21st Ave S Saint Petersburg, FL 33711 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** 2. On 10/4/21 at 10:55 a.m., Resident #28 was observed seated on the bed in his room working on some paperwork. The resident appeared clean, dry and had no odors. He was fully dressed and able to be interviewed. Resident #28 was admitted to the facility on [DATE] with diagnoses of post laminectomy syndrome, gastroparesis, anxiety, chronic pain syndrome, angina, morbid obesity, Diabetes Mellitus, and hypertension. A review of the orders for Resident #28 revealed an order dated 9/27/21 for Buspirone Hydrochloride tablet give 7.5 milligrams by mouth every 12 hours for anxiety. A review of the Medication Administration Record (MAR) revealed Resident #28 had been receiving Buspirone Hydrochloride (a psychotropic medication) as ordered since 9/18/21. No evidence of behavioral or side effects monitoring for the medication was documented in the resident's record during the months of September or October 2021. A review of the comprehensive care plan for Resident #28 revealed the following: Focus Area: The resident uses psychotropic medications related to anxiety to manage anxiety, neuropathic pain management. (initiated 9/28/21) Goal: Will have minimal side effects Interventions: Administer medications as ordered. Observe/document for side effects and effectiveness; Observe for potential side effects may include dizziness, drowsiness, confusion, headache, anxiety, tremors, stimulation fatigue, depression, insomnia, hallucinations, weakness, unsteadiness, orthostatic hypotension, blurred vision, tinnitus, constipation, dry mouth, nausea, vomiting, anorexia, diarrhea, rash, dermatitis. On 10/5/21 at 10:11 a.m., Resident #28 was observed in the physical therapy department participating in therapy. He had no signs of pain or distress. He appeared cooperative with no behaviors noted. The resident completed all therapy without difficulties. On 10/6/21 at 2:57 p.m., an interview was conducted with the Consulting Pharmacist. The Pharmacist stated she had not done a review of Resident #28 for the month of October yet and was actually working on that currently. She indicated that when a resident was on psychotropic medications, the nursing staff entered an order into the system for the behavior and side effects monitoring. She stated this should be done when the order for a psychotropic medication was given. On 10/6/21 at 3:06 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated typically during the morning meeting, a review of all the residents was conducted and residents who were on psychotropic medications had the behavior and side effects monitoring order placed into the record at the time of the meeting. The DON stated, the nurses should also put the order in for the side effects and behavior monitoring when they received the order. She stated the monitoring was considered a nursing process order. She stated they review new orders in the morning meeting and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 7 of 11 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 105713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Health and Rehabilitation Center 3456 21st Ave S Saint Petersburg, FL 33711 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 that was when it was usually caught. The DON confirmed Resident #28 should have had the side effects and behavioral monitoring entered for the medication the entire time it was being administered. A review of the facility policy entitled Behavior Monitoring Record (effective October 2021) indicated the following: Residents Affected - Few Policy: To qualitatively document the frequency of identified behavioral symptoms. To document the type of interventions used to reduce or eliminate the behavior and the effectiveness of the interventions. To document side effects of psychoactive medications on the MAR. The behavior monitoring record will be initiated on residents/taking psychoactive medications that require behavior monitoring. Procedure: 1. Enter the following information into the electronic medical record. 2. Describe the specific behavior to be monitored. 3. Code the interventions determined to address the specific behavior. 4. Enter the frequency of the behavior on each shift. 5. Enter the letter code of the interventions chosen to address the behavior. 6. Enter the outcome code of the intervention. Based on record review and interview, the facility failed to ensure that behavior and side effects monitoring was recorded for two (Residents # 50 and #28) of five sample residents who were reviewed for unnecessary medications. Findings included: 1. Resident #50 was originally admitted to the facility on [DATE] with the primary diagnosis of end stage renal disease. Other pertinent diagnoses included but were not limited to anxiety disorder, major depressive disorder, unspecified convulsions, and bipolar disorder. A review of the quarterly Minimum Data Set (MDS) dated [DATE], section C (Cognitive Patterns) reflected a Brief Interview for Mental Status (BIMS) of 15 indicating that Resident # 50's cognition was intact. A review of the active physician orders dated 10/04/21 for Resident # 50 included the psychotropic medications Risperidone tablet 1 mg (milligrams) by mouth one time a day for mood disorder. There was no physician order for the monitoring of behaviors or for the monitoring of side effects related to psychotropic medications. A review of the plan of care for Resident # 50 with a revision date of 7/15/2021, included a focus on behavioral, with interventions that stated: Document episodes of behavior and review to determine the effectiveness of interventions. The plan of care also revealed a focus on the uses of psychotropic medication. Goals for psychotropic drug use indicate that: Resident will have minimal side effects. Interventions included: Observe, document for side effects and effectiveness. A review of the medication administration record (MAR) for the period of 10/01/21 to 10/06/21, revealed that the psychotropic medications were administered as ordered and no documentation for the effectiveness, side effects, or behavior monitoring was provided. On 10/06/21 2:58 p.m. in a phone interview with the consultant pharmacist, she stated she would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 8 of 11 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 105713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Health and Rehabilitation Center 3456 21st Ave S Saint Petersburg, FL 33711 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 have expected nursing to have in place behavior and side effects monitoring for the use of psychotropic medication. On 10/06/21 3:06 p.m. in an interview with the DON, she stated that she developed a process to review medication orders in the morning meeting including psychotropic medications, to ensure orders were carried out appropriately and monitoring was in place. She stated that it was essentially the nurse's responsibility to input behavior and side effects monitoring in the resident's electronic medical record (EHR). She stated that the reason the monitoring got dropped, and not carried over, was because the resident went out to the hospital and was readmitted to the facility. The DON stated that it was her expectation that the nurses ensure that monitoring was in place for residents receiving psychotropic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 9 of 11 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 105713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Health and Rehabilitation Center 3456 21st Ave S Saint Petersburg, FL 33711 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure that resident food was stored under sanitary conditions in one of one refrigerator/freezer designated for resident food storage The facility failed to ensure that foods were labeled properly and discarded for food safety, failed to ensure no staff food was stored with resident food items, and failed to monitor the refrigerator/freezer for safe food storage temperatures. A tour of the facility resident nourishment pantry areas was conducted on 10/5/21 at 12:00 p.m. with Staff C, Registered Nurse (RN), Unit Manager (UM). She confirmed that there was only one refrigerator/freezer in the facility used for storage of resident's personal food, including food brought in by visitors and family. She revealed the refrigerator/freezer was located in the main dining room. Observation of the refrigerator/freezer revealed a typed sign posted on the freezer compartment that read STAFF ONLY. Staff C immediately removed the sign during the observation but replaced it upon request for photographic evidence to be obtained. There were no other signs posted and there were no temperature logs observed posted on the refrigerator/freezer or in the area. Upon opening the refrigerator compartment, an assortment of unlabeled food items was observed including partially consumed beverages in cups and bottles and what appeared to be personal lunch bags. There was an assortment of items contained in plastic grocery bags. Most of the items were without labels or dates. Staff C said it did not appear to her that all the food items in the refrigerator belonged to residents. She said she was not aware of any temperature log for the refrigerator or the freezer. Observation of the freezer compartment revealed unlabeled food items including an uncovered beverage with ice in it. Staff C said housekeeping and activities staff oversaw maintaining the refrigerator/freezer. Photographic evidence obtained. The facility Certified Dietary Manager (CDM) was interviewed on 10/05/21 at 12:10 p.m. and confirmed that the dietary staff/department did not have any responsibilities for maintaining the refrigerator/freezer in the dining room. Observation was conducted of the refrigerator/freezer in the dining room on 10/05/21 at 2:47 p.m. A new sign was observed posted on the refrigerator door that read, Resident food storage only. Only staff are permitted to open and close fridge. Items must be labeled and dated. A temperature log was observed posted on the freezer door and the date of 10/01/21 had been filled out with a refrigerator temperature of 33 and a freezer temperature of 0. During the observation the facility Regional Nurse Consultant (RNC) entered the room. She confirmed she had posted the temperature log and made the entry for 10/01. She said she had made an error and put her entry on the wrong date, clarified entry should have been made for that day (10/05) since this was the first date it was posted and completed. She replaced the log with one that had entry for 10/05. Photographic evidence obtained. An interview was conducted with the facility Administrator (NHA) and the facility Director of Nursing (DON) on 10/05/21 at 2:53 p.m. The DON confirmed that corrections had been made since the observation conducted that morning because Staff C had made them aware of the identified concern. The DON said that when they observed the contents of the refrigerator and freezer, they found a lot of the food wasn't labeled or dated and they had discarded those items. The NHA said that refrigerator/freezer had traditionally been for resident's personal food items. The DON said that she had interpreted the posted sign STAFF ONLY to mean it was a staff food refrigerator. Both parties said they had never provided instructions to the staff about what food items could be stored there. The NHA said the expectation had always been that nursing staff on the 11:00 p.m. - 7:00 a.m. shift was responsible to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 10 of 11 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 105713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alpine Health and Rehabilitation Center 3456 21st Ave S Saint Petersburg, FL 33711 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 - Some check and log the refrigerator/freezer temperatures, make sure all food items were labeled and dated, and discard any food items that were not labeled or dated properly. Previous temperature logs were requested for review and the NHA said there were none prior to the one started today (10/5/21) and confirmed they had not been done previously. The NHA reported the following process for food storage and labeling: resident name, food identifier, resident room number, and the date the item was first placed in the refrigerator. He said after an item was stored for 3 days it should be removed and discarded. He said that packaged food, unopened, could be stored until expiration date. The NHA confirmed that the sign posted on the refrigerator had been re-written to make it clear that the refrigerator/freezer was for resident food only and that only staff were allowed to access the refrigerator/freezer. He confirmed he did not want residents accessing for infection control measures. The NHA revealed he had begun in-servicing with facility staff that day (10/05/21) on the policy/procedure for resident food storage in that refrigerator/freezer and procedure for monitoring and logging the temperatures. Review of facility policy and procedure titled, Safe handling, storage, and reheating of food from visitors our outside source effective January 2021 revealed: When food items are intended for later consumption, the nursing staff will: 1. Ensure the food item(s) are in a sealed container, stored in the pantry refrigerator, and labeled with the current date and name of the resident. 2. Food will be stored for up to 3 days and then discarded. Refrigerators are equipped with thermometers and checked by staff daily to ensure maintaining a temperature at or less than 41 degrees F (Fahrenheit) and freezer at or less than 10 degrees F. 1. Temperatures will be logged. Storage of frozen items may be retained for 30 days .Shelf stable items may be retained up to the listed expiration date. Nursing staff will check the refrigerator daily for temperature, expired food, and is responsible for cleaning up spills on an as needed basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 11 of 11