Inspection visit

InspectionDecember 1, 2023

ALHAMBRA POST ACUTECMS #55529225 citations on this visit

25 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 25 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 perform a medication self-administration assessment prior to allowing Resident 12 to self-administer medications. Residents Affected - Few This failure resulted in Resident 12 not taking ordered medication at the appropriate time, with the potential for adverse health outcomes related to incorrect medication administration. Findings: During a review of Resident 12's admission Record dated 11/28/23, which showed Resident 12 was admitted to the facility on [DATE]. Resident 12 had diagnoses that included hemiplegia and hemiparesis (severe or complete loss of strength to one side of the body) affecting the left side, dysphagia (difficulty and/or pain swallowing), and a gastrostomy (a surgical opening through the skin of the abdomen to the stomach). During a record review of the Medication Administration Record, dated 11/2023, the record showed Licensed Vocational Nurse 1 (LVN 1) administered Miralax (a medication to treat occasional constipation) powder to Resident 12 at 9:00 a.m. on 11/27/23. During a concurrent observation and interview on 11/27/23 at 10:15 a.m., a small unlabeled and undated medication cup with white powder was on Resident 12's bedside table. Resident 12 stated the powder was Miralax medication, and his nurse left it on the resident's bedside table while performing the morning medication administration. Resident 12 stated he would take the Miralax later. During a concurrent interview and record review with LVN 1 on 11/27/23 at 3:17 p.m., Resident 12's Electronic Health Record was reviewed. LVN 1 stated she left Miralax powder at Resident 12's bedside, and she did not witness Resident 12 take the medication. LVN 1 stated she usually leaves the medication at bedside for Resident 12 to take later at his request. LVN 1 further stated she did not know where to locate the self-administration assessment for Resident 12. LVN 1 also stated she was unable to find any record of the Medication Self Administration evaluation in Resident 12's electronic health record. During a record review of the facility policy titled Self-Administration of Medication, revised 2/2021, indicated as part of the evaluation comprehensive assessment, the interdisciplinary team (IDT-professionals from various disciplines who work in collaboration to address a resident with multiple physical and psychological needs) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 38 Event ID: 555292 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 12/01/2023 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 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure privacy and right to send secure mail when a stack of residents' mail was left unattended on top of an unlocked mail box located outside the building. Residents Affected - Some This failure had the potential to cause mail and identify theft. Findings: During a resident council (group) meeting on 11/28/23 at 10:02 a.m., Resident 3 stated the residents' mail was left outside the mail box unattended. During an observation and concurrent interview on 11/28/23 at 2:47 p.m., and accompanied by Activity Director (AD), the mail box located outside the building by the entrance door showed the mail box was not locked and a stack of residents' mail left unattended on top of the mail box. During an interview on 11/28/23 at 3:10 p.m., Administrator (Admin) stated he will make sure the mail box was locked. During an interview on 11/30/23 at 9:26 a.m., with Staffing/House Keeping Coordinator (SC), SC stated she was designated to collect the residents' mail from the mailbox. SC said she had the key to the mail box but forgot to lock the mail box. SC stated the mail left on top of the mail box were residents' bills that were meant to be taken to the post office to be mailed out. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 2 of 38 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 12/01/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer and facilitate the preparation of an advance directive, including the right to accept or refuse medical-surgical treatment for seven of seven sampled residents upon admission. These failures resulted in Resident 3, 12, 24, 29, 30, 38, and 200 not being aware of their right to specify their wishes for medical-surgical care should they become incapacitated. Findings: 1.During a review of Resident 3's admission Record printed on 11/28/23, the record indicated Resident 3 was admitted to the facility on [DATE]. During a review of Resident 24's admission Record printed on 11/28/23, the record indicated Resident 24 was admitted to the facility on [DATE]. During a review of Resident 30's admission Record printed on 11/28/23, the record indicated Resident 24 was admitted to the facility on [DATE]. During a review of Resident 200's admission Record printed on 11/28/23, the record indicated Resident 24 was admitted to the facility on [DATE]. During a concurrent interview and record review on 11/27/23, at 1:08 p.m., with Medical Record (MR), the Electronic Healthcare Record (EHR) and the paper chart for Residents 3, 24, 30 and 200 were reviewed for the presence of an Advanced Directive (a legal document that provide instructions for medical care that go into effect if you cannot communicate your wishes). MR stated that Advanced Directives were not in either resident records, nor was there any documentation that assistance was offered to Resident 3, 24, 30 and 200 to complete an Advanced Directive. During an interview on 11/27/23 at 1:23 p.m., with Licensed Vocational Nurse (LVN 4), LVN 4 stated, The nurse doing the resident's admission is the one who checks if the resident has an Advance Directive in place, and it appears that this was not done. During an interview on 11/27/23 at 1:35 p.m., with Resident 3, Resident 3 stated he was not asked about an Advance Directive during admission and during his stay. During an interview on 11/27/23 at 1:40 p.m., with Resident 24, Resident 24 stated she does not recall being asked about an Advance Directive. During an interview on 11/27/23 at 1:43 p.m., with Resident 30, Resident 30 stated, The nurse who admitted me did not ask me if I had an Advance Directive or provide any paperwork regarding Advanced Directives. During an interview on 11/27/23 at 2:00 p.m., with Resident 200, Resident 200 stated she does not recall being asked about an Advance Directive during admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 3 of 38 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 12/01/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm 2. During a concurrent interview and record review with Social Services Director (SSD), on 11/29/23 at 10:17 a.m., the EHR and paper chart were reviewed for the presence of an Advance Directive for Resident 12 and Resident 29. SSD stated the Advance Directives were not in either resident records, and no documentation that assistance was offered to Resident 12 and Resident 29 to complete an Advance Directive. Residents Affected - Some During an interview with the facility Administrator (ADM) on 11/29/23 at 10:30 a.m., ADM stated the prior SSD was dismissed, and partly due to the failure to ensure Advance Directives were completed or offered to residents. During an interview on 11/30/23 at 11:37 a.m., the Licensed Vocational Nurse 1 (LVN 1) stated the risk of not providing residents assistance for completing an Advance Directive could result in staff not knowing or following residents wishes related to life-sustaining measures. 3. During a record review of the admission Record dated 11/29/2023, the record indicated Resident 38 was admitted to the facility 07/11/2023. During a concurrent interview and record review on 11/27/23 at 01:11 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 38's hardcopy chart and Electronic Health Record (EHR) was reviewed. LVN 4 stated she was unable to find a copy of Advanced Directives (AD) for Resident 38. LVN 4 stated facility inquired the new residents about advance directives upon admission. LVN 4 stated if there was one available then facility requested the families to bring a copy, so that it can be scanned into the Resident's chart. LVN 4 stated if residents did not have one and would like to have advance directives completed, then they were referred to the Social Services Director. LVN 4 also stated If residents refused to have advance directives completed, it has to be indicated in writing, either in the hard copy or electronic medical chart. LVN 4 then stated she was unable to any documentation if Resident 38 was offered to have one. During an interview on 11/29/23 on 09:21 a.m. with Director of Social Services (SSD), the SSD stated she was newly hired at the facility. SSD stated having advance directives on file was important to ensure Residents were taken care of in accordance with their wishes in regards of their financials, medical diagnosis, placement etc. The SSD also stated it was important to give an opportunity to residents to ensure if they wanted to have an advance directive or not. During a review of the facility's policy and procedure (P&P) titled Advanced Directives dated September 2022, indicated .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment .1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if she or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive provided in a manner that is easily understood by the resident or representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 4 of 38 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 12/01/2023 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 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, interview and record review the facility failed to make information on how to file a grievance or complaint available to six (3, 19, 22, 24, 26 and 38) of seven sampled residents. Residents Affected - Some This deficient practice had the potential to cause residents fear and emotional distress. Findings: During a residents council (group) meeting on 11/28/23 at 10:02 a.m., Resident 3, 19, 22, 24, 26 and 38 stated they do not know how to file a grievances. During further interview on 11/28/23 at 10:02 a.m., Resident 19 stated she had no information on how to file a grievance. Resident 19 said If you have a grievance it is ignored. Review of admission Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 5/30/23, indicated Resident 19's Basic Interview of Mental status (BIMS) score was 12 (meaning moderately impaired cognition). Resident 19 was oriented to correct year and day of the week. Resident 19 had clear speech, makes self understood and understand others. During an interview on 11/28/23 at 2:56 p.m., Activity Director (AD), AD stated she reviewed grievances protocols during monthly resident group meetings. AD stated facility had a binder by nurses station with information for residents and family member for filing grievances. AD stated she brought it up sometimes and remind residents to also talk to social worker and AD with grievance concerns. During an observation and concurrent interview on 11/29/23 at 10:44 a.m., accompanied by AD, AD stated the grievance binder with information's and copies of forms for completion of written grievances was not in the designated location. AD said she will look for the grievance binder. Further review of resident group meeting minutes for August, September and October 2023 on 11/29/23 at 10:44 a.m., in the presence of AD did not indicate that grievance procedure was reviewed with residents during monthly resident group meetings. Review of facility's policy and procedure titled, Resident Concern/Grievance Program, updated 12/17/06, indicated; The resident concern/grievance program is intended to reflect the facility policy which acknowledges the right of residents to voice concerns and the expectation of prompt effects by facility to resolve them. This program is supported by the Resident Council. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 5 of 38 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 12/01/2023 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that missing property for one of one sampled resident (Resident 24) was accounted for and addressed. Residents Affected - Few This failure placed Resident 24 at risk for psychosocial stress and feeling vulnerable. Findings: During an interview on 11/27/23 at 9:24 a.m., Resident 24 stated she noticed her bank card was missing from her bedside tray table at 8:00 a.m., and notified the Licensed Vocational Nurse (LVN 4) and was told the card was not found in the room. Resident 24 further stated, I do not have the bank phone number or a phone. I am not sure what to do now. During an interview on 11/27/23 at 09:50 a.m., the Director of Nursing (DON) stated she was not aware of any reports of Resident 24's missing bank card. During an interview on 11/27/23 at 11:14 a.m., LVN 4 stated Resident 24 informed her of the missing bank card and a search was conducted of Resident 24's room. Resident 24 was provided a phone to call her responsible party. During a concurrent interview and record review on 11/29/23 at 11:16 a.m., with DON. The progress notes in the electronic healthcare record (EHR) for Resident 24 was reviewed. DON stated she found it concerning that staff did not inform her and document Resident 24's complaint and missing property. DON confirmed a thorough investigation was not completed for Resident 24's missing bank card. During a concurrent interview and record review on 11/29/23 at 12:18 p.m., with LVN 3, Resident 24's Inventory of Personal Effects, dated 8/31/22 was reviewed. LVN 3 stated the Inventory of Personal Effects list did not list a bank card. LVN3 stated she was not aware of resident 24's report of missing a bank card, I was not informed of this by anyone. LVN3 stated the Inventory of Personal Effects is to be completed on admission and should be updated as items are brought in for the resident. LVN3 verified the list was not updated, I have never seen the list updated as items are brought in for the residents. During an interview on 11/29/23 at 1:10 p.m., with Administrator (Admin), Admin stated he was not aware of resident 24's missing the bank card until notified by the surveyor this morning. Admin stated he was not aware of the facility staff being aware of resident 24's reports of the lost bank card. During an interview on 11/29/23 at 1:21 p.m., resident 24 stated losing the bank card, and not getting any help from the facility made her feel not good. During an interview on 11/29/23 at 1:49 p.m., Admin stated the facility policy for reports of lost items are to be investigated immediately, and a resolution must be completed within seven days. Admin stated the facility did not investigate resident 24's report of lost bank card immediately. During an interview on 11/30/23 at 10:23 a.m., LVN4 stated she did not document resident 24's report of lost bank card in the EHR. LVN4 stated she was not aware of the policy and procedure when residents report lost item. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 6 of 38 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 12/01/2023 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 11/30/23 at 10:28 a.m., with Director of Staff Development (DSD), the Staff in-service training records and acknowledgement of facilities polices for LVN3 was reviewed. DSD stated LVN3 attended and signed in staff in-services held on 06/19/23 and 08/14/23,, the topic of both these in-services were Abuse and staff's responsibility of notifying the appropriate authority, when it comes to abuse, resident to resident, verbal, physical, financial, isolation, or any other type of abuse. DSD stated LVN3 has also signed an acknowledgment of being informed of the Theft and Loss policy on 6/28/23 and agreed to participate in a facility search to locate any lost items of a resident. DSD stated, it's important to search for resident's lost property immediately to help locate items, and it's the policy. During a review of facility policy and procedure, titled Lost and Found dated January 2008, indicated, Our facility shall assist all personnel and residents in safe-guarding their personal property .6. Resident or family complaints of missing items must be reported to the Director of Nursing. 7. Lost and found records will be maintained for one (1) year, then destroyed. 8. Reports of misappropriation or mistreatment of resident property are immediately investigated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 7 of 38 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 12/01/2023 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a comprehensive Minimum Data Set assessment (MDS, an assessment tool used to direct resident care) for one (Resident 249) sampled resident as required within 14 calendar days after admission. This failure had the potential to result in no assessment of the residents' needs, strengths, and goals of care. Findings: Review of Resident 249's MDS assessment indicated Resident 249 was admitted on [DATE]. Resident 58's admission comprehensive assessment with the Assessment Reference Date (ARD) dated 11/1/2023 was completed on 11/15/2023. The ARD is the last day of the observation period the assessment covers for the resident. During an interview on 12/01/23 at 10:22 a.m., Registered Nurse/MDS Resource (MDS RN), MDS RN stated Resident 249's admission MDS assessment was completed late because of staffing issues. MDS RN stated the facility had no MDS coordinator. Review of the Long -Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 19, indicated the admission (Comprehensive) assessment must be completed by the 14th day of the resident's stay. Annual reassessment (Comprehensive) must be completed within 366 days of the most recent comprehensive assessment. [Reference:https://downloads.cms.gov/files] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 8 of 38 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 12/01/2023 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, the facility failed to follow federal requirements to submit Quarterly Minimum Data Set (MDS, an assessment tool used to guide care) assessment for one of 14 sampled residents (Resident 28) within 14 days after its completion. Residents Affected - Few The failure resulted in late submission of Resident 28's quarterly MDS assessment. Findings: During a record review of the admission Record dated 11/29/23, the record indicated Resident 28 was admitted to the facility 06/01/20. During a concurrent phone interview and record review on 11/29/23 at 03:25 p.m. with MDS Resource Registered Nurse (MDS RN), Resident 28's quarterly MDS assessment dated [DATE] was reviewed. MDS RN stated the assessment was completed on 11/03/23. The MDS RN stated she worked remotely and was dependent on input and assessments from different disciplines at the facility, including the Director of Nursing and Social Services. MDS RN further stated a quarterly MDS assessment should be submitted within 14 days of its completion, indicating Resident 28's quarterly MDS assessment should have been submitted by 11/16/23. MDS RN also stated the facility was late in completing and submitting the MDS assessments lately. During a review of MDS 3.0 Final Validation Report dated 11/27/23, the report showed Resident 28's MDS dated [DATE] was submitted to CMS on 11/27/23, indicating it was 11 days late. During a review of the facility's policy and procedure titled, MDS Completion and Submission Timeframes, dated July 2017 indicated, (2) Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Review of Resident Assessment Instrument Manual dated 10/2019, page 2-17, indicated Quarterly MDS assessment should be transmitted no later than MDS completion date + 14 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 9 of 38 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 12/01/2023 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 0641 Ensure each resident receives an accurate assessment. 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 the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate for two ( Residents 5 and 6) of two sampled residents when; Residents Affected - Few -MDS section G did not reflect Resident 5's contractures (fixed tightening of muscle, tendons, ligaments, or skin. It prevents normal movement of the associated body part) to lower extremities (hip, knee, ankle, foot) and limitation in range of motion. -MDS section G did not reflect Resident's 6 contractures to upper extremities (shoulder, elbow, wrist and hand). These failure had the potential for residents to not receive appropriate care and services. Findings: Review of the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included unspecified osteoarthritis (the wearing down of the protective tissue at the ends of bones cartilage occurs gradually and worsens over time). Review of the MDS dated [DATE], Section G indicated Resident 5 had no limitation in range of motion to upper and lower extremities. During an observation on 11/28/23 at 9:10 a.m., Resident 5 laid in bed awake and verbally responsive. Resident 5 had contractures to the lower extremities. During an interview on 11/29/23 01:38 p.m., the certified nursing assistant 1 (CNA 1) stated she was a regular care giver for Resident 5 that had contractures to both legs. CNA 1 further stated Resident 5 had always been contracted since she started to work at the facility over a year ago. During an interview on 11/29/23 at 1:56 p.m., with Licensed Vocational Nurse (LVN 4), LVN 4 stated over a year and half ago Resident 5 refused to get out off bed and developed contractures. During an interview on 11/29/23 at 3:37 p.m., Registered Nurse/MDS Resource (MDS RN), MDSRN stated the facility did not have an MDS coordinator and it's hard to find an MDS coordinator for the facility. MDSRN further stated residents MDS are completed remotely with assistance from facility staff. MDSRN stated the facility MDS coordinator that completed Resident 5's section G no longer works at the facility. 2.During a review of Resident 6's admission Record printed on 11/28/23, the record indicated Resident 6 was admitted to the facility on [DATE]. During a record Review of the quarterly Minimum Data Set (MDS-an assessment used to guide care) dated 04/17/23, and printed on 11/29/23, the assessment showed Resident 6 had No Impairment in Upper extremity (shoulder, elbow, wrist, hand). During a record Review of the quarterly Minimum Data Set (MDS-an assessment used to guide care) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 10 of 38 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 12/01/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 07/07/23, and printed on 11/29/23, the assessment showed Resident 6 had No Impairment in Upper extremity (shoulder, elbow, wrist, hand). During a concurrent interview and record review on 11/30/23, at 10:45 a.m., with Director Of Nursing (DO) the MDS 3.0 Section G - Function Status for resdient 6 was reviewed. DON stated the assessment documented was wrong, she is contracted, and does not have any upper body strength. During a concurrent interview and record review on 11/30/23, at 10:51 a.m., with Licensed Vocational Nurse (LVN 3), the MDS 3.0 Section G - Function Status for resident 6 was reviewed. LVN 3 stated resident 6 had upper and lower extremity contracture, The MDS assessment documented was wrong, resident 6 is fully contracted, and does not have any upper body strength. The MDS nurse works remotely and, in my opinion, the MDS nurse must be here in-person to see the resident to correctly perform the assessments. During a telephone interview on 11/29/23 at 3:35 p.m., with Minimum Data Set Registered Nurse (MDS RN), MDS RN stated she was based remotely and had not conducted an in-person face to face assessment of residents, including resident 6. Review of facility's policy and procedure, titled Certifying Accuracy of the Resident Assessment, revised November 2019, indicated; any person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 11 of 38 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 12/01/2023 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 Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a person-centered care plan for one of 14 sampled residents (Resident 38). Resident 38 did not have an individualized plan of care for her new diagnosis of Schizophrenia (a mental disorder usually exhibited with delusions - false beliefs, hallucinations - seeing or hearing things that don't exist), and new use of Seroquel (antipsychotic for Schizophrenia) medication. This failure placed Resident 38 at risk and not receive individualized care for her clinical condition. (Cross Reference F758) Findings: During a record review of the admission Record dated 11/29/23, which indicated Resident 38 was admitted to the facility 07/11/23. During an observation and interview on 11/27/23 at 9:43 a.m., Resident 38 was standing at the door of her room and was pleasantly confused at the time. During a record review of Resident 38's Minimum Data Set (MDS, an assessment used to guide plan of care) assessment dated [DATE], the Brief Interview for Mental Status (BIMS) score was 5 out 15, indicating severely impaired mental status. The assessment also showed Resident 38 had a diagnosis of non-Alzheimer's Dementia (changes in the brain that affect memory and the ability to perform daily abilities). During a concurrent interview and record review with Director of Nursing (DON), on 11/28/23 at 2:56 p.m., Resident 38's Electronic Health Record (EHR) was reviewed. DON stated on 11/10/23, a psych (psychiatric) nurse was visiting the facility to assess residents with mental issues. DON further stated the icensed staff (unable to state who) approached the psych nurse to assess Resident 38. DON also stated the psyche nurse had the psychiatrist assess Resident 38 via video call and prescribed Seroquel for Resident 38. During a concurrent interview and record review with Director of Nursing (DON), on 11/30/23 at 3:55 p.m., Resident 38's Electronic Health Record (EHR) was reviewed. DON stated on 7/13/23, Resident 38 was prescribed Zyprexa (antipsychotic for schizophrenia) 5 milligrams (mg), to give 0.5 tablet for agitation every eight hours for 14 days. DON stated the Zyprexa order was discontinued on 7/27/23 and Resident 38 received Zyprexa on four different occasions during that 14 day period. DON further stated she was unable to find any documentation whether licensed nurses were monitoring for Zyprexa side effects and monitoring and documenting behaviors related to Zyprexa use. During a concurrent interview and record review with DON, on 11/28/23 at 2:56 p.m., Resident 38's EHR was reviewed. DON stated on 11/10/23, the psychiatrist prescribed one half tablet of 25 mg (12.5 mg) Seroquel in the morning and one tablet of 25 mg Seroquel in the evening for a new diagnosis of Schizophrenia. DON stated the Medication Administration Record dated 11/2023 indicated Resident 38 was receiving the medication everyday twice a day since 11/10/23. DON further stated she was unable to find any documentation that staff monitored and documented behavior manifestations related to the use of Seroquel or had a care plan related to the new diagnosis of Schizophrenia and use of Seroquel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 12 of 38 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 12/01/2023 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete since 11/10/23 and Zyprexa 7/2023. DON also stated the care plan was important to see if the treatments were effective. During a review of the facility's policy and procedures (P&P), Care Planning-Interdisciplinary Team, dated 3/22 indicated, Comprehensive, person-centered care plans are based on resident assessments and developed by an Interdisciplinary Team. Event ID: Facility ID: 555292 If continuation sheet Page 13 of 38 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 12/01/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review and revise one of one sampled resident (Resident 6), the Activities of Daily Living (ADL) care plan for almost seven years. This failure placed Resident 29 at risk for impaired psychosocial and physical well-being. Findings: During a record review of Resident 6's admission Record dated 11/28/23, the record indicated that Resident 6 was admitted to the facility on [DATE]. During a concurrent observation and interview with Licensed Vocational Nurse (LVN 3), on 11/29/23 at 8:46 a.m., Resident 6 was sleeping in bed. LVN 3 stated Resident 6 has been out of bed in a chair for the past few days and is usually up in a chair on weekends. LVN 3 was not aware if Resident 6 was turned every two hours by the Certified Nursing Assistant (CNA). LVN 3 stated resident 6 requires total care for ADLs and contracted in her upper and lower extremities. During a concurrent observation and interview with Certified Nursing Assistant (CNA 3), on 11/29/23 at 09:41 a.m., CNA 3 stated she receives report from the licensed nurse at the beginning of the shift about which residents need to be gotten out of bed. CNA 3 stated Resident 6 is total care for ADLs and has no strength in her upper or lower extremities. During a concurrent interview and record review with LVN 4, on 11/30 at 10:47 a.m., the care plan for Resident 6 was reviewed. LVN 4 stated the care plan for Physical Mobility and ADL self-care incorrectly indicated Resident 6 is able to: Propel self around in wheelchair and uses ½ side rails as an enabler to assist with turning, positioning and safety consent given verbally. LVN 4 further stated the care plan was not updated since 2017, and has never seen Resident [6] self-propel in a wheelchair or assist with her ADLs. During a review of facility's policy and procedures (P&P) titled, Care Planning - Interdisciplinary Team dated March 2022, indicated the Interdisciplinary Team is responsible for the development of resident care plans .2. Comprehensive, person-centered care plans are based on resident assessments .6. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 14 of 38 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 12/01/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a shower for two of two sampled Residents (Residents 18 and 298) accoridng to the shower schedule. Residents Affected - Few The failure resulted in Resident 298 not feeling important and placed Resident 18 and Resident 298 at risk for compromised hygiene and at risk for infections. Findings: 1.During a record review of Resident 18's undated face sheet,Resident 18 was admitted to the facility on [DATE]. During a record review of Resident 18's Minimum Data Sheet (MDS- an assessment used to guide plan of care) dated 10/18/23, indicated Resident 18 required one staff assistance for bathing. During a record review of Resident 18's Activities of Daily Living (ADL) Care Plan, dated 07/13/21, which indicated Resident 18 has an ADL self-care performance deficit and limited mobility. Resident 18 is totally dependent on 1 staff to provide bath/shower as necessary. During an observation on 11/27/23 at 9:31 a.m., Resident 18 was lying in bed wearing a hospital gown and awake, but did not respond to questions. During a phone interview on 11/28/23 at 1:56 p.m. with Resident 18's Family Representative (FR) 1, FR 1 stated they visited Resident 18 at least four-five times a week. FR 1 stated Resident 18's memory was not 100%. FR 1 inquired to staff about Resident 18's showers and was told they were short staffed. FR 1 could tell that the staff did not provide a shower to Resident 18. During an interview on 11/30/23 at 04:41 p.m., CNA 3 stated Resident 18 required one staff assistance with shower. During a concurrent interview and record review on 11/29/23 at 08:59 a.m., at the nursing station, with Certified Nursing Assistant (CNA) 2, a blue binder labeled, Shower and Skin Record was reviewed. CNA 2 stated the Skin Observation & Bathing Sheet were completed every time a resident received a shower and documented in the Electronic Health Record (EHR). CNA 2 stated Resident 18's shower days were Mondays and Thursdays. CNA 2 stated she was unable to find the shower sheets record for Resident 18. During a concurrent interview and record review on 12/01/23 at 10:04 a.m., with Infection Preventionist (IP) 1, Resident 18's EHR ADL documentation sheet dated 11/2023 was reviewed. IP 1 stated she was unable to find documentation for Resident 18 if she received a shower on 11/23/23. IP 1 stated it was important for residents to receive showers for hygiene and to prevent infection. 2. During a record review of Resident 298's undated face sheet, Resident 298 was admitted to the facility on [DATE]. During a record review of Resident 298's MDS dated [DATE], indicated Resident 298's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating intact mental status. The assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 15 of 38 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 12/01/2023 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 0677 showed Resident 298 required one staff assistance for bathing. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/30/23 at 04:41 p.m. Certified Nursing Assistant (CNA) 3 stated Resident 298 required one staff assistance with shower. Residents Affected - Few During a concurrent observation and interview on 11/27/23 at 09:41 a.m., Resident 298 was lying in bed. Resident 298 stated she was admitted to the facility three weeks ago and has been requesting staff to assist her with showers. Resident 298 stated she felt like she had no shower for three weeks nor bed or sponge bath and it made her feel like, I'm not important. Resident 298 stated staff told her they were busy, and/or it was not her scheduled shower day. During a concurrent interview and record review on 11/30/23 at 01:26 p.m. with IP 1, the Shower and Skin Record binder was reviewed. There were no Skin Observation & Bathing Sheet for Resident 298 in the binder. IP 1 stated Resident 298 did not receive a shower or refuse one. During a review of the undated Shower Schedule record, the Shower Schedule record indicated, Resident 298's shower days were Tuesdays and Fridays. During a concurrent interview and record review on 12/01/23 at 10:04 a.m., with IP 1, Resident 298's EHR ADL documentation sheet dated 11/2023 was reviewed. IP 1 stated Resident 298 did not receive nor refused shower on 11/24/23. During a record review of the undated ADL Policy indicated, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 16 of 38 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 12/01/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to follow safe pharmacy services when the following were noted: Residents Affected - Some 1. Facility did not have morning medications readily available for administration for two of two sampled residents (Resident 22 and Resident 11). Resident 22 did not receive antidepressant medication. Resident 11 did not receive anticoagulant (used to prevent blood clots) as prescribed by the physician. (Cross reference F 759). 2. Facility did not maintain accounting records for controlled medications (medications with potential for abuse) for an active resident (Resident 19) and a discharged resident (Resident 299). These failures resulted in Resident 22 and Resident 11 to receive medications that were not accordng to physician orders and had the potential for drug diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use). Findings: During a concurrent interview and record review on 11/28/23 at 8:22 a.m., with Licensed Vocational Nurse (LVN 3), Resident 22's medication orders were reviewed. LVN 3 stated Resident 22 was to receive 60 milligrams (mg) of Fluoxetine (Prozac-antidepressant) in the morning. During a concurrent observation and interview on 11/28/23 at 8:24 a.m., LVN 3 searched North hall medication cart and stated she only had 40 mg of Fluoxetine capsule and Fluoxetine 20 mg capsule medication was not available (to administer total of 60 mg) for Resident 22. LVN 3 stated she had called the pharmacy to re-order Fluoxetine 20 mg on 11/17/23. LVN 3 further stated she was not sure how other nurses were administering the correct dose all this time. LVN 3 then administered Fluoxetine 40 mg to Resident 22. During an interview on 11/28/23 at 9:37 a.m., LVN 3 stated she checked the facility's emergency medication supply and Fluoxetine 20 mg was not available in the facility. During an Electronic Health Record (EHR) review of Resident 11's physician orders for 11/2023, which indicated to administer one tablet of Apixaban (anticoagulant or blood thinner) 5 mg via G-tube (gastrostomy tube inserted into the stomach to provide nutrition and medications), two times a day to prevent blood clots and give 5 ml (milliter) of Ferrous Sulfate Syrup (iron) 300 (60 Fe) mg/5ml via G-tube, one time a day for supplement. During a concurrent medication administration observation and interview on 11/28/2023 at 9:41a.m., LVN 1 did not administer Resident 11's Apixaban 5mg tablet and Ferrous Sulfate Syrup medication. LVN 1 stated medications were not available in the South Hall medication cart or in the facility. During a concurrent observation and interview on 11/28/23 at 3:30 p.m., with LVN 5, Resident 11's bottle of Apixaban 5 mg was in the top right drawer of the South Hall medication cart. LVN 5 stated Liquid Iron was not in the medication cart. During a concurrent observation and interview on 11/28/23 at 3:40 p.m., LVN 7 stated Liquid Iron (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 17 of 38 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 12/01/2023 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 0755 was not in the medication cart. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 11/28/23 at 3:52 p.m., with Director of Nursing (DON), DON stated Liquid Iron supply was not available in the OTC cabinet in the medication room and Coordinator (SC 1) was responsible for ordering OTC supply. Residents Affected - Some During a concurrent interview and record review on 11/28/23 at 4:13p.m., with SC 1, OTC delivery receipt form for the month of 10/2023 and 11/2023 were reviewed. The record indicated Liquid Iron was not ordered during that period. SC 1 stated they did not have Liquid Iron in the facility. 2. During a record review of the face sheet indicated Resident 299 was discharged on 8/10/23. During a concurrent observation and interview on 11/29/23 at 10:04 a.m., with DON, 30 capsules of Marinol (cannabinoid) 2.5 mg in a bubble pack was in the refrigerator for Resident 299. DON stated Resident 299 was discharged and controlled medications for discharged residents should be in a locked cabinet in her office. During a phone interview on 12/01/23 at 8:51a.m., with Pharmacy Consultant (PC 1), PC 1 stated Marinol was considered a controlled substance and must be given to DON once the resident is discharged . During a concurrent interview and record review on 11/29/23 at 10:52 a.m., with DON, a black safe box was at the corner of DON's office. DON stated all discontinued narcotic and controlled medications were stored in that box. The box had Resident 19's Oxycodone-Acetaminophen 10/325mg bottle medications in a sealed white plastic bag without a count/accounting sheet. During a phone interview with PC 1 on 12/1/23 at 8:51 a.m., PC 1 stated all controlled medications should be accounted for and a log should be created even for medications not coming from facility's contracted pharmacy. Record review of the facility's policy and procedure titled, Controlled Substances indicated, 13. Controlled Substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed and 14. Accountability records for discontinued controlled substances are kept with the unusual supply until it is destroyed or disposed of as required by applicable law or regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 18 of 38 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 12/01/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure two (Resident 19 and 38) of five sampled residents were free from unnecessary drugs when - Resident 19 was administered Zyprexa (antipsychotic) medication for yelling and verbally abusive behavior. - Resident 38 was administered an antipsychotic medication without adequate behavior and adverse medication side effect monitoring. These failures had the potential for residents to receive unnecessary drugs and to suffer adverse medication side effects. Findings: Review of admission Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 5/30/23, indicated Resident 19's Basic Interview of Mental status (BIMS) score was 12 (meaning moderately impaired cognition). Resident 19 was oriented to correct year and day of the week. Resident 19 had clear speech, makes self understood and understand others. Resident 19 had no potential indicators of psychosis ( a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). Resident 19 exhibited no physical, verbal or other behavioral symptoms directed towards others, such as hitting or scratching and screaming. Resident 19's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). Review of care plan initiated 5/24/23, indicated Resident 19 was an elopement risk/wanderer related to decreased cognition, thought process, and safety awareness. Review of the order summary report dated 9/22/23 indicated the physician prescribed Resident 19 Zyprexa 2.5 mg, one tablet by mouth once a day for psychotic disorder manifested by yelling and verbally abusive behavior. According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa can increase the risk of death in elderly people who have memory loss and is not approved for use in psychotic conditions related to dementia. [Reference: https://www.[NAME].comp]. Review of the Medication Administration Record (MAR), dated 11/1/2023 through 11/30/2023, indicated Resident 19 was administered Zyprexa 2.5 mg by mouth once a day for yelling and verbally abusive behavior. During an interview on 11/28/23 at 11:08 a.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated, Resident 19 was pleasant had no yelling or verbally abusive behavioral problems. CNA 1 said Resident 19 liked to go out to smoke, and Resident 19's daughter visited and brought Resident 19 cigarettes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 19 of 38 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 12/01/2023 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 During an interview on 11/29/23 at 9:15 a.m., with Director of Nursing (DON), DON stated, Resident 19 was administered Zyprexa for verbally abusive behavior and combativeness when she made attempts at leaving the facility. During an interview on 11/29/23 at 9:29 a.m., Licensed Vocational Nurse (LVN 4) stated, Resident 19 was redirectable when she asked to go home. During an interview on 12/01/23 at 9:04 a.m., the Pharmacist Consultant (PC 1), PC 1 stated, yelling and verbally abusive behavior were not appropriate indications for the use of Zyprexa. PC 1 further stated the use of antipsychotic medication for residents with dementia had increased risk of death. 2. During a record review of the admission Record dated 11/29/2023, the record indicated Resident 38 was admitted to the facility on [DATE]. During a record review of Resident 38's Minimum Data Set (MDS), an assessment used to guide plan of care) assessment dated [DATE], Brief Interview for Mental Status (BIMS) score was 5 out 15, indicating severely impaired mental status. Resident 38 had a diagnosis of non-Alzheimer's Dementia (a general term referring to changes in the brain that affect memory and the ability to perform daily abilities). The assessment also showed Resident 38 received antipsychotic medication as needed since her admission to the facility. During an observation and interview on 11/27/23 at 9:43 a.m., Resident 38 was standing at the door of her room and was pleasantly confused at that time. During an interview with Resident 38's Certified Nursing Assistant (CNA 4), on 12/1/23 at 8:20 a.m., CNA 4 stated Resident 38 exhibited behaviors like yelling, verbally abusive and wandering into other residents' room, but was easily re-directable. CNA 4 also stated at times Resident 38 asked her to get her car. CNA 4 stated she did not hear about any other behaviors exhibited by Resident 38. During an interview with Resident 38's night shift Registered Nurse (RN 2), on 12/1/23 at 7:27 a.m., RN 2 stated Resident 38 was very confused and hard to redirect when she was newly admitted to the facility. RN 2 further stated Resident 38 often looked for her car and was not combative during her shift. During a concurrent interview and record review with DON, on 11/28/23 at 2:56 p.m., Resident 38's EHR was reviewed. DON stated, since Resident 38 was admitted to the facility, she had behaviors of wanting to go home, and not wanting to participate in activities. DON stated, the facility staff attempted to re-orient Resident 38, but she continued to exhibit the behavior of wanting to go home. DON stated, on 11/10/23, a psyche nurse was visiting the facility. DON also stated the Psyche nurse had the Psychiatrist assess Resident 38 via video call and prescribed Seroquel for Resident 38. During a concurrent interview and record review with DON, on 11/30/23 at 3:55 p.m., Resident 38's EHR was reviewed. DON stated, on 7/13/23, Resident 38 was prescribed Zyprexa 5 mg to give 0.5 tablet for agitation every eight hours for 14 days. DON stated the Zyprexa order was discontinued on 7/27/23, and Resident 38 received Zyprexa on four different occasions during those 14 days. DON stated she was not sure if agitation is an appropriate indication for use of Zyprexa. DON was unable to find (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 20 of 38 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 12/01/2023 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 any documentation that licensed nurses were monitoring Zyprexa side effects or documenting behaviors. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with DON, on 11/30/23 at 4:05 p.m., Resident 38's EHR was reviewed. On 11/10/23, the physician prescribed one half tablet of 25 mg Seroquel in the morning and one tablet of 25 mg Seroquel in the evening for a new diagnosis of Schizophrenia. DON stated Resident 38 was receiving the medication everyday, twice a day since 11/10/23. DON was unable to find any documentation if staff monitored/documented behavior manifestations related to use of Seroquel. Residents Affected - Some During an interview and record review with DON on 11/28/23 at 02:56 p.m., Resident 38's nursing progress notes from 10/30/23 till 11/28/23 was reviewed. Resident 38 was agitated, verbally abusive, confused on two days on 10/30/23 and 11/6/23. DON stated she was unable to find any documentation the facility attempted to try non-pharmacological interventions to manage Resident 38's behaviors during 10/2023 and 11/2023, prior to starting her Seroquel medication. During a phone interview with Resident 38's medical doctor (MD 1) and concurrent interview and record review, on 11/30/23 at 3:55 p.m., in the presence of DON, MD 1 stated she was notified that Resident 38 had behaviors of elopement and hitting staff. MD 1 stated she was aware the Psychiatrist prescribed Seroquel for Schizophrenia manifested by disorganized thinking for Resident 38, however did not know if disorganized thinking was an appropriate indication for Schizophrenia and use of Seroquel. During an interview with DON on 11/30/23 at 4:15 p.m., DON stated the Psychiatrist only emailed her the orders for Seroquel on 11/10/23. DON stated, there was no IDT discussion of risks and benefits of Seroquel and/or a new diagnosis of Schizophrenia manifested by disorganized thinking. The Psychiatrist was unavailable for interview during the survey. During an interview on 12/01/2023 at 08:48 a.m. with PC 1, PC 1 stated, she did not think agitation was an approved indication for the use of antipsychotic medications. PC 1 stated a person needs a prior diagnosis and repeated behavior patterns to diagnose someone with Schizophrenia. PC 1 stated she expected the facility to monitor and be documenting behavior manifestations in Resident 38's clinical record. During a review of policy and procedure (P&P) titled, Antipsychotic Medication Use, dated July,2022 which indicated #17- staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications; #18-nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician . During a of P&P titled, Behavioral Assessment, Intervention and Monitoring, dated March 2019, when medications are prescribed for behavioral symptoms, documentation will include: (a) rationale for use, (b) potential underlying causes of the behavior, (c) other approaches and interventions tried prior to use of antipsychotics medications, (d) potential risks and benefits of medications as discussed with resident, (f) dosage, (g) duration and (h) monitoring for efficacy and adverse consequences. Review of the P&P, titled, Antipsychotic Medication Use, revised July 2022, indicated Residents will not receive medications that are not clinically indicated to treat a specific condition. Diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 21 of 38 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 12/01/2023 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 alone do not warrant the use of antipsychotic medication. Level of Harm - Minimal harm or potential for actual harm Antipsychotic medications will not be used if the only symptoms are one or more of the following; wandering, restlessness, impaired memory, inattention or indifference to surroundings, nervousness, uncooperativeness . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 22 of 38 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 12/01/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure three of six sampled residents for medication administration observation (Residents 200, 11, and 5) received medications per the physician's orders. Residents Affected - Some This failure resulted in a 13.16% medication error rate and Resident 200, 11 and 5 to not receive prescribed medications as ordered. Findings: During a medication administration observation, on 11/28/2023 at 8:07 a.m., Licensed Vocational Nurse (LVN) 3 administered Ventolin HFA (bronchodialator) 90 microgram (mcg) inhaler treatment to Resident 200. LVN 3 did not document the administration in Resident's 200's Medication Administration Record (MAR). During a concurrent interview and record review on 11/28/23 at 12:50 p.m. with LVN 3, the Electronic Health Record (EHR) for Resident 200's MAR dated 11/28/23 was reviewed. LVN 3 stated the record indicated she did not document Ventolin HFA 90 mcg inhaler administration for Resident 200 at the time of administration that day. During medication administration observation on 11/28/2023 at 8:47a.m., LVN 3 administered one tablet of Aspirin 81 mg (milligram) and one tablet of Vitamin D 10 microgram (mcg) to Resident 5. During a concurrent interview and record review on 11/28/23 at 12:55 p.m., Resident 5's EHR was reviewed. LVN 3 stated the physician orders showed to administer two tablets of Aspirin 81 mg and one tablet of Vitamin D3 1000 IU (international units) once a day. LVN 3 stated Resident 5 did not like two tablets of Aspirin to be taken together, and she gave the 1 tablet earlier at 7:30 a.m. LVN 3 stated she did not document the early administration of one tablet of Aspirin in Resident 5's MAR. LVN 3 also stated she was unable to find any care plan regarding Resident 5's choice to not take two tablets of Aspirin together at 9:00 a.m. LVN 3 stated she was aware that medication administration should be documented immediately after it has been done. During a concurrent observation and interview on 11/28/23 at 12:55 p.m. with LVN 3, North Hall medication cart was observed. LVN 3 stated she had two different types of Vitamin D in the cart, she did not look closely and missed getting the right medication for Resident 5 that day. During an EHR review of Resident 11's physician orders for 11/2023, the order indicated to administer one tablet of Apixaban (anticoagulant or blood thinner) 5 mg via G-tube (a tube inserted in the stomach to provide nutrition and medications) two times a day to prevent blood clots; and to give 5 ml (milliter) of Ferrous Sulfate Syrup (iron) 300 (60 Fe) mg/5ml via G-tube one time a day for supplement. During a concurrent medication administration observation and interview, on 11/28/2023 at 09:41a.m., LVN 1 did not administer Resident 11's Apixaban 5mg tablet and Ferrous Sulfate Syrup/Liquid Iron medication. LVN 1 stated the medications were not available in the South Hall medication cart or in the facility. During a concurrent observation and interview on 11/28/23 at 3:30p.m., with LVN 5, Resident 11's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 23 of 38 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 12/01/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Apixaban 5mg bottle of medication was in the top right drawer of the South Hall medication cart. LVN 5 stated Liquid Iron was not in the medication cart and it should be in the over the counter (OTC) supply cabinet in the medication storage room. During a concurrent observation and interview on 11/28/23 at 3:40 p.m., LVN 7 did not find Liquid Iron in the North Hall medication cart. During a concurrent observation and interview on 11/28/23 at 3:52p.m., with Director of Nursing (DON), DON stated Liquid Iron supply was not available in the OTC cabinet in the medication room. DON stated Staffing Coordinator (SC 1) was responsible for ordering OTC supply. During a concurrent interview and record review on 11/28/23 at 4:13p.m. with SC 1, the OTC delivery receipt form for 10/2023 and 11/2023 were reviewed. The record indicated Liquid Iron was not ordered. SC 1 stated they did not have Liquid Iron in the facility. During a concurrent interview and record review on 11/28/23 at 3:52p.m. with DON, Resident 11's MAR and nursing progress notes dated 11/28/23 were reviewed. DON stated the record indicated Apixaban and Liquid Iron medication were not administered on 11/28/23. DON also stated that administered medication should be documented right away and given on time. During an interview on 11/29/23 at 8:52 a.m. with LVN 1, LVN 1 stated she did not notify Resident 11's doctor that she did not administer Apixaban and liquid iron supplement to Resident 11 on 11/28/23. During an interview with DON on 12/1/23 at 9:47 a.m. DON stated nurses were expected to administer the correct medications and follow five rights (right dose, right time, right medication, right route, and right resident) of medication administration. DON stated if nurses did not follow this, they were endangering residents' life. DON stated nurses should administer correct medication even if it was a supplement only. During a review of the undated facility's policy and procedure titled, Medication Administration (Orals) and Documentation of Medication Administration indicated, 7.5-7. Pour the correct number of tablets into the medication cup; 1. A nurse or certified medication aide (where applicable) documents all medication administered to each resident on the resident's medication administration record (MAR); 2. Administration of medication is documented immediately after it is given; 3.f. Document reason(s) why a medication was withheld, not administered, or refused (as applicable). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 24 of 38 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 12/01/2023 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 - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to store medications appropriately when the following were noted: 1. Resident 5's Lotemax eye drops bottle was not labeled with open date. 2. Facility did not dispose or destroy medications for discharged residents and/or expired 11 of 11 sampled residents (Residents 37, 40, 33, 20, 301, 302, 303, 32, 99, 21, 304). 3. Facility did not dispose of expired over the counter (OTC) medications and stored open bottles of OTC medications mixed with ready-to-use medication in the medication storage room. 4. Facility did not monitor and maintain a temperature log for medication storage room for September, October, and November of 2023. These failures had the potential to result in unsafe medication administration and storage practices. Findings: 1. During medication administration observation on 11/28/23 at 09:05 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 5's Lotemax 0.5% eye drop (steroid medication used for swelling) was without an open date on the bottle or the box. LVN 3 stated the medication label indicated the pharmacy delivered the medication on 6/13/23. During a phone interview on 12/01/23 at 8:51a.m., with Pharmacy Consultant (PC) 1, PC 1 stated everything must have an open date including the eye drops, and the open bottle of eye drops should be disposed of after 30 days. 2.During a concurrent observation and interview on 11/29/23 at 10:04 a.m. with the Director of Nursing (DON) in the medication room,showed the following medications stored inside a clear plastic storage container: Resident 37's Humalog insulin (used to manage blood sugar levels) vial, two bottles of Amantadine (treats Parkinson's disease, commonly known as shaking palsy) 50 milligrams (mg)/5 milliliters (ml), one Heparin (blood thinner) 50,000 unit/10 ml vial, Amlodipine (used for high blood pressure) 5mg tab bubble pack; Resident 40's one bottle of Lactulose (laxative) 10mg/15ml; Resident 33' 9 patches of Lidocaine (anesthetic) 5%; Resident 20's five Carbidopa-Levo ER (treats Parkinson's disease) 25-100 mg tab bubble pack and Quetiapine (psychotropic) medication commonly used to treat mental disorder) 100mg tab bubble pack; Resident 301's three boxes of DuoNeb vial (respiratory treatment); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 25 of 38 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 12/01/2023 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 Resident 302's Humalog 100unit/ml vial; Level of Harm - Minimal harm or potential for actual harm Resident 303's Lantus (long acting insulin) 100unit/ml vial; Residents Affected - Many Resident 32's two bubble packs of Carvedilol (used for heart conditions) 3.125mg tablets, one bubble pack of Ondansetron HCL ( anti nausea and vomiting) 4 mg tablets, one bubble pack of Omeprazole DR (used to treat certain stomach and esophagus problems) 20 mg capsules, and one bubble pack of Atorvastatin (used to lower fat levels in the blood) 80 mg tablets; Resident 99's Valsartan-HCTZ (high blood pressure medication) 80-12.5 mg tab, Flecainide Acetate (used for irregular heartbeats) 100 mg tab, Atorvastatin 40 mg tab, Nitrofurantoin (for urinary tract infection) 100 mg bubble packs; Resident 21's two bubble packs of Sevelamer Carbonate (controls high blood levels of phosphorus in people with chronic kidney disease on dialysis) 800 mg tablets; Resident 304's Hydroxyzine HCL (treats anxiety disorders and allergic conditions) 25 mg, Levofloxacin (antibiotic) 750 mg, Metronidazole (used to treat infections) 500 mg bubble packs; DON stated the above medications belonged to discharged or expired residents and were stored in the medication room for destruction. DON stated some of the discharged /expired residents were gone for over a month. and licensed nurses were supposed to dispose of the medications in a disposal bin kept in the utility room. 3. During a concurrent observation and interview on 11/29/23 at 10:04 a.m. with DON, a gray colored Intravenous supply emergency kit with expiration date 9/2023 and issued on 12/21/2022, including over the counter (OTC) medications mixed with unopened supply were inside a brown cabinet in the medication storage room as follows: One undated open bottle of Vitamin C 500 mg, one undated open bottle of Cranberry 450 mg tablets, four expired bottles of Bisacodyl EC (laxative) 5 mg with expiration date 9/2023; One expired bottle of Mi-Acid Gas Relief ; 80 mg tablets with expiration date 05/2023; two expired bottles of Senna Syrup (relieves constipation) with expiration date 10/2023. DON stated the nurses should keep the opened OTC bottle in the medication cart and should not be stored in the medication room to prevent cross contamination. DON stated expired medications should be disposed of and should not be used for residents. During a review of the facility's undated policy and procedure titled, Storage of Medication indicated, 4. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During a concurrent interview and record review on 11/29/23 at 10:30 a.m., with DON, the Temperature Log for September, October and November 2023 were reviewed. DON stated licensed nurses were expected to check the medication storage refrigerator temperature and document it in the temperature log twice a day. The Temperature Log indicated temperatures were not monitored on 9/27, 10/2, 10/14, 10/26, 11/1, 11/7, 11/12, 11/13 and 11/19/23. During a review of the facility's policy and procedure titled, Cleaning Medication Storage Areas, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 26 of 38 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 12/01/2023 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 dated August 2017 indicated, Check refrigerator's temperature daily and maintain between 38-46 degrees Fahrenheit. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 27 of 38 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 12/01/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents were served palatable food when, Residents Affected - Few 1. The lunch for Resident 17 was not fortified as ordered by the physician. 2. The evening snack of Peanut Butter and Jelly (PB&J) sandwiches were not prepared according to the menu. This deficient practice placed the residents at risk of decreased nutrient intake and bland food, and potential weight for 2 residents who received food from the kitchen out of a census of 44. Findings: 1. During an observation on 11/28/23 at 11:10 a.m., a meal delivery cart holding Resident 17's lunch had a meal ticket (diet order) indicating, Special Diets: Fortified. During a record review of Resident 17's physician diet order, dated 3/23/23, printed on 12/1/23 indicated, Fortified Diet, Pureed texture, Thin Liquids consistency, for chocking on rice, add health shake with meals. During a concurrent observation and interview with Dietary Supervisor (Diet Sup) and Dietary [NAME] (Cook), on 11/28/23 at 12:06 p.m., Resident 17's meal tray was prepared as a puree texture meal. The tray contained pureed baked chicken with rosemary sauce, pureed boiled red potatoes, pureed green beans, and pureed cornbread. [NAME] stated she did not know how to fortify a meal. Diet Sup confirmed the [NAME] did not fortify Resident 17's lunch as ordered by the physician. Diet Sup stated the [NAME] should have added butter to the lunch tray to meet the fortification requirements. During an interview on 11/29/23 at 11:45 a.m., with Registered Dietician (RD), RD stated she was concerned about the kitchen cooks not fortifying the diets as ordered by physicians. They need to know how to fortify a meal because they are the ones preparing the meal, they need more training. 2. During an interview on 11/28/23 at 10:45 a.m., with Resident 3, Resident 3 stated the PB&J sandwiches have a thin layer of PB and the sandwiches are not palatable. During an interview on 11/30/23 at 4:17 p.m., Dietary [NAME] (Cook 1), [NAME] 1 stated he was responsible for making the PB&J sandwiches. [NAME] 1 stated he was not trained to follow a recipe or how to locate the PB&J recipe. [NAME] 1 further stated he made the sandwiches by applying a layer of peanut butter on one loaf of bread and a layer of jelly on the other loaf of bread. During an interview and record review on 11/28/23 at 4:40 p.m., with Diet Sup, the electronic repository of dietary recipes was reviewed for the PB&J sandwiches. Diet Sup stated the PB&J recipe was not available for the kitchen staff in a paper format for easy reference. Diet Sup verified that only she had access to the electronic repository for all recipes. Diet Sup stated, [NAME] 1 should have used the Orchid Scoop (rounded #40 scoop) to scoop up peanut butter for each sandwich. Diet Sup verified each scoop of the Orchid Scoop contained ¾ (three/fourths) of an ounce for each sandwich. Diet Sup stated [NAME] 1 did not use the Orchid Scoop. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 28 of 38 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 12/01/2023 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility provided document, untitled and undated, indicated rounded # 40 Orchid scoop is equivalent to ¾ (three/fourth) of a fluid Ounce. Review of the policy and procedure titled, Fortified Diet dated 2020, indicated The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status .Example of adding calories may include - Extra margarine or butter to food items .Approximate Calories of foods used for Fortifying Diet: Butter, Margarine or Mayonnaise - 1 tsp (teaspoon) = 35 calories . Review of the facility provided document, Recipe: Peanut Butter and Jelly Sandwich Noon & Evening (undated) indicated, Directions: 1. Spread 2 tbsp (rounded # 40 scoop) peanut butter +1-2 Tbsp (#40) jelly per sandwich. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 29 of 38 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 12/01/2023 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and record review, the facility failed to follow their policy for the Use and Storage of Food & beverages Brought in for Resident and provide safe and sanitary storage, handling, and consumption of food brought to residents by family and visitors for two of 44 residents, when: Residents Affected - Many 1.The staff refrigerator contained Resident 198's food that was not dated and stored with other unlabeled and undated staff food. This had the potential for cross contamination. 2. Resident 298 wanted to eat food brought for her birthday and have it for dinner and was told staff could not warm the food and ate cold lobster that was unpalatable. These failures had the potential for food contamination and food borne illness, and food not served at the preferred temperature diminished the enjoyment of the meal. This had the potential to affect other residents receiving food brought from outside sources for storage. Findings: 1. During a concurrent observation and interview on 11/29/23 at 4:22 p.m., with Administrator (Admin), the Staff designated white refrigerator in the Staff Break room had a container with cooked, partially used and undated, liquid food with green vegetable and white meat labeled with Resident 198's name and room number. Admin verified the undated food belonged to Resident 198 and was not supposed to be stored in the staff refrigerator and did not have discard or use-by-date. Admin stated the facility does not have a dedicated refrigerator or microwave designated for resident use to store and heat food brought in by family and visitors. During an interview with the Dietary Supervisor on 11/29/23 at 4:40 p.m., with Dietary Supervisor (Diet Sup), Diet Sup confirmed all food brought from home for staff were stored in the staff refrigerator and heated using the staff's microwave in the breakroom. During an interview on 12/01/23 at 1:27 p.m., with Resident 198, Resident 198 stated the food stored at the facility was wonton soup and brought in by family on 11/21/23. Resident 198 stated the facility had not provided a policy either orally or in writing regarding food brought in family or visitors. During an interview on 12/01/23 at 1:28 p.m., with Resident 298, Resident 298 stated she often has food brought in by family and other visitors and stores the food for her. Resident 298 stated the facility had not shared a policy either orally or in writing regarding food brought in by family and other visitors. 2. During a concurrent observation and interview on 11/27/23 at 09:41 a.m., with Resident 298, Resident 298 stated the facility did not warm the lobster brought from home on her birthday 11/22/23. Resident 298 stated she wanted to eat the lobster for dinner. Resident 298 stated she asked staff to warm it for her but one of the supervisors told the staff they cannot warm the lobster. Resident 298 stated she ate the cold lobster and it tasted nasty and was not the same. During an interview on 12/01/23 at 08:30 a.m. with Certified Nursing Assistant (CNA) 3, assigned to Resident 298 on 11/22/23, CNA 3 stated staff were not allowed to heat up food for Resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 30 of 38 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 12/01/2023 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policy and procedure (P&P) titled, Use and Storage of Food & beverages Brought in for Resident, dated December 2016 indicated, .It is the Policy of this facility to provide a safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors .1. Upon admission resident and families will be given a copy of this policy and offered a handout on safe food handling practices. 2. Food brought in from the outside will be checked by a member of the food and nutrition department or a licensed nursing staff .b. Food item(s) will be labeled with resident's name, content, the date it was prepared, if known, and a discard/use by date .c .If the food is an item to be served hot, reheat to >165F (one time only) in the facility designated microwave oven, prior to service .8. Separate food storage and preparation areas (including a microwave oven) are designated for use for food brought in from outside sources . Event ID: Facility ID: 555292 If continuation sheet Page 31 of 38 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 12/01/2023 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** During a review of Resident 30's admission Record Report printed on 11/28/23, showed Resident 30 was admitted to the facility on [DATE]. Residents Affected - Many During a interview on 11/27/23, at 10:01 a.m., with Licensed Vocational Nurse (LVN 4), LVN 4 stated Resident 30 is alert and oriented and is able to verbalize his needs. During an observation and interview on 11/27/23, at 09:30 a.m., Resident 30 was receiving O2 at 2 liters/minute (L/min), and tubing dated 11/02/23. Resident 30 stated, I have had the same tubing since I have been here. During an observation and interview on 11/29/23, at 12:31 p.m., with LVN 3, LVN 3 confirmed the date on the oxygen tubing as 11/2/23. LVN 3 stated the O2 tubing must be changed every week. During a concurrent interview and record review on 11/29/23 at 12:33 p.m., with LVN 3, the eMAR for resident 30 was reviewed. LVN 3 stated she was unable to locate any documentation of O2 tubing change in the eMAR. LVN 3 stated the risk for not changing the O2 tubing is the spread of infection to the resident and others. 4. During a review of Resident 12's admission record titled admission Record dated 11/28/23, the record showed Resident 12 was admitted to the facility on [DATE]. Resident 12 had diagnoses of hemiplegia and hemiparesis (severe or complete loss of strength to one side of the body) affecting left side, dysphagia (difficulty and/or pain swallowing), and GT. During a concurrent observation and interview on 11/27/23 at 10:30 a.m., a foul odor was observed in Resident 12's room. Licensed Vocation Nurse 1 (LVN 1) stated the smell was likely due to Resident 12's GT site. LVN 1 stated Resident 12's GT often became gunky and smelly. During an observation on 11/27/23 at 10:36 a.m., Registered Nurse 1 (RN 1) went to Resident 12's room to change the GT dressing at GT site. RN 1 did not perform hand hygiene prior to donning gloves. Resident 12's GT dressing was noticeably soiled with dark brown matter, and no date or initials were visible on the dressing. RN 1 removed the soiled dressing, then cleaned the area with normal saline. RN 1 did not perform hand hygiene and glove change, then dated and initialed the GT dressing. Next, RN 1 applied Moisture Lotion (Emollient moisturizing treatment) to Resident 12's lower legs without performing hand hygiene and donning new gloves. During an interview with DON on 11/30/23 at 11:45 a.m., DON stated the risks of not dating/initialing dressings could result in wound care not being performed timely, and failure to perform hand hygiene and clean dressing change procedures could result in infection and cross-contamination. During a record review of facility's policy and procedures (P&P) titled, Dressings, Dry/Clean revised 9/2013, indicated, before touching a soiled dressing: Wash and dry your hands thoroughly, Put on clean gloves, loosen tape and remove soiled dressing, Pull glove over dressing and discard into plastic or biohazard bag, Wash and dry your hands thoroughly, Open dry, clean dressing, Label tape or dressing (new) with date, time and initials , Using clean technique, open other products, Wash and dry hands thoroughly, Put on clean gloves, (prior to assessment, cleaning wound site and applying new dressing) . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 32 of 38 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 12/01/2023 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 - Many During a record review of the P&P Infection Prevention - Hand Hygiene revised 10/2022, which indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial (bacteria, fungi, protozoa, etc.) or non-antimicrobial) and water for the following situations: h. before moving from a contaminated body site to a clean body site during resident care. 5. During an observation on 11/27/23 at 10:30 a.m., Resident 12's incentive spirometer was seen uncovered, on the floor, atop a pair of Resident 12's shoes. During an interview on 11/30/23 at 11:43 a.m., IP stated incentive spirometers should be kept off the floor and away from sources of contamination to ensure that the device is clean and safe for resident's use. Based on observation, interview, and record review, the facility failed to follow infection prevention and control practices when the following were noted: 1. Oxygen tubing nasal canula for four of four sampled residents (Resident 18, 298, 11 and 30) was unlabeled and undated. 2. Two Licensed Vocational Nurses (LVN 3 and LVN 1) did not perform hand hygiene during medication administration for two of the seven sampled residents (Resident 16 and 11). 3. Medication storage refrigerator in the medication storage room was dusty and sticky to touch. 4. Licensed Nurse did not label a wound dressing for a gastrostomy tube (GT, a tube inserted into the stomach to provide liquid nutrition, fluids, and medications) site with date and staff initials. Licensed Nurse did not perform hand hygiene during wound care for one of two residents (Resident 12). 5. Resident 12's Spirometer (handheld device to help practice deep breaths) was stored on top of his shoes on the floor. These failures had the potential for delayed wound healing for Resident 12 cross contamination and spread of infections to residents at the facility. Findings: 1.During a concurrent observation and interview on 11/27/23 at 9:31 a.m., in Resident 18's room with Registered Nurse (RN) 1, oxygen (O2) nasal cannula (two prong tubing placed in the nares to receive oxygen) was wrapped around the handle of the O2 concentrator (delivers filtered O2 from the air), open to air, without a label or date. The nasal prongs had brown discoloration. RN 1 stated the tubing doesn't look dirty but does not look clean either. During a concurrent observation and interview on 11/27/23 at 09:41 a.m. in Resident 298's room, O2 nasal cannula tubing was not labeled while Resident 298 was receiving O2 treatment. Resident 298 stated, They never replace the tubing. Resident 298 stated she was admitted to the facility about three weeks ago. During an observation on 11/27/23 at 9:54 a.m. in Resident 11's room, the O2 nasal cannula tubing was hanging on the O2 tank holder hook without a label and touching the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 33 of 38 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 12/01/2023 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 - Many During a concurrent observation and interview on 11/27/23 at 11:24 a.m., in Resident 298's and Resident 11's shared room with Infection Preventionist (IP) 1, the O2 nasal cannula tubing for Resident 298 and Resident 11 was observed. Resident 298 and Resident 11's O2 nasal cannula was still unlabeled and Resident 11's tubing was still hanging on the oxygen tank holder hook touching the floor. IP 1 stated the oxygen nasal cannula should be stored in an antimicrobial bag when not in use, labeled with date and changed weekly. During a concurrent interview and record review on 11/27/23 at 12:03p.m. with IP in the IP and Director of Rehab (DOR) office, the order summary for Residents 298, 18 and 11 was reviewed. The order summary dated 11/24/23 for Resident 298 indicated, change oxygen tubing every night shift every Saturday. IP stated Resident 18 and 11 has no order to change oxygen tubing weekly. IP stated residents were at risk for respiratory infections if nasal cannula tubing was not labeled and changed weekly. During a review of the facility's policy and procedure titled, Respiratory Therapy Performed by Nursing Services - Prevention of Infection, dated 2/08/20, indicated, Change the oxygen cannula and tubing every (7) days, or as needed (PRN) and Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. During a review of Resident 30's admission Record Report printed on 11/28/23 showed Resident 30 was admitted to the facility on [DATE]. During an interview on 11/27/23, at 10:01 a.m., with Licensed Vocational Nurse (LVN 4), LVN 4 stated Resident 30 is alert and oriented and able to verbalize his needs. During an observation and interview on 11/27/23 at 09:30 a.m., Resident 30 was receiving O2 at 2 liters/minute (L/min), and the O2 tubing was dated 11/02/23. Resident 30 stated, I have had the same tubing since I have been here. During an observation and interview on 11/29/23 at 12:31 p.m., with LVN 3, LVN 3 confirmed the O2 tubing date was 11/2/23. LVN 3 stated the O2 tubing must be changed every week. During a concurrent interview and record review on 11/29/23 at 12:33 p.m., with LVN 3, the electronic medication administration record (eMAR) for Resident 30 was reviewed. LVN 3 stated she was unable to locate any documentation of O2 tubing change in the eMAR. LVN 3 stated the risk for not changing the O2 tubing is the spread of infection to the resident and others. 2. During medication administration observation on 11/28/23 at 09:09 a.m., Licensed Vocational Nurse (LVN) 3 prepared Resident 16's morning medications without performing hand hygiene and put on a new pair of gloves, went into Resident 16's room, administered morning medications, removed gloves and did not perform hand hygiene. LVN 3 then unlocked the medication cart, poured Milk of Magnesia (laxative) medication in a medication cup, without performing hand hygiene and donned a new pair of gloves, locked the medication cart, and administered medication to Resident 16. During an interview on 11/28/23 at 9:30a.m., LVN 3 stated I use hand sanitizer between each resident and when I change gloves. I don't touch residents much. During medication administration observation on 11/28/23 at 10:02 a.m., LVN 1 prepared Resident 11's medications, put gloves on, and went inside Resident 11's room with medications cups. Certified Nursing Assistant (CNA) 3 picked up a basin of water from the bedside table used after Resident 11's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 34 of 38 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 12/01/2023 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 - Many sponge bath. LVN 1 placed four medication cups, one four ounces plastic cup and one white plastic spoon on top of the table without cleaning and disinfecting the area. LVN 1 did not change gloves after touching bathroom doorknob to get warm water in the sink prior to giving Resident 11's medication through a GT. LVN 1 used the plastic spoon that was in contact with the uncleaned table to mix the crushed tablet and water in the medication cup and poured the medication into the syringe connected to Resident 11's G-tube to deliver the medication. During an interview on 11/28/23 at 10:16 a.m. LVN 1 stated it was necessary to change gloves after touching contaminated surfaces such as doorknob and sink faucet to not cross contaminate and introduce any bacteria into the Resident 18's gut. LVN 1 further stated she should have wiped the dirty bedside table with purple top germicidal wipes prior to putting medication cups on top of it. During a review of the undated facility's policy and procedure titled, Handwashing/Hand Hygiene, indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c. Before preparing or handling medication; l. After contact with objects in the immediate vicinity of the resident; m. After removing gloves. 3. During a concurrent observation and interview on 11/29/23 at 10:04 a.m. with the Director of Nursing (DON) in the medication room, the medication storage refrigerator had sticky brown material and stains on the shelf where medications were stored. The refrigerator had dust build up on the top of the refrigerator. DON stated the nurses were responsible for cleaning the refrigerator. During a concurrent interview and record review on 11/29/23 at 10:30 a.m., with DON, temperature logs for the medication room to document and track date, temperature for medication, and food refrigerator, and refrigerator cleaning was reviewed. The log indicated, Cleaning of Refrigerator: Indicate if the F-Food or M-Medication refrigerator was cleaned. The DON stated she was unable to find any documentation if staff cleaned the medication refrigerator for September, October, and November 2023. During a review of the facility's policy and procedure titled, Cleaning Medication Storage Areas, dated August 2017, indicated, 1. Keep refrigerators clean and defrost weekly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 35 of 38 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 12/01/2023 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 implement the pneumococcal immunization (a vaccine to protect against pneumonia, an infection of the lungs caused by bacteria, fungi or viruses) policy for three of five sampled residents (Resident 12, Resident 13, and Resident 38) when they did not receive a pneumonia vaccine immunization. Residents Affected - Some This failure placed Resident 12, 13 and 38 at risk for pneumonia. Findings: During a record review of the Electronic Health Record (EHR) of Resident 12, the record showed Resident 12 was admitted on [DATE], A review of Resident 13's EHR showed, Resident 13 was admitted on [DATE]. A review of Resident 38's EHR showed Resident 38 was admitted on [DATE]. During an interview and record review on 11/30/23 at 11:30 a.m., the Infection Preventionist (IP 1) immunization records for Residents 12, 13, 38 were reviewed. IP 1 stated she was unable to find the pneumonia vaccine immunization records for Residents 12, 13, and 38. Record review of the Infection Prevention-Immunizations, Influenza (an acute respiratory infection caused by influenza viruses) and Pneumococcal (Resident), revised October 2018, indicated,Each resident is offered a pneumococcal immunization unless immunization is medically contraindicated (not recommended) or the resident has already been immunized. For residents who receive vaccination, the following information will be documented in the resident's electronic health record, under immunization tab: The date of vaccination, lot number, expiration date and site of vaccination. If declined, document the reason why resident did not receive the influenza and/or pneumococcal immunization. (Electronic Immunization Record). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 36 of 38 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 12/01/2023 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 and interview, the facility had sixteen residents (Rt) rooms (room [ROOM NUMBER], 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17 and 18) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings. Findings: During an observation on 11/29/23 at 8:29 a.m., in the presence of Administrator (Admin) and accompanied by Maintenance Supervisor (MS), the following rooms and corresponding sq. ft per bed were identified: Room Activity/Room Size Floor Area 1 Rt room /200 sq. ft 66 sq. ft 3 Rt room /200 sq. ft 66 sq. ft 4 Rt room /140 sq. ft 70 sq. ft 5 Rt room/ 200 sq. ft 66 sq. ft 6 Rt room/ 140 sq. ft 70 sq. ft 7 Rt room /200 sq. ft 66 sq. ft 8 Rt room /140 sq. ft 70 sq. ft 9 Rt. room /140 sq. ft 70 sq. ft 10 Rt room /200 sq. ft 66 sq. ft 11 Rt room/ 140 sq. ft 70 sq. ft 12 Rt room /200 sq. ft 66 sq. ft 14 Rt room /200 sq. ft 66 sq. ft 15 Rt room/ 140 sq. ft 70 sq. ft 16 Rt room /200 sq. ft 66 sq. ft 17 Rt room/ 140 sq. ft 70 sq. ft (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 37 of 38 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 12/01/2023 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 18 Rt room /200 sq. ft 66 sq. ft Level of Harm - Potential for minimal harm During an interview on 11/29/23 at 8:30 a.m., Certified Nursing Assistant (CNA 2) stated there was enough space to provide care for residents. CNA 2 stated she had no problems going in and out with necessary care equipment. Residents Affected - Many During an interview on 11/29/23 at 8:36 a.m., CNA 1 stated there was no problem with space when care was provided to residents. CNA 1 stated it was easy to provide care for residents in these rooms. CNA 1 said residents are provided care with ease. During an interview on 11/29/23 at 8:43 a.m., Resident 22 stated there was enough room space for her belongings and had no concerns about space. During an interview on 11/29/23 at 8:43 a.m., Resident 26 stated she had enough room space for her belongings and care. During an observation and concurrent interview on 11/30/23 at 9:22 a.m., in the presence of CNA 3, CNA 3 stated there was enough space to conveniently provide care for residents in the rooms and for residents that need a hoyer lift (device to transfer resident in and out of bed). CNA 3 stated there was no heavy equipment kept in the rooms that might interfere with resident's care. There was no negative consequences attributed to the decreased space in the sixteen rooms. Granting of the room size waiver is recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 38 of 38

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Citations

25 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0554GeneralS&S Dpotential for harm
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
0576GeneralS&S Epotential for harm
F576 - The resident has the right to have reasonable access to the use of a telephone,
Ensure residents have reasonable access to and privacy in their use of communication methods.
0578GeneralS&S Epotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0585GeneralS&S Epotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0602GeneralS&S Dpotential for harm
F602 - The resident has the right to be free from abuse, neglect, misappropriation of re
Protect each resident from the wrongful use of the resident's belongings or money.
0636GeneralS&S Dpotential for harm
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
0640GeneralS&S Dpotential for harm
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0758GeneralS&S Epotential for harm
F758 - Medication Errors
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.
0759GeneralS&S Epotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Fpotential for harm
F761 - Labeling of Drugs and Biologicals
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.
0804GeneralS&S Dpotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0813GeneralS&S Fpotential for harm
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0883GeneralS&S Epotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0912GeneralS&S Cno actual harm
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
0006GeneralS&S Dpotential for harm
Conduct risk assessment and an All-Hazards approach.
0035GeneralS&S Cno actual harm
Provide family notifications of emergency plan.
0039GeneralS&S Dpotential for harm
Conduct testing and exercise requirements.
0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.

FAQ · About this visit

Common questions about this visit

What happened during the December 1, 2023 survey of ALHAMBRA POST ACUTE?

This was a inspection survey of ALHAMBRA POST ACUTE on December 1, 2023. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ALHAMBRA POST ACUTE on December 1, 2023?

Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to self-administer drugs if determined clinically appropriate."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·December 1, 2023