Inspection·March 11, 2022

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed to conduct an annual comprehensive Minimum Data Set assessment (MDS, an assessment tool used to direct resident care) for one sampled resident (Resident 2) as required. This deficient practice had the potential to result in the lack of assessment of the residents' needs, strengths, and goals of care. Findings: Review of Resident 2's MDS assessment Section A indicated an annual (comprehensive) assessment was due 1/14/22. Resident 2's MDS Assessment Reference Date (ARD, the last day of the observation period that the Resident assessment covers) was 1/14/22, but was completed on 3/1/22 (46 days after the Assessment Reference Date). During an interview on 3/11/22 at 9:32 a.m., the Licensed Vocational Nurse/MDS coordinator (MDS 1) stated the MDS assessments were late because the facility did not have a full time MDS coordinator. During an interview on 3/11/22 at 10:08 a.m., MDS 2 stated according to the RAI (Resident Assessment Instrument) policy, assessments should be completed 14 days after the date of assessment. MDS 2 further stated the facility did not have an MDS Coordinator during the assessment period. During an interview on 3/11/22 at 9:13 a.m., the Administrator (Admin) stated he was aware of the late MDS assessments. Admin stated the facility had a part-time Licensed Vocational Nurse to assist with the MDS. The facility's policy and procedure titled, Late & Missed Minimum Data Set (MDS) Assessment dated May 2019, indicated the facility shall adhere to RAI Manual assessment schedules as required by federal and state agencies. The annual/comprehensive MDS assessments should be completed 14 days after the ARD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 2 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for five of six residents (Resident 3, 4, 5, 6, and 7) that were reviewed for resident assessments, the facility failed to assess residents using the quarterly review instrument in a timely manner. Residents Affected - Some This failure had the potential to result in the delay of assessment of residents' needs and goals of care and inability to monitor each residents' decline and progress over time. Findings: During an interview and concurrent record review on 3/11/22 at 10:08 a.m., with the Licensed Vocational Nurse/MDS coordinator (LVN/MDS 1) stated all Minimum Data Set (MDS, an assessment tool used to direct resident care) assessments should be completed timely based on the requirement in the Resident Assessment Instrument (RAI, a system for evaluation and documentation in long-term care) manual. LVN/MDS 1 stated the MDS assessments indicated the following: - Resident 3's quarterly MDS assessment dated [DATE] was completed 3/1/22 (44 days after the Assessment Reference Date (ARD, the last day of the observation period that the assessment covers for the resident, the ARD is the date of the assessment). - Resident 4's quarterly MDS assessment dated [DATE] was completed 3/1/22 (39 days after the ARD). -Resident 5's quarterly MDS assessment dated [DATE] was completed 3/7/22 (43 days after the ARD). -Resident 6's quarterly MDS assessment dated [DATE] was completed 3/1/22 (36 days after the ARD). -Resident 7's quarterly MDS assessment dated [DATE] was completed on 3/1/22 (29 days after the ARD). During an interview on 3/11/22 at 9:32 a.m., LVN/MDS 1 stated the MDS assessments were late because the facility did not have full time MDS coordinator. During an interview on 3/11/22 at 10:08 a.m., LVN/MDS 2 stated, according to the RAI policy, assessments should be completed 14 days after the date of assessment. During an interview on 3/11/22 at 9:13 a.m., the Administrator (Admin) stated he was aware of the late MDS assessments, and had a part time Licensed Vocational Nurse to assist with the MDS. The facility's policy and procedure titled, Late & Missed Minimum Data Set (MDS) Assessment dated May 2019, indicated the facility shall adhere to RAI Manual assessment schedules as required by federal and state agencies. The annual/comprehensive MDS assessments should be completed 14 days after the ARD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 3 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one (Resident 39) sampled resident's Pre-admission Screening Resident Review (PASRR) was referred to the appropriate state mental authority for Level II evaluation and determination when Resident 39's PASRR for serious mental illness was not accurately completed. Residents Affected - Few This deficient practice had the potential to prevent Resident 39 from receiving appropriate required mental health services. Findings: Review of Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 8/10/21, indicated the Preadmission Screening and Resident Review (PASRR) was coded zero-meaning, Resident 39 was not considered by the State Level II PASRR process to have a serious mental illness. However, Resident 39's diagnoses included a psychotic disorder, mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and a sense of mental fragmentation, depression and anxiety. Review of the PASRR screening dated 1/3/22 indicated Resident 39 did not have a diagnosed mental disorder such as depression, anxiety, psychotic, delusional (false beliefs) and or mood disorder. During an interview and concurrent record review on 3/08/22 at 9:54 a.m., the Marketing Director (MD) stated she recently assumed the responsibility for completing the PASRR. MD stated Resident 39's PASRR was not completed accurately and Resident 39 was not referred to the State Mental Authority for specialized mental health services. The facility's policy and procedure titled, Pre-admission Screening Resident Review (undated), indicated the facility as a medicaid certified nursing facility, ensure that level 1 of the PASRR is completed to determine if they are mentally ill . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 4 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interviews and record review, the facility failed to develop and implement comprehensive care plans for five sampled residents (Resident 6, 12, 32, 34 and 39) when; Residents Affected - Some 1 The care plan was not developed to address Resident 6's lower extremity impairments. 2. Resident's 6, 12, 32, 34 and 39 care plans did not address the use of psychotropic medications, such as Seroquel (antipsychotic) and Depakote (medication for mood disorder) for behavioral manifestation (psychotropic medications are drugs used to treat mental illnesses). These deficient practices had the potential to result in residents not receiving appropriate care, monitoring, and treatment. Findings: 1. Review of Resident 6's Annual Minimum Data Set (MDS- an assessment and care screening tool used to guide care) dated 7/23/21, indicated Resident 6 had limitations in the upper and both lower extremities shoulder, elbow, wrist, hand, hip, knee, ankle and feet). Resident 6 had diagnoses that included arthritis (painful inflammation and stiffness of the joints). During an observation 3/07/22 at 11:17 a.m., Resident 6 had long crooked, foot toenails and left foot drop (difficulty lifting the front part of the foot). Review of the order summary indicated the physician had prescribed Resident 6 to receive PT (Physical Therapy) evaluation and treatment but only to be done when the family is in the building. During an interview on 3/07/22 at 11:17 a.m., the Director of Nursing (DON) stated the facility did not meet to discuss any other interventions. DON could not provide the care plan that had interventions for Resident 6's upper and lower extremity impairments, crooked foot toe nails, and left foot drop. During an interview on 3/11/22 at 9:32 a.m., the Licensed Vocational Nurse/MDS coordinator (MDS 1) stated facility did not have full time MDS coordinator for completing the comprehensive care plans. 2. Review of Resident 6's order summary dated 11/12/21 indicated the physician prescribed Seroquel 25 mg (milligram) give 0.5 mg tablet by mouth in the morning for agitation related to dementia (memory disorder) with behavior. Review of Resident 12's order summary dated 5/20/21 indicated the physician prescribed divalproex sodium (Depakote) 125 mg 2 capsules by mouth daily for mood disorder. Review of Resident 32's order summary dated 2/9/22 indicated the physician prescribed Risperidone (generic for Risperdol) 0.25 mg one tablet in the morning and evening for senile dementia with behavior. Review of Resident 34's order summary dated 6/11/21 indicated the physician prescribed Seroquel 25 mg one tablet two times daily, quetiapine fumate (generic for Seroquel) 50 mg two times daily for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 5 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 psychosis and Zoloft 50 mg by mouth daily for self isolation. Level of Harm - Minimal harm or potential for actual harm Review of Resident 39's order summary dated 2/8/22 indicated the physician prescribed Risperdal 0.5 mg one tablet by mouth in the morning and afternoon for agitation. Residents Affected - Some During a review of Residents 6, 12, 32, 34, and 39's care plans and concurrent interview on 3/11/22 at 8:30 a.m., the Director of Nursing (DON) stated the facility did not have an MDS coordinator at the time to develop, revise and update the residents' use of psychotropic medication care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 6 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide one (Resident 26) sampled resident restorative nursing care (RNA) for Resident 26's contracture (shortening of the muscles, tendons or other tissue, often leading to deformity and rigidity of joints) of the right leg. Residents Affected - Few This deficient practice had the potential to cause Resident 26 further decline in range of motion. Findings: During an observation on 3/8/22 at 9:28 a.m., Resident 26 was in bed and had a contracture of the right leg. During an interview on 3/8/22 at 9:28 a.m., the Director of Rehab (DOR) stated Resident 26 had an Occupational Therapy (OT) evaluation only and was to continue having RNA services, three times a week for bilateral lower extremities. Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 1/8/22, indicated Resident 26 had limited range of motion and impairment to the lower extremity, hip, knee, ankle and foot. Resident 26 had diagnoses that included degenerative disease of the nervous system. Review of the order summary on 3/8/22 at 1:33 p.m., the physician prescribed on 2/9/22 for Resident 26 to continue on RNA three times a week for bilateral upper extremities/ bilateral lower extremities and passive range of motion. During an interview on 3/8/22 at 1:31 p.m., the Certified Nursing Assistant/Restorative Nursing Assistant (CNA/RNA 1) stated she did not know if Resident 26 was on RNA and thinks Resident 26 received OT. During an interview on 3/9/22 at 10:58 a.m., the Director of Nursing (DON) stated Resident 26 did not receive restorative nursing care for the right leg contracture. and the RNA order was overlooked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 7 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 191) received supplemental oxygen according to the physician's order. Residents Affected - Few This failure resulted in Resident 191 receiving more supplemental oxygen without a physician's order. Findings: During an observation on 3/8/22 at 10:15 a.m., in Resident 191's room, Resident 191 was seen sitting in bed receiving oxygen at three liters per minute via nasal cannula (a device to provide supplemental oxygen therapy) from an oxygen concentrator (medical device that gives extra oxygen). During a concurrent observation and interview on 3/9/22, at 12:21 a.m., with Registered Nurse (RN) 1 in Resident 191's room, the oxygen concentrator was delivering three liters of oxygen per minute to Resident 191 via nasal cannula. RN 1 confirmed the oxygen concentrator was set to deliver three liters of oxygen per minute because the rate could be titrated (changed based on resident's response). A review of Resident 191's Orders, indicated a PRN (as needed) order dated 2/9/22 for, O2 (oxygen) at 2 l/min (liters per minute) NC (nasal cannula) for SOB (shortness of breath). There were no additional orders for oxygen titration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 8 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interviews and record review, the facility failed to ensure that one Certified Nursing Assistant (CNA 3) had the skilled competency evaluation completed, and for three CNAs (CNA 4. 5 and 6 ) from registry (temporary employees) had training on dementia prior to providing residents care. This deficient practice had the potential to cause residents to received inappropriate care and injuries. Findings: During a record review of the employee files on 3/9/22 at 2:55 p.m., in the presence of the Administrative Resource (AR) , the facility could not provide CNA 3's skilled competency evaluation. CNA 3 was hired 1/5/22. Review of the Registry CNA files on 3/10/22 at 9:47 a.m., with the Administrator (Admin), three CNAs 4, 5 and 6 did not receive Dementia training on record. During an interview on 3/9/22 at 1:30 p.m., the Director of Staff Development (DSD) stated she was newly hired. During an interview 3/10/22 at 9:47 a.m., Admin stated Registry Agencies are responsible for the training of the CNAs. The facility could not provide CNAs 4, 5 and 6's dementia training record. Review of the agency's CNA orientation checklist did not include dementia training. The policy and procedure titled, Competency Evaluation dated July 2019 indicated, it is the facility's policy to perform competency evaluation for all employees. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 9 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 - Some 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. Based on interviews and record review, the facility failed to ensure three sampled residents (Resident 6, 32, 34 and 39) with diagnosed Alzheimer's Dementia (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out simplest tasks) were free from unnecessary drugs. -Resident 6 was administered Seroquel (an antipsychotic) without adequate clinical indication for continued usage. -Resident 32 was administered Risperidone (an antipsychotic) without adequate clinical indication for continued usage. -Resident 34 was administered Quetiapine and Seroquel (antipsychotics) without adequate clinical indication for continued usage. -Resident 39 was administered Risperidone (an antipsychotic) without adequate clinical indication for continued usage. {A psychotropic drug is any drug that affects brain activities associated with mental processess and behavior} {According to the manufacturer of Seroquel, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular e.g. heart failure, sudden death}. [Reference: https://www.drugs.com/pro/seroquel.html]. This failure had the potential for residents to receive unnecessary medications and had the potential for the residents to suffer adverse medication side effects. Findings: Review of Resident 6's order summary dated 11/12/21 indicated the physician prescribed seroquel 25 mg give 0.5 mg tablet by mouth in the morning for agitation related to dementia with behavior Review of Resident 32's order summary dated 2/9/22 indicated the physician prescribed risperidone 0.25 mg one tablet in the morning and 0.5 mg by mouth in the evening for senile dementia with behavior manifestation of kicking, yelling and irritability. Review of Medication Administration Record (MAR) dated 2/10/22 to 2/28/22 and 3/1/22 to 3/8/22, indicated Resident 32 was administered Risperidone 0.25 mg by mouth in the morning and 0.5 mg by mouth in the evening for senile dementia. During an observation on 3/7/22 at 11:43 p.m., Resident 32 was pleasant with incomprehensive conversation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 10 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 During an interview on 3/7/22 at 12:45 p.m., Certified Nursing Assistant (CNA3) stated Resident 32 sometimes get agitated. CNA3 said Resident 32 was cooperative when care was explained. During an interview 3/9/22 at 9:11 a.m., CNA1 stated Resident 32 was cooperative when care was explained. CNA1 stated Resident 32 get agitated when 2 staff members approached with care. Residents Affected - Some Review of Resident 34's Annual Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 5/7/21, indicated Resident 34's diagnoses included Non-Alzheimer's Dementia. Review of Resident 34's order summary dated 6/11/21 indicated the physician prescribed seroquel 25 mg one tablet two times daily, Quetiapine Fumate 50 mg two times daily for psychosis Review of MAR dated 3/1/22 to 3/8/22, indicated Resident 34 was administered Seroquel 25 mg by mouth two times a day and Quetiapine Fumate 50 mg one tablet two times a day for psychosis manifested by anxiety and agitation . Further review inidicated Resident 34 was administered Quetiapine Fumate without behavioral indication. Review of Resident 39's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 8/10/21, indicated Resident 39's diagnoses included Non-Alzheimer's Dementia. Review of Resident 39's order summary dated 2/8/22 indicated the physician prescribed risperdal 0.5 mg one tablet by mouth in the morning and afternoon for agitation Review of MAR dated 2/1/22 to 2/28/22 and 3/1/22 to 3/8/22, indicated Resident 39 was administered Risperdal 0.5 mg one tablet by mouth in the morning and afternoon for agitation. During an interview on 3/7/22 at 1:26 p.m., CNA2 stated resident had no behavior but had sun downing in the afternoon when he kicked when agitated. During an interview on 3/9/22 at 9:03 a.m., CNA1 stated Resident 39 said get agitated towards evening. CNA1 said Resident 39 liked to walk, listen to music and color books . CNA1 stated towards evening when CNA1 walked Resident 39 that reduced his agitation. During a review of Resident 6, 32, 34 and 39's clinical records and concurrent interview on 3/11/22 at 8:30 a.m., Director of Nursing (DON) stated facility's IDT team did not meet and discussed residents behavioral manifestation with appropriate non pharmacological interventions before ordering and administration of antipsychotic /psychotropic medications. The facility's policy and procedure titled, Psychoactive Medication Management indicated: Indication for use is the identified documented clinical rationale for administering a medication that is based upon an assessment of the resident condition and therapeutic goals and is consistent with manufacturer's recommendations and/or clinical standard of practice, medication references, clinical studies or evidence-based review articles that are published in medical and/or pharmacy journal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 11 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure proper labeling of medications for two of six sampled residents (Residents 18 and 23) when nasal spray and inhaler (medication inhaled into lungs through the mouth) were not labeled with the resident's name. This failure had the potential to result in medication being used on another resident and cross-contamination (transfer of bacteria from one person, object, or place to another). Findings: During a concurrent observation and interview on 3/10/22 at 8:30 a.m., with the Licensed Vocational Nurse (LVN) 1, at South Hall medication cart, Resident 18's Fluticasone nasal spray (relieves allergy symptoms) bottle was labeled, 1A. Resident 23's Alvesco inhaler (to reduce swelling of the airways) had no label. LVN 1 indicated, only room numbers are placed on nasal sprays and inhalers and there is a risk of cross contamination if these medications are not labeled correctly and given to the wrong resident. During an interview on 3/10/22, at 10:07 a.m., with Director of Nursing (DON), DON indicated, medications should be labeled with resident name and room number and if medications get mixed up and are administered to a different resident it could spread disease. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 12 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record review, the facility failed to follow proper sanitation and food storage practices and ensure staff maintained competencies for kitchen service as follows. Residents Affected - Some a. Hand washing sink not working b. Kitchen floor tiles with brownish discoloration c. Dietary aide (DA 1) had long, acrylic fingernails d. Ice machine with whitish residue on hinges front and side e. Ice machine filters had dust residue f. Dish washer temperature was not logged on 3/6/22 g. Dish wash racks had blackish/brownish discoloration h. Sanitizing solution testing log was not initiated for March 2022 i. Double door refrigerator hinges had greenish discoloration These deficient practices had the potential to result in foodborne illness. Findings: During the initial tour of the kitchen on 3/07/22 at 10:10 a.m., accompanied by the Dietary Supervisor (DS), showed the hand washing sink was not working, and the kitchen floor tiles had brownish discoloration. The Ice machine had whitish residue on the hinges on the front and side, the ice machine filters had dusty residue and the dish washer temperature was not recorded on the log on 3/6/22. Further observations showed the dish wash racks had blackish/brownish discoloration, and the sanitizing solution testing log was not initiated for March 2022. The double door refrigerator hinges had greenish discoloration. During an interview on 3/7/22 at 10:10 a.m., DS stated she had to cook and had not paid attention to the sanitation logs. DS further stated the Dietician (RD) was aware of the staffing problems in the kitchen and RD had not provided the sanitation assessment of the Kitchen. During an interview on 3/07/22 at 10:30 a.m., DA 1 stated the kitchen department had requested for new dishwashing racks. During an interview on 3/08/22 at 8:28 a.m., DS stated she had been working as a cook for several months and had not done some of her job functions i.e. competencies and sanitation. During tray line on 3/08/22 at 11:37 a.m., in the presence of DS and RD, DA 1 wore long, acrylic fingernails. DA 1 did not wear gloves when handling the food processor to puree dessert for lunch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 13 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 During an interview on 3/8/22 at 11:37 a.m., DA 1 stated she was not allowed to use acrylic long finger nails with food preparations. During an interview on 3/08/22 at 11:45 a.m., DS stated the hand wash sink was not working for over a month. DS said the dietary staff used the food prep sink for hand washing and moved food preparation over to the three compartment sink. During an interview on 3/10/22 at 9:40 a.m., the Maintenance Supervisor (MS) stated the faucet of the hand washing sink was not working for about 4 weeks. MS stated the previous Administrator had ordered to replace the faucet. MS stated he was in the kitchen on Saturday for maintenance and found the faucet had not been replaced. During an interview on 3/10/22 at 10:20 a.m., the Administrator (Admin) stated the replacement faucet was ordered on 3/9/22. The facility Policy and Procedure titled, Sanitation, undated. indicated; The food service area shall be maintained in a clean and sanitary manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 14 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 0880 Provide and implement an infection prevention and control program. 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 implement their infection prevention and control program when: Residents Affected - Some 1. Licensed nurse picked up a medication pill with bare hands and placed the pill inside a medication cup and administered it to Resident 34. 2. Licensed nurse placed Fluticasone (medication sprayed into nose to relieve symptoms of allergies such as runny nose and sneezing) nasal spray bottle into the scrub uniform pocket to transport and administered it to resident 18. 3. No tuberculosis (TB- infectious bacterial disease that mainly affects the lungs) screening was done for high-risk resident upon admission (Resident 191). These failures had the potential to spread infectious diseases to facility residents. Findings: 1. During an observation on 3/10/22, at 8:49 a.m., at the South Hallway medication cart, Licensed Vocational Nurse 1 (LVN 1) removed a pill from the packaging and dropped it on top of the medication cart and picked it up with bare hands. LVN 1 then placed the pill inside of a medication cup and administered the pill to Resident 34 to swallow. During an interview on 3/10/22, at 8:51 a.m., LVN 1 stated she does not usually drop pills, but it is hard to get them out of the packaging sometimes and she just did hand hygiene. During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 9/18, the P&P indicated, .hands are washed with soap and water and gloves applied prior to handling tablets . 2. During an observation on 3/10/22, at 8:43 a.m., LVN 1 placed the Fluticasone nasal spray bottle in her scrub top pocket, then went to Resident 18's room and administered the medication by nose to Resident 18. During an interview on 3/10/22, at 10:07 a.m., with Director of Nursing (DON), DON stated medications should be transported to and from the medication cart using a small basket. 3. A review of Resident 191's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnosis of thrombocytopenia (low number of platelets in the blood), anemia (lack of red blood cells leading to reduced oxygen flow to organs) and bradycardia (slow heart rate). During a concurrent interview and record review on 3/10/22, at 12:37 p.m., with DON, Resident 191's Medication Administration Record (MAR), dated February 2022 was reviewed. The MAR indicated, on 2/12/22 at 16:54, LVN 1 documented Resident 191 did not receive PPD (purified protein derivative injected under the skin to test for tuberculosis). On 2/15/22 at 16:03, LVN 2 read PPD as negative. There were no further attempts to administer PPD per MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 15 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 3/10/22, at 12:44 p.m., with LVN 1, Resident 191's Medication Administration Record (MAR), dated February 2022 was reviewed. LVN 1 indicated, resident 191 refused PPD on 2/12/22. Order for PPD stays highlighted in MAR for several days until administered. Confirmed she worked 2/13/22, but did not attempt to administer PPD again. During an interview on 3/11/22, at 10:37 a.m., with DON, DON stated facility must administer PPD within 72 hours of new admission. If resident is allergic to PPD, facility will complete TB screening form and do chest x-ray (imaging that creates pictures of the inside of the body). Confirms no TB screening form was completed for Resident 191. During a review of the facility's policy and procedure (P&P) titled, Tuberculosis (TB) Control Plan, dated November 2017, the P&P indicated, The facility will follow California Department of Health guidance instruction in the prevention, control and management of tuberculosis. The Guidelines for Prevention and Control of Tuberculosis in California Long Term Care Facilities, dated May 2013 by California Dept of Public Health (CDPH- state department responsible for public health in California) indicates, A two-step TST (tuberculin skin test - also known as a PPD) procedure is required as part of the admission health screening. TB symptom screen must be performed upon admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 16 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to ensure the designated Infection Preventionist (infection control nurse) completed the specialized training in infection prevention and control. Residents Affected - Many This failure had the potential to contribute to residents' development of healthcare acquired infections (infections from receiving treatment at a healthcare facility). Findings: During a concurrent interview and record review, on 3/9/22, at 10:03 a.m., with the Infection Preventionist (IP), IP indicated the completion of the CDC (Centers for Disease Control and Prevention - national public health agency) Nursing Home Infection Preventionist Training Course. Upon review of the training completion certificates, the modules were completed for the course, but the final exam had not been completed. IP stated she did not take the final exam and did not have a certificate of completion for the course. IP did not take any other infection preventionist courses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 17 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of five sampled Residents (Residents 37, 90 and 191) were educated and offered influenza (Flu - a contagious respiratory illness caused by influenza virus) vaccination and four of five sampled residents (Residents 32, 37, 90 and 191) were educated and offered pneumococcal (PNA- a disease that can cause infection in the lung) vaccination. Residents Affected - Some These failures had the potential to place Residents 37, 90 and 191 at higher risk for becoming infected and spread Flu to others and or acquire pneumococcal infections. For Resident 32, the risk of becoming infected with and spreading pneumococcal infection. Findings: During a concurrent interview and record review on 3/10/22, at 10:56 a.m., with the Infection Preventionist (IP), Resident 191's medical record was reviewed. Resident 191 was admitted to the facility on [DATE]. IP confirmed, no record of resident having received flu or pneumococcal vaccine prior to admission. There were no records of the facility educating resident on the benefits and potential side effects of the flu and pneumococcal vaccines or offering either vaccine to resident. IP stated it's important for residents to receive vaccines because many are immunocompromised (a weak immune system making it difficult to fight off infection) and are living close together at the facility. During a concurrent interview and record review on 3/10/22, at 11:09 a.m., with IP, Resident 37's medical record was reviewed. Resident 37 was admitted to the facility on [DATE]. IP confirmed there was no record of the resident having received flu or pneumococcal vaccine prior to admission. No records of the facility having educated the resident on the benefits and potential side effects of the flu and pneumococcal vaccines or offering either vaccine to resident. During a concurrent interview and record review on 3/10/22, at 11:25 a.m., with IP, Resident 32's medical record was reviewed. Resident 32 was admitted to facility on 12/7/21. IP confirmed there was no record of resident having received pneumococcal vaccine prior to admission. There was no record of the facility educating Resident 32 on the benefits and potential side effects of the pneumococcal vaccine or offering vaccine to resident. During a concurrent interview and record review on 3/10/22, at 11:37 a.m., with IP, Resident 90's medical record was reviewed. Resident 90 was admitted to the facility on [DATE]. IP confirmed there was no record of the resident having received the flu or pneumococcal vaccines prior to admission. There was no record of educating Resident 90 of the benefits and potential side effects of the flu and pneumococcal vaccine or offering either vaccine to resident. A review of the facility's policy and procedure (P&P) titled, Influenza Plan, dated November 2017, indicated, Prior to yearly flu season (October 1 - March 31 of the following year), provide educational material to residents and employees. If resident and responsible party agrees, administer flu vaccination. A review of the facility's policy and procedure (P&P) titled, Pneumococcal Plan, dated November 2017, indicated, Screen residents upon admission to determine if a pneumococcal vaccine has been received. Provide resident or responsible party with vaccine information sheet. If resident and responsible party agrees and there is no contraindication, administer pneumococcal vaccination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 18 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to educate and offer COVID-19 (a new coronavirus that causes a respiratory viral infection that is easily spread) vaccine to one of 36 sampled residents (Resident 191). This failure resulted in Resident 191 being at higher risk for severe complications including death when the facility had an outbreak of COVID-19 on 2/25/22. A review of Resident 191's Face Sheet indicated, resident was admitted to facility on 2/9/22 with diagnosis of thrombocytopenia (low number of platelets in the blood), anemia (lack of red blood cells leading to reduced oxygen flow to organs) and bradycardia (slow heart rate). During a concurrent interview and record review, on 3/10/22 at 10:56 a.m., with Infection Preventionist (IP), Resident 191's medical record was reviewed. IP stated that vaccinations are provided to residents based on the discharge summary from the hospital, and confirmed no COVID-19 vaccination documentation was in the hospital Discharge summary dated [DATE]. IP further stated Resident 191 had not been educated or offered COVID-19 vaccination since being admitted to the facility. During a review of the facility's policy and procedure (P&P) titled, COVID-19 Vaccination, dated December 2021, the P&P indicated, provide periodic training for unvaccinated staff and residents and/or resident representative. Complete consents for residents and employees as well as document doses received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 19 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to develop and implement a comprehensive staff COVID-19 (a new coronavirus causing a respiratory infection that is easily spread) vaccination policy and procedure (P&P) when: Residents Affected - Many 1. The P&P did not include the required elements of tracking, and develop a process for requesting and granting COVID-19 vaccine exemption. 2. One COVID-19 vaccine religious exemption was not approved or denied for the (Dietary Aide-1 (DA 1) of two staff members. This failure had the potential to expose staff and residents to COVID-19. Findings: 1. During an interview on 3/10/22 at 2:16 p.m., with the Infection Preventionist (IP), IP stated there is no established process for staff to apply for a vaccine waiver or track when waivers are received. During an interview on 3/20/22, at 3:01 p.m., with the Administrator (Adm), Adm stated staff who want a COVID-19 vaccination exemption request a declination form. If it is a religious exemption, a letter from a religious source must be included and co-signed by Adm. For medical exemption requests,the facility must have a letter from the doctor. Adm further stated there is nothing in the policy that requests need to be cosigned by Adm or about granting exemptions received. A review of the facility's policy and procedure (P&P) titled, Mandatory COVID-19 Vaccination Order, dated January 2022 indicated, Complete declination form indicating understanding of the reason for COVID-19 vaccination. If there is a religious or medical reason for accommodations, document the information on the forms. 2. During an interview on 3/9/22, at 1:44 p.m., with DA 1, DA 1 stated when he applied for the position, he notified the facility that he was unvaccinated. The facility gave him a form to fill out and he submitted it with a letter from his pastor. DA 1 has been working at the facility for three weeks. DA 1 was not sure if his exemption was granted because the facility never told him. During a concurrent interview and record review, on 3/10/22 at 3:01 p.m., with Adm, DA 1's COVID-19 Vaccine Declination Form, dated 2/28/22, was reviewed. Adm stated the previous administrator granted requests for vaccination exemptions and there was no new COVID-19 vaccination exemption requests since he started on 2/21/22. Adm stated he has not reviewed DA 1's request yet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 20 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the required 80 square feet (sq ft) of living space per resident in 15 resident rooms, affecting 33 of 36 current residents. This failure had the potential to result in a lack of adequate space for the provision of care by facility staff and for lack of sufficient space for residents to have personal belongings at bedside. Findings: During entrance conference on 3/7/22, at 10:13 a.m., with the Administrator (Adm), Adm confirmed the facility currently has a room waiver. During random observations on the days of the survey, 33 of 33 residents in rooms 1, 3, 4, 5, 6, 7, 8, 9, 10, 12, 14 and 16 required assistance getting out of bed, with personal care, including eating and dressing. Certified Nursing Assistants (CNA) were observed assisting residents to eat and move from bed to a wheelchair. The Restorative Nursing Assistant (RNA) was observed providing therapy in resident rooms. Licensed Nurses (LN) were observed providing medication at the bed side. Residents were observed using walkers or wheelchairs in their rooms with adequate space to move about safely and without obstruction. A review of the Client Accommodations Analysis form dated 3/11/22, indicates the following square feet per resident for rooms with requested waiver: room [ROOM NUMBER]: 71.47 sq ft per resident room [ROOM NUMBER]: 69.15 sq ft per resident rooms [ROOM NUMBERS]: 70.04 sq ft per resident Rooms 5, 12, 14 and 18: 69.5 sq ft per resident rooms [ROOM NUMBERS]: 68.88 sq ft per resident room [ROOM NUMBER]: 69.84 sq ft per resident room [ROOM NUMBER]: 70.68 sq ft per resident room [ROOM NUMBER]: 73.92 sq ft per resident room [ROOM NUMBER]: 69.77 sq ft per resident room [ROOM NUMBER]: 70.40 sq ft per resident There was sufficient space for provision of care and emergency access to all rooms. There was sufficient space for storage of personal items and there were no complaints from residents or family members. There were no negative consequences attributable to the decreased space in rooms nor were any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 21 of 22 Printed: 05/15/2026 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 555292 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 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 0912 safety concerns noted. The survey team recommends renewal of waiver for the afore mentioned rooms. Level of Harm - Potential for minimal harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 22 of 22