Inspection·December 14, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cove base (baseboard) protruding from the wall. At the toilet base, that meets the floor had a dark brown substance surrounding the base. The transition from the bathroom floor into the shower had a gap between the floor and tile. In this gap was black bio growth and dirt. The doorframe of the bathroom had visible wood showing, which had cracks in it. Small pieces of wood could be seen. (Photographic Evidence Obtained) An interview was conducted with the Housekeeping and Laundry Supervisor (HLS) on 12/13/23 at 9:58 a.m. The HLS confirmed the bathroom between rooms [ROOM NUMBERS] was missing tile, and the cove base was protruding from the wall. The bathroom between rooms [ROOM NUMBERS] had protruding cove base, the toilet base had a dark brown substance, the gap between the shower and bathroom floor, and the door frame having splintered wood. The HLS stated the housekeepers have been letting maintenance know about both of these concerns for a while now. During an interview on 12/13/23 at 3:05 p.m. the Maintenance Director (MD) confirmed the findings above and said, I know. The MD stated he had an audit of the environment and has been in contact with a vendor. No audit or vendor contact had been given prior to the exit of the survey on 12/14/23. Review of the policy and procedure titled, Physical Environment, with an effective date of January 1, 2020 showed: Policy - A safe, clean, comfortable, and home-life environment is provided for each resident/patient, . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 2 of 19 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 12/14/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for 10 residents (4, 7, 15, 19, 22, 28, 31, 40, 42, 44) of 33 sampled residents. Findings included: 1. Review of Resident #4's admission Record revealed she was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses of generalized anxiety disorder, major depressive disorder, and psychosis. Review of Resident #4's PASARR, dated 8/7/23, revealed qualifying mental health diagnoses of anxiety disorder and depressive disorder, and no PASARR Level II was required. Review of Resident #4's admission Minimum Data Set (MDS), dated [DATE], Section I Active Diagnoses, revealed a diagnosis of anxiety disorder. Review of the Annual MDS, dated [DATE], and a Quarterly MDS, dated [DATE], Section I Active Diagnoses, revealed diagnoses of anxiety disorder, depression, and psychotic disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 2. Review of Resident #15's admission Record revealed she was admitted on [DATE] with diagnoses of psychosis, dementia and major depressive disorder. Review of Resident #15's PASARR, dated 7/29/23, revealed a qualifying mental health diagnosis of depressive disorder, and no PASARR Level II was required. Review of Resident #15's Medicare 5-day MDS, dated [DATE], Quarterly MDS, dated [DATE], and 7/21/23, Section I Active Diagnoses, revealed diagnoses of depression and psychotic disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 3. Review of Resident #22's admission Record revealed he was admitted on [DATE] with diagnoses of anxiety disorder, major depressive disorder, psychosis, and dementia. Review of Resident #22's PASARR, dated 8/7/23, revealed qualifying mental health diagnoses of anxiety and depressive disorder, and that no PASARR Level II was required. Review of Resident #22's admission MDS, dated [DATE], Section I Active Diagnoses, revealed a diagnosis of anxiety. Review of the Quarterly MDS, dated [DATE], 6/5/23, 3/14/23, revealed diagnoses of anxiety disorder, depression, and psychotic disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 4. Review of Resident #28's admission Record revealed she was admitted on [DATE] with diagnoses of anxiety disorder, major depressive disorder, and delusional disorders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 3 of 19 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 12/14/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #28's PASARR, dated 7/13/23, revealed there were no qualifying mental health diagnoses, and no PASARR Level II was required. Review of Resident #28's admission MDS, dated [DATE], and the Quarterly MDS, dated [DATE], and 5/26/23, Section I Active Diagnoses, revealed diagnoses of depression and psychotic disorder. Review of the Quarterly MDS, dated [DATE], and an Annual MDS, dated [DATE], Section I Active Diagnoses, revealed diagnoses of anxiety disorder, depression, and psychotic disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 5. Review of Resident #31's admission Record revealed he was re-admitted on [DATE] with diagnoses of dementia, bipolar disorder, anxiety disorder, and major depressive disorder. Review of Resident #31's PASARR, dated 7/13/23, revealed a qualifying mental health diagnosis of depressive disorder, and no PASARR Level II was required. Review of Resident #31's Annual MDS, dated [DATE], and Quarterly MDS, dated [DATE], and 11/28/23, Section I Active Diagnoses, revealed diagnoses of anxiety, depression and bipolar disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 6. Review of the admission Record showed Resident #7 was initially admitted to the facility on [DATE] with diagnoses to include anxiety disorder, major depressive disorder, recurrent, mood disorder due to known physiological condition with mixed features and unspecified dementia, unspecified severity, with other behavioral disturbances. Review of Resident #7's care plan showed, Cognition: [Resident #7] has impaired cognition function/dementia or impaired thought process related to short term memory loss. The Goal showed, [Resident #7] will be able to communicate basic needs on a daily basis through the review. The Interventions included: Explain care before providing it, Ask yes/no questions in order to determine the resident's needs, Administer medication as ordered. A second focus showed, Psychotropic Medication: [Resident #7] uses antidepressant to manage: Depressive Disorder. The Goal showed, [Resident #7] will be at the lowest dose required to reduce symptoms while minimizing adverse effects to ensure maximum function ability both mentally and physically through the next review. The Interventions included: Administer medications as ordered, Psychiatric services per order, Consult with pharmacy and MD to consider dosage reduction, observe/document for potential side effects for Anti-Depressants. Review of the Annual Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive impairment). Section I Active Diagnoses showed, Non Alzheimer's Dementia, Anxiety Disorder, Depression and Bipolar Disorder. Review of the Level I PASARR, dated 07/13/23, showed Resident #7 had anxiety disorder. The diagnoses bipolar disorder, depressive disorder and a secondary diagnosis of dementia were not marked. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 7. Review of the admission Record showed Resident #44 was initially admitted to the facility on [DATE] with diagnoses to include anxiety disorder, major depressive disorder, recurrent, unspecified psychosis not due to a substance to known physiological condition and unspecified dementia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 4 of 19 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 12/14/2023 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 0644 unspecified severity, with anxiety. Level of Harm - Minimal harm or potential for actual harm Review of Resident #44's care plan showed, Cognition: The resident has impaired cognitive function/dementia or impaired through process related to Moderately impaired [brief interview for mental status] BIMS score of 8-12, Dementia. The goal showed, The resident will be able to communicate basic needs on a daily basis through the next review. The Interventions included: Explain care before providing, provide orientation and validation, administer medications as ordered, anticipate and meet needs per physical/non-verbal indications and use brief, simple consistent words, cues and statements. A second focus showed, Psychotropic Medication: [Resident #44] uses psychotropic mediation related to antidepressant to manage depression and Antianxiety to manager anxiety. The Goal showed, will have minimal side effects. The Interventions included: Psychotropic side effects monitoring, administer medications as ordered, psychological services per physician order and as needed, psychiatric services per physician order and as needed and psychotic medications will be reviewed at least quarterly. Residents Affected - Some Review of the admission MDS, dated [DATE], showed a BIMS score of 12 (moderate cognitive impairment). Section I Active Diagnoses showed, Non Alzheimer's Dementia, Anxiety Disorder, Depression and Psychotic Disorder. Review of the Level I PASARR, dated 07/16/23, showed Resident #44 did not have Anxiety Disorder, Depressive Disorder, Psychotic Disorder or a secondary diagnosis of Dementia marked. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 8. Review of the admission Record showed Resident #19's original admission on [DATE] and the last readmission was on 1/03/2023. Resident #19 had the following diagnoses: bipolar, traumatic brain injury, unspecified symptoms and signs involving cognitive function and awareness, major depressive disorder, anxiety, schizophrenia, and numerous other co-morbidities. Review of the medical record showed Resident #19 had a Level II PASARR completed prior to a readmission on [DATE]. The recommendations of the Level II PASARR were: resident should have psychiatric medical management with a prompt referral to psychiatry upon admission; supportive counseling: patient should be encouraged to participate in activities appropriate for her level of functioning; care staff should monitor for depressive symptoms as well as symptoms of psychosis; if a significant change in her mental status occurs it is recommended that an additional Level II review be conducted; Nursing Home placement is recommended. Resident #19 had a significant change of condition MDS completed on 2/08/2022 and received a new diagnosis of unspecified dementia with other behavioral disturbances on 10/01/2022. Resident #19 did not have a new PASARR Level II completed as recommended upon a change of condition. 9. Review of the admission Record showed Resident #40 was initially admitted to the facility on [DATE] with diagnoses to include anxiety disorder, major depressive disorder, recurrent, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia, unspecified severity, with other behavioral disturbances. Resident #40 was readmitted on [DATE] with the above diagnoses, and a new diagnosis of Alzheimer's Disease. Review of the Level I PASARR, dated 09/19/2022, showed Resident #40 had depressive disorder and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 5 of 19 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 12/14/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some history of dementia, no other diagnoses were listed. The form stated no in the questions relating to a secondary diagnosis of dementia. There was no Level II PASARR available for review. 10. Review of the admission Record showed Resident #42 was initially admitted to the facility on [DATE] with the following diagnoses to include anxiety, intracerebral hemorrhage and bipolar II disorder. Resident #42 was readmitted on [DATE] with the above diagnoses and a new diagnosis of major depressive disorder, recurrent. Review of the Level I PASARR, dated 3/09/2023, did not show any diagnoses marked. There was no Level II PASARR available for review. During an interview on 12/14/23 at 12:05 p.m. the Director of Nursing (DON) stated, I make sure all PASARRs are accurate. The DON stated, PASARRs are reviewed on admission, when a resident was changed on medication, or when a resident gets a new diagnosis. The DON stated, I ensure they are accurate and complete. The DON stated, If a Level II is needed we will contact [oversight company] and if they qualify for a Level II those recommendations should be care planned and there would be coordination of care. The DON stated, We will review all new diagnoses on admission and during behavior meetings that occur weekly. Review of the facility's Policy and Procedure titled PASARR Requirements Level I and Level II - Florida, effective February 2021, from the Social Service Manual revealed: pre admission screening for mental illness and intellectual disabilities is required to be completed prior to admission to a nursing home. The screening is reviewed by admissions to ensure appropriate placement in the least restrictive environment and to identify any specialized services the applicant may need. Screening applies to all new admissions into a Medicaid certified nursing facility regardless of pay or source A resident review must be completed when there has been a significant change in a resident mental or physical condition resident review . PASARR Level I, Procedure . 2. Social services or registered nurse will review to determine if a serious mental illness (SMI) and intellectual disability (ID) or both exist while reviewing the PASARR form. The existence of either, or both, condition triggers the requirement for level II review and will be provided to the appropriate state agency by the social services director upon admission. The social services director/nursing administration will review for completion and accuracy during the clinical meeting process . PASARR Level II . 3. Level 2 PASARR must be completed if the below are listed but not limited to: * is there an indication the resident has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individuals developmental stage * the resident has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion, or diagnosis of, SMI, ID, or both and *are currently exhibiting interpersonal issues, *difficulty maintaining concentration, persistence and pace, *difficulty with adaptation to change *an indication that the resident has received treatment for mental illness with an indication that they have experienced at least one of the following: psychiatric treatment more intensive than outpatient care (partial hospitalization or inpatient hospitalization) *experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 6 of 19 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 12/14/2023 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 0644 intervention by housing or law enforcement official . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 7 of 19 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 12/14/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review the facility failed to ensure one resident (#27) out of 3 residents observed for insulin medication administration received care in accordance with professional standards of practice related to the time of administration of short acting insulin, in relation to the time the resident received her lunch meal. Residents Affected - Few Findings included: Review of Resident #27's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with diagnoses to include type 2 diabetes mellitus with ketoacidosis without coma, morbid (severe) obesity due to excess calories, and lack of coordination. Review of Resident #27's physician's order revealed an order, with a start date of 2/23/23 and no end date, for Novolog Injection Solution 100unit/ml [Milliliters] inject per sliding scale: If 0-149= 0 Less than 60 call MD [Medical Doctor]; 150-200=2 [units] 201-250= 4; 251-300= 6; 301-350= 8; 351-400= 10 Greater that [sic] 401 given [sic] 12 units and call MD, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with ketoacidosis without coma. Review of Resident #27's December 2023 Medication Administration Record (MAR) revealed the Novolog sliding scale order with a start date of 2/23/23 was timed to be administered at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m. A medication administration observation was conducted on 12/13/23 at 11:07 a.m. with Staff C, Licensed Practical Nurse (LPN). Resident #27's blood sugar was 203. Staff C, LPN drew up 4 units of Novolog and she confirmed there was 4 units in the syringe. She administered the insulin using aseptic technique, discarded her supplies in the appropriate receptacles, washed her hands and signed off the insulin in the medical record. Review of the facility's MEALTIMES & SCHEDULE, undated, revealed the [NAME] Hall were scheduled to receive their breakfast at 8:00 a.m. The lunch meal is scheduled for 12:30 p.m. and the dinner meal is scheduled for 6:00 p.m. An interview was conducted with Resident #27 on 12/13/23 at 12:42 p.m. The resident said she feels the same as she did before she received insulin. An observation was conducted on 12/13/23 at 12:46 p.m. Resident #27 received her lunch tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 8 of 19 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 12/14/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 12/13/23 at 12:27 p.m. with the Director of Nursing (DON) and he confirmed insulin is ordered to be given approximately one hour before meals are delivered. An interview was conducted with the facility's Medical Director on 12/13/23 at 4:49 p.m. He said, .The way short acting insulin works is it starts to work within 20-30 minutes and peaks within an hour, hour and a half. If the order reads before meals, I would want the resident to receive their meals within 30 minutes of receiving the medication. He said receiving insulin at 11:07 a.m. and her meal tray coming at 12:46 p.m., that's a little late, should be within a half hour. Review of the facility's policy titled, Medication Administration General Guidelines, dated 09/18, revealed the following: .Medication Administration: .14. Medications are administered within 60 minutes of scheduled time, except before and after meal orders, which are administered based on mealtimes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 9 of 19 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 12/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure one resident (#35) out of four residents reviewed had a smoking evaluation completed to ensure safety during smoking. Findings included: During an interview on 12/11/23 at 7:44 a.m. Resident #35 stated the facility was supposed to let residents smoke at certain times but they make us wait and are about 15 to 20 late. Resident #35 stated, then once we get out there to smoke, we are then rushed to get done to come back in. An observation on 12/11/23 at 9:00 a.m. showed residents were exiting the door to the smoking designated area to smoke. Review of the facility's scheduled smoke times showed: 7:00 a.m. 9:00 a.m. 11:00 a.m. 1:30 p.m. 3:00 p.m. 5:00 p.m. 7:00 p.m. 9:00 p.m. An observation on 12/11/23 at 11:05 a.m. showed Resident #35 was outside smoking on the designated smoking area with supervision. Review of the admission Record showed Resident #35 was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease, lack of coordination, muscle weakness (generalized) and other abnormalities gait and mobility. Review of the care plan showed Resident #35 was a current smoker with a goal resident will remain safe while smoking. The interventions included: inform of designated smoking areas and times, smoking materials are kept by facility staff and supervised smoking as indication. Review of the Resident, Family, Visitor Smoking Safety Education and Acknowledgement Form, showed Resident #35 signed and dated the form, acknowledging the smoking rules and protocols, on 10/31/23. Review of Resident #35's admission Minimal Data Set (MDS), dated [DATE], showed Resident had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 10 of 19 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 12/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few brief interview for mental status (BIMS) of 15 (cognitively intact) and was marked as a current smoker in section A Identification Information. Review of Resident #35's medical record showed no smoking evaluation was completed or available. During an interview on 12/12/23 at 3:10 p.m. the Director of Nursing (DON) stated we do a smoking evaluation on residents the first time they go out to smoke. The DON stated we go out with the resident the first time to smoke to assess them for safety and complete the smoking evaluation. During an interview on 12/12/23 at 3:35 p.m. the DON stated, I do not see a smoking evaluation in the chart. The DON stated he would have expected a smoking evaluation to have been completed the first time Resident #35 went out to smoke. Review of the facility's policy titled, Smoking/Tobacco Use, dated October 2021, showed, Initiate and complete and admission Data Collection and Initial Plan of Care or a quarterly or prn [as needed] Data Collection form if the resident requests smoking privileges. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 11 of 19 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 12/14/2023 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide intravenous (IV) care according to standards of practice for one resident (#40) out of one resident reviewed. Residents Affected - Few Findings included: Review of Resident #40's admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses not limited to Alzheimer's Disease, dementia, and pressure ulcer of unspecified site, unstageable. Review of Resident #40's physician orders revealed an order, with a start date of 12/11/23 and an end date of 12/16/23, for Cefepime intravenous solution 1gram/50ml [milliliters] .use 1 gram intravenously every 8 hours for wound infection for 5 days obtain midline for IV infusion. An intravenous medication administration observation with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM), was conducted on 12/13/23 at 2:26 p.m. for Resident #40. Staff A, LPN/UM primed the IV tubing with cefepime 1 gram for 5-6 seconds, removed the IV tubing cap, cleaned the IV cap, connected the IV tubing to the resident's midline and with her right gloved hand she pushed the button on the IV pump to begin running the medication and confirmed the IV pump was running. The surveyor asked Staff A, LPN/UM to stop the pump as she did not fully prime the tubing. An observation was then conducted with Staff A, LPN/UM and confirmed the IV filter, which was connected to the IV tubing, was not primed and the majority of the IV tubing below the IV pump was not primed. Staff A, LPN/UM, confirmed the tubing was not fully primed and began to prime the tubing holding the uncapped tip of the IV tubing with her right gloved hand until there was a drop coming out of the IV tubing tip. Staff A, LPN/UM clamped the IV tubing, and connected the IV tubing to the resident's midline IV. Staff A, LPN/UM said she should have cleaned the midline IV and the IV tubing before connecting the tubing to the midline IV since she touched the tip with her gloved hands. She cleaned the IV tubing tip with an alcohol wipe and the resident's midline IV cap with the same alcohol wipe and connected the tubing to the midline IV and ran the pump. She did not check the midline insertion site during the medication administration observation. Staff A, LPN/UM went to the computer and charted the cefepime medication administration and said she charted U meaning the insertion site was unremarkable. She went back into the resident's room, lifted up his shirt sleeve. Resident #40 was observed to have kerlex gauze wrapped completely around the resident's IV site and dressing. Staff A, LPN/UM said, I just put that dressing on because I don't want him to mess with his IV. She said she put the gauze dressing on 12/9/23 and confirmed there was no date on the gauze dressing. Staff A, LPN/UM lifted up the gauze dressing and there was a piece of gauze under the clear IV dressings covering the IV insertion site completely. (Photographic Evidence Obtained) What does priming the IV tubing mean? It means you will be allowing the solution in the bag to flow through the tubing to remove any air in the line. It is very important to remove any air or bubbles from the tubing before infusion so an air embolism can be avoided, According to an online learning resource https://www.merlot.org/merlot/viewMaterial.htm?id=773403234. On 12/13/23 at 2:45 p.m. the Director of Nursing (DON) observed Resident #40's IV dressing and confirmed the IV insertion site should be visible and should not have a piece of gauze over the insertion site. He also confirmed IV tubing should be fully primed before hooking the resident up to an IV. The DON was notified when the IV tubing was primed, staff held the tip of the IV tubing with her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 12 of 19 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 12/14/2023 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 0694 gloved hands and then connected the IV tubing to the IV without cleaning it first. Level of Harm - Minimal harm or potential for actual harm Review of Resident #40's Medication Administration Record (MAR) revealed an order dated 12/9/23 for IV: Document IV site appearance every shift: U=unremarkable . Review of the documentation dated 12/13/23 for day shift revealed Staff A, LPN/UM documented U. Residents Affected - Few Review of the facility's policy Administration of IV Fluids and Medications ., dated 08/16, revealed the following: Purpose To correctly and aseptically set up the primary IV bag and tubing. .Procedure: .5. Open clamp. Prime tubing. Close clamp. .7. If using pump, thread tubing into pump according to directions. Program pump. 8. Scrub needless connector on resident's catheter with antiseptic wipe. 9. Attach IV tubing to needless connector. 10. Open clamps on IV tubing and begin infusion. .13. Document according to facility procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 13 of 19 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 12/14/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 failed to ensure respiratory care and services was consistent with professional standards of practice for one resident (#4) out of 33 sampled residents. Residents Affected - Few Findings included: Review of Resident #4's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included chronic obstructive pulmonary disease, morbid obesity, need for assistance with personal care, nasal congestion, and obstructive sleep apnea. Review of Resident #4's physician orders revealed an order with a start date of 12/2/23 and no end date for Oxygen at 2LPM [liters per minute] Via NC [nasal cannula] PRN [as needed] for shortness of breath. An observation was conducted on 12/11/23 at 9:17a.m. of Resident #4 receiving 2.5LPM of oxygen via a nasal cannula. (Photographic Evidence Obtained) An observation and interview were conducted on 12/12/23 at 10:48 a.m. as Resident #4 was observed to be in bed with her nasal cannula on. The oxygen concentrator was observed to be between the resident's head of her bed and the wall. The oxygen concentrator dial flow was observed to be set to 2.5LPM. The resident said she wears her oxygen all the time because she has COPD (chronic obstructive pulmonary disease). She said her oxygen is supposed to be set on one to two LPM. She said the nurses look at the oxygen every day and they change the tubing. The nasal cannula was labeled 12/11/23. (Photographic Evidence Obtained) An observation was conducted on 12/13/23 at 9:10 a.m. of Resident #4 in bed, her head of the bed elevated with her nasal cannula on and connected to the oxygen concentrator. The oxygen concentrator was observed to be between the head of the bed and the wall with the oxygen dial flow display facing the wall. The resident's oxygen was set to 3LPM. (Photographic Evidence Obtained) An interview was conducted on 12/13/23 at 9:11 a.m. with Staff C, Licensed Practical Nurse (LPN). She said the resident is supposed to be on 2LPM oxygen. Staff C, LPN went into Resident #4's room to confirm her oxygen setting. Staff C, LPN said, It's hard. We have to tip it back to see what she is set on and I can't turn it, it's hard. Staff C, LPN was unable to view Resident #4's oxygen setting. Staff C, LPN walked out of the resident's room and reviewed Resident #4's oxygen orders and said the resident is supposed to be on 2 liters oxygen as needed. She said the order is as needed because the resident takes her oxygen on and off. An observation was conducted on 12/13/23 at 10:05 a.m. of Resident #4 in bed with her nasal cannula on and connected to her oxygen concentrator. The concentrator was observed to be in-between the head of the bed and the wall with the oxygen dial flow display facing the wall and not visible. The resident said, The nurse just came in and tried to move the oxygen, but she couldn't. I told her she was going to have to get maintenance to move the bed to get it out. (Photographic Evidence Obtained) Review of Resident #4's December 2023 Treatment Administration Order (TAR) revealed no documentation the resident was administered 2LPM of oxygen via nasal cannula as needed for shortness of breath, including no documentation oxygen was administered on 12/11/23, 12/12/23 and 12/13/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 14 of 19 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 12/14/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #4's care plan, initiated on 11/9/21, revealed, The resident has Oxygen Therapy r/t [related to] Ineffective gas exchange. The goal included, Will experience minimal to no shortness of breath. Interventions included, Administer oxygen as ordered. (Refer to current POS/MAR [physician's order sheet/medication administration record] for current order). An interview was conducted with the Director of Nursing (DON) on 12/13/23 at 11:05 a.m. He observed Resident #4's oxygen concentrator between her headboard and the wall. The DON said, That should not be there. Review of the facility's policy titled, Oxygen Therapy, dated November 2023, revealed the following: Policy Oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease proceed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 15 of 19 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 12/14/2023 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. On 12/13/2023 at 11:45 a.m. an ice chest on the [NAME] Hallway was observed to have brown and pink bio growth around the upper edge of the chest, the ice scoop was sitting in a tray with water and pink bio growth was observed in the corners. (Photographic Evidence Obtained) An interview was conducted with the Assistant Director of Nursing (ADON) on 12/13/2023 at 11:53 a.m. The ADON confirmed the ice chest had pink and brown bio growth around edges as well as in the ice scoop tray. The ADON stated, I thought they cleaned this yesterday with the ice machine, but I guess they did not. The ice chest and scoop should not be left like this. Review of the facility's policy titled, Cleaning and Sanitation, dated September 2021, showed, The facility promotes a clean and sanitary environment for its employees, residents and visitors. The entire Food and Nutrition Services team maintains clean and sanitary kitchen facilities and equipment. [sic] walls, floors, ceiling, equipment and utensils are clean, sanitized and in good working order. Based on observation and interviews the facility failed to ensure one of one ice machine for the facility and one ice chest on the [NAME] Hallway was clean and free from bio growth in the Ice Machine Room. Findings included: During an observation on 12/12/23 at 12:30 p.m. there was one ice machine in the facility located on the [NAME] Hall Ice Machine Room. The ice chute of the ice machine had a black and brown bio growth substance on the inside of the chute where the ice comes out. (Photographic Evidence Obtained) During an interview on 12/12/23 at 1:00 p.m. the Dietary Manager (DM) stated the ice machine located in the [NAME] Hall Ice Machine Room was the only ice machine for the entire facility. The DM stated the Maintenance Department was responsible for cleaning the ice machine. The DM was shown the black and brown bio growth substance and stated, How did that get there. During an interview on 12/12/23 at 1:17 p.m. Staff D, Regional Nurse Consultant (RNC) stated the facility did expect the ice machine to be cleaned and free from bio growth. During an interview on 12/12/23 at 1:20 p.m. the Director of Nursing (DON) stated the ice machine should be clean and not dirty like that. During an interview on 12/12/23 at 1:25 p.m. the Administrator stated, I will shut down the ice machine, so it does not get used, until it gets cleaned. During an interview on 12/14/23 at 11:38 a.m. the Maintenance Director (MD) stated there was a third-party company who comes into the facility to ensure the ice machine was well maintained and clean on the inside of the machine. The MD stated he was responsible for the cleaning of the outside of the ice machine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 16 of 19 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 12/14/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain accurate medical records related to insulin documentation for two residents (#28 and #27) out of four residents reviewed for medication administration. Findings included: 1. Review of Resident #28's admission Record revealed she was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus and diabetes mellitus due to underlying condition with hyperglycemia. Review of Resident #28's December 2023 Medication Administration Record (MAR) revealed a physician's order, with an order date of 9/11/23 and no end date, for insulin glargine subcutaneous solution. Inject 32 units subcutaneously at bedtime for antidiabetics. Review of Resident #28's December MAR revealed on 12/1/23, 12/2/23, 12/3/23, 12/5/23, 12/7/23, and 12/11/23 the medication was documented as NS. Review of Resident #28's November 2023 MAR revealed the same medication was documented as NS on 11/1/23, 11/3/23, 11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/13/23, 11/15/23, 11/16/23, 11/17/23, 11/21/23, 11/22/23, 11/24/23, 11/27/23 and 11/28/23. Review of the MAR Chart Codes revealed NS=Side Effects Present: No. Review of Resident #28's December 2023 MAR revealed a physician's order with an order date of 12/6/22 with no end date for Novolin R Injection Solution 100 unit/ML (Insulin Regular (Human)) Inject as per sliding scale: if 70 - 130 = 0; [units] 131-180=4; 181-240=8; 241-300=10; 301-350=12; 351-400=16 >400 give 20 units and call MD (medical doctor), subcutaneously two times a day for DM. On 12/1/23 the resident's blood sugar (BS) was documented as 277 at 5:00 p.m. The administration documentation revealed NS. On 12/2/23 the BS was documented as 130 at 5:00 p.m. The administration documentation revealed NS. On 12/3/23 the BS was documented as 130 at 5:00 p.m. The administration documentation revealed NS. On 12/5/23 the BS was documented as 138 at 9:00 a.m. The administration documentation revealed NS. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 17 of 19 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 12/14/2023 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 0842 On 12/7/23 the BS was documented as 130 at 9:00 a.m. The administration documentation revealed NS. Level of Harm - Minimal harm or potential for actual harm On 12/7/23 the BS was documented as 138 at 5:00 p.m. The administration documentation revealed NS. On 12/11/23 the BS was documented as 188 at 9:00 a.m. The administration documentation revealed NS. Residents Affected - Some On 12/11/23 the BS was documented as 143 at 5:00 p.m. The administration documentation revealed NS. Review of Resident #28's November 2023 MAR revealed her sliding scale insulin medication was documented as NS for the 5:00 p.m. doses 16 out of 30 opportunities. Review of Resident #28's diabetes mellitus care plan, initiated on 7/2/23, revealed, The resident has Diabetes Mellitus as evidence by: Hypertension, Type 2 diabetes. The goal revealed, Minimize effects of Hypoglycemia and Hyperglycemia. Interventions included, Routine insulin as ordered (refer to order for current order). Sliding scale coverage as ordered (Refer to Orders for current order) . An interview was conducted with the Director of Nursing (DON) on 12/12/23 at 6:10 p.m. He said, there is opportunity for education regarding the documentation of insulin. The DON stated one of the staff members that documented NS, I had him show me what he does, and he has been administering the medication but he's not clicking the add location button for the location where the insulin was administered. There is a drop-down box (on the electronic medical record) and he records it, but, because he doesn't click the add location button the system doesn't think he administered the medication, so it brings him to the code screen, and he chooses the code of no side effects therefore it was recording NS. The staff would never know it was a problem because they don't look at the MARs after everything is documented. 2. Review of Resident #27's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with diagnoses included but not limited to, type 2 diabetes mellitus with ketoacidosis without coma, morbid (severe) obesity due to excess calories, and lack of coordination. Review of Resident #27's physician's order revealed an order with a start date of 2/23/23 and no end date for Novolog Injection Solution 100unit/ml [Milliliters] inject per sliding scale: If 0-149= 0 Less than 60 call MD [Medical Doctor]; 150-200=2 [units] 201-250= 4; 251-300= 6; 301-350= 8; 351-400= 10 Greater that [sic] 401 given [sic] 12 units and call MD, subconsciously before meals and at bedtime related to type 2 diabetes mellitus with ketoacidosis without coma. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 18 of 19 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 12/14/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #27's December 2023 MAR revealed the Novolog sliding scale order with a start date of 2/23/23 was timed to be administered at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m. A medication administration observation was conducted on 12/13/23 at 11:07 a.m. with Staff C, Licensed Practical Nurse (LPN). Resident #27's blood sugar was 203. Staff C,LPN drew up 4 units of Novolog and she confirmed there was 4 units in the syringe. She administered the insulin using aseptic technique, discarded her supplies in the appropriate receptacles, washed her hands and signed off the insulin in the medical record. Review of Resident #27's MAR was conducted on 12/13/23 at 11:14 a.m. and revealed an order for NovoLog injection solution. Inject 3 units subcutaneously before meals related to type 2 diabetes mellitus with ketoacidosis without coma. On 12/13/23 the medication was signed off as administered for the 11:00 a.m. dose by Staff C, LPN. Resident #27's NovoLog sliding scale order to be given before meals and at bedtime, with a start date of 2/23/23 and no end date, was documented as administered for the 11:30 dose for a blood sugar of 203. An interview was conducted with Resident #27 on 12/13/23 at 11:15 a.m. She said, I'm supposed to get 3 units on top of my sliding scale, but sometimes I don't get it just depending on what my blood sugar was. The nurses know my body better than I do. I didn't have diabetes before my coma. But I haven't gotten any more insulin since you were here. Review of Resident #27's Quarterly Minimum Data Set (MDS), Section C - Cognitive Patterns, dated 10/26/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating Resident #27 is cognitively intact. An interview was conducted on 12/13/23 at 11:36 a.m. with Staff C, LPN. She said, I signed off her 3 units of insulin because I'm about to go do it right now. I just had to do some paperwork. I like to wait 30 minutes in between; even though it's the same medicine because I don't want to give her too much at one time. An interview was conducted on 12/13/23 at 12:42 p.m. with Resident #27. She said, the nurse came in and gave her the second insulin shot. The resident said she feels the same as she did before she received insulin. Review of the facility's policy titled, Medication Administration General Guidelines, dated 09/18, revealed the following: .Documentation: 1. The individual who administers the medication, dose, records the administration on the resident's MAR immediately following the medication being given . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105713 If continuation sheet Page 19 of 19