Health inspection·November 21, 2024

F 0565 the resident and/or representative. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 2 of 20 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 11/21/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the Level I Preadmission Screening and Resident Review (PASARR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) assessment for one of one sampled resident (Resident 31). This failure had the potential for residents to not received appropriate care and services. Findings: During a review of Resident 31's admission Record, dated November 20 2024, the record indicated Resident 31 was originally admitted to the facility on [DATE]. During a concurrent interview and record review on 11/19/24 at 4:01 p.m. with Director of Nursing(DON), DON stated the facility was expected to complete a PASARR screening prior to residents' admission to the facility. DON could not provide Resident 31's Level 1 PASARR. DON stated Resident 31's Level 1 PASARR was not done. DON stated when Resident 31 was admitted to the facility she was a newly hired DON and did not know why Resident 31 did not have level 1 screening for PASARR completed. DON stated residents on psychotropic medication need to be screened for Level 1 PASARR. During an interview on 11/21/24 at 11:50 a.m. with admission Coordinator(AC), AC stated she was responsible to coordinate with hospital case managers prior to residents admissions to the facility. AC stated she did not know about Resident 31 level 1 PASARR because she was hired after Resident 31's admission to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 3 of 20 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 11/21/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent falls and implement resident-centered care interventions for one (Resident 31) of four sampled residents when, Resident 31 had repeated unwitnessed falls. This failure caused Resident 31 to continued to fall and had the potential to result in injuries. Findings: During a review of Resident 31's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/17/24, indicated Resident 31's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 31's score was 03, meaning poor cognition. Resident 31's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). Resident 31 was independent and once standing had the ability to walk at least 150 feet in corridor or similar space. Resident 31's behavior included wandering , the wandering placed Resident 31 at significant risk of getting to a potential dangerous place. During an observation on 11/20/24 at 1:19 p.m. Resident 31 wandered the hallways looking into other residents rooms. Review of Resident 31's Interdisciplinary Team (IDT- an approach to healthcare that integrates multiple disciplines through collaboration). The IDT progress notes indicated Resident 31 was at risk for falling and had the following falls: 6/28/24-Resident 31 had unwitnessed fall with no injury. 7/19/2-Resident 31 had unwitnessed fall with injury (hematoma on nose and face). Resident 31 was up ambulating went into the dining room and had an unwitnessed fall. Resident 31 laid face down head to the side assisted to the floor in the hallway when he tried to stand up and lost his balance. Resident 31's nose was swollen and discolored with small amount of blood from nose Resident 31 was transferred to the hospital for further evaluation and treatment. 9/1/24-Resident 31 lost her balance and fell on her buttock at the nursing station. 9/10/24-Resident 31 had an unwitnessed fall with no injuries. During a review of Resident 31's Change of Condition Evaluations (COC), dated 9/26/24, the COC indicated Resident 31 had unwitnessed fall, observed sitting on the floor, difficult to assess or redirect due to dementia. During a concurrent interview and record review on on 11/20/24 at 9:01 a.m. with the Director of Nursing (DON), Resident 31's IDT progress notes, COCs and fall care plan were reviewed. The IDT progress notes indicated prior interventions before each fall included remind resident to ask for help and current interventions after falls included redirection and reorientation. Resident 31's care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 4 of 20 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 11/21/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated provide verbal reminders to ask for assistance as needed. DON stated Resident 31 wandered around the facility and had some falls in room and sometimes in the hallways. During an interview on 11/20/24 at 1:14 p.m. Certified Nursing Assistant (CNA2), CNA2 stated Resident 31 wandered around the facility, goes to every other residents' room and closet. CNA2 stated Resident 31 was very confused difficult to redirect. During an interview on 11/20/24 at 2:39 p.m. with DON, DON stated despite the interventions Resident 31 continued to wanders into other residents rooms despite redirection and reorientation. DON stated the interventions before and after falls are the same. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 5 of 20 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 11/21/2024 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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, for one of two sampled residents (Resident 31), the facility failed to developed and implement person-centered interventions to prevent Resident 31 with dementia from wandering into the rooms and closets of other residents. Residents Affected - Few Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptom and rates of progression. (Adapted from: About Dementia. Alzheimer's Foundation of America. 30). This failure had the potential to cause residents increase confusion and distress. Finding: During a review of Resident 31's admission Record (AR), the AR indicated, Resident 31's was an [AGE] year old female admitted to the facility on [DATE]. Resident 31's primary diagnoses included non traumatic subdural hemorrhage and Dementia without behavioral disturbance. During a review of Resident 31's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/17/24, indicated Resident 31's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 31's score was 03 meaning poor cognition. Resident 31 had no potential indicators of psychosis, no hallucination, no delusions. Resident 31 exhibited wandering and rejection of care behavior. The MDS indicated Resident 31's wandering placed the resident at significant risk of getting to a potentially dangerous place. Resident 31's wandering significantly intrude on the privacy or activities of others. Resident 31's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 31's risk for elopement/exit seeking/wandering related to alter cognitive care plan, initiated 1/29/24 interventions did not address Resident 31 wandering into the rooms and closets of other residents. During a resident council meeting on 11/19/24 at 11:13 a.m. Resident 16, 17, 18, 36 and 38 complained that Resident 31 wandered into their rooms and takes their belongings e.g sweater. Resident 31 wanders into thier rooms day and night, rummages through their stuff. Resident 16, 17, 18, 36 and 38 are upset they do not like the situation sometimes Resident 31 tickle their feet, take their belongings. Residents stated Resident 31 need to be in a specialized facility to care for her conditions. During an interview on 11/20/24 at 1:14 p.m. with Certified Nursing Assistant (CNA2), CNA2 stated Resident 31 wandered around the facility goes into other residents rooms and closet. CNA2 stated Resident 31 was very confused, difficult to redirect. During an observation on 11/20/24 at 1:19 p.m. Resident 31 wandered in hallways looking into other residents rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 6 of 20 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 11/21/2024 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/20/24 at 2:39 p.m. with Director of Nursing (DON), DON stated Resident 31 continued to wander into other residents rooms despite redirection and reorientation. DON said other residents complained about Resident 31 wandering into their rooms in the evenings and at night. During an interview on 11/21/24 at 8:20 a.m. with Certified Nursing Assistant 3 (CNA3), CNA3 stated Resident 31 wandered around a lot. Resident 31 wandered into other residents rooms and closets picked up other residents' belongings. Resident 31 redirection depends on the days, some times Resident 31 yells and screams. CNA 3 stated other residents stated they don't want Resident 31 in their rooms because she picked up their belongings. During an interview on 11/21/24 at 8:24 a.m. with Certified Nursing Assistant 4 (CNA4), CNA4 stated Resident 31 wanders around in the facility. CNA4 stated Resident 31 looks for her clothes in other residents' closets. Resident 31 was always looking for something in other residents' room. During an interview on 11/21/24 at 9:35 a.m. Activities Director (AD), AD stated It was hard for Resident 31 to participate in activities, she is by her self . Resident 31 think we are stealing her clothes she cannot comprehend. Resident 31 roams the facility with her bag so we give her the space sometimes she walks in and goes out of other residents rooms, sat on bed looking out the window. AD stated other residents argued with Resident 31. AD said Resident 31 goes into other residents' room and take their clothes, things on their dresser, some of the resident don't tolerate some times she goes into men room. AD stated Resident 31's redirection depends on her mood sometimes she argues and she wants to go home looking for her keys. During an interview on 11/21/24 at 10:44 a.m. with Resident 31's Medical Doctor (MD) 1, MD 1 stated Resident 31 had profound dementia and subdural hematoma. MD 1 stated Resident 31's dementia was so severe. MD 1 stated Resident 31 will benefit from a dementia unit. During a review of the facility's policy and procedure (P&P) titled, Dementia-Clinical Protocol, revised 2022, the P&P indicated, The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 7 of 20 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 11/21/2024 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 observation, interview and record review, the facility failed to ensure three (Resident 27, 31 and 145) of five sampled residents were free from unnecessary drugs when; 1. Resident 27 was administered Seroquel (an antipsychotic - drugs used to treat schizophrenia and bipolar serious mental health conditions and not approved for use in psychotic conditions related to dementia.) medication for wandering; 2. Resident 31 had a new diagnosis of schizophrenia (a serious mental health conditions capable of affecting the mind, emotions, and behavior); 3. Resident 31 with diagnosis of dementia was administered Zyprexa (an antipsychotic) medication for yelling and screaming; 4. Resident 145 was administered antipsychotic medication without adequate indication for use. These failures had the potential for residents to receive unnecessary medications and had the potential for the residents to suffer adverse medication side effects. Findings: 1. During a review of Resident 27's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 3/8/24, indicated Resident 27's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 27's score was 01 meaning poor cognition. Resident 27 had no behavior of wandering. Resident 27 had no physical or verbal behavioral symptoms directed towards others e.g., hitting, kicking, pushing, scratching, grabbing or screaming at others, verbal/vocal symptoms like screaming or disruptive sounds. Resident 27 had no potential indicators of psychosis. Resident 27's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 27's Order Summary Report dated 11/12/24, indicated the physician prescribed Resident 27, Seroquel oral tablet 25 mg give 0.5 tablet by mouth in the afternoon for wandering and behavioral disturbances. During a review of Resident 27's Medication Administration Record (MAR), dated 11/12/24 to 11/18/24 indicated Resident 27 was administered seroquel 25 mg give 0.5 tablet by mouth in the afternoon for wandering and behavioral disturbances. Further review of Resident 27's MAR dated 10/1/24 to 10/31/24 indicated Resident 27 was administered seroquel 25 mg give 0.5 tablet by mouth in the afternoon for agitation and tearfulness. During a review of Resident 27's Pre-admission Screening Resident Review (PASRR) evaluation, dated 4/15/22, the PASRR indicated Resident 27 has no serious mental illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 8 of 20 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 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm During an observation on 11/18/24 at 10:48 a.m. in the hallway south station Resident 27 appeared well groomed wanders up and down the hallway and was redirected by staff to her bed. During an interview on 11/19/24 at 9:08 a.m. with Certified Nursing Assistant (CNA) 1, CNA1 stated Resident 27 was redirectable and nice. CNA 1 said Resident 27 liked to sit outside her room. Residents Affected - Some During a review of Resident 27's Consultant Pharmacist's Medication Regimen Review (MRR), dated 8/13/24, the MRR indicated to please review indication for seroquel use. MRR indicated Resident 27 has a diagnosis of dementia . 2. During a review of Resident 31's Discharge Summary (D/S), dated 7/11/23, the D/S indicated, Resident 31's principal diagnoses was dementia and secondary diagnoses included dementia, severe protein-calorie malnutrition, ground level fall, subdural hematoma, subarachnoid hemorrhage. During a review of Resident 31's admission Record (AR), the AR indicated, Resident 31's was an [AGE] year old female admitted to the facility on [DATE]. Resident 31's primary diagnoses included non traumatic subdural hemorrhage and Dementia without behavioral disturbance. The AR did not show that Resident 31 had a diagnosis of schizophrenia upon admission to the facility. During a review of Resident 31's admission Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/18/23, indicated Resident 31's active diagnoses did not include diagnosis of schizophrenia. During a concurrent interview and record review on 11/20/24 at 9:01 a.m. with the Director of Nursing (DON), Resident 31's D/S, AR and order summary report were review. The physician order indicated Resident 31 was prescribed Zyprexa oral tablet 2.5 mg by mouth at bed time for schizophrenia manifested by disorganized thought process. DON stated Resident 31 had dementia. DON said Resident 31 was not admitted with schizophrenia diagnosis. DON stated the psychiatry added the schizophrenia diagnosis with consultation. DON stated Resident 31 wanders around the facility. DON said somehow along the way Resident 31 was diagnosed with schizophrenia. DON said she did not know why Resident 31 was diagnosed with schizophrenia. During a review of Resident 31's Psychiatric Progress Report, dated 2/9/23, the Nurse Practitioner notes indicated Resident 1 had unclear confusion vs possible psychotic and disorganized thinking. Resident 31 diagnostic impression included other specified schizophrenia spectrum and dementia without behavior. During an interview on 11/21/24 at 10:44 a.m. with Resident 31's Medical Doctor (MD) 1, MD 1 stated Resident 31 had profound dementia and subdural hematoma. MD 1 stated he did not diagnosed Resident 31 with schizophrenia. MD 1 stated Resident 31 was on Zyprexa for agitation. MD 1 stated Resident 31's dementia was so severe that he was not capable of diagnosing Resident 31 with schizophrenia. MD 1 stated Resident 31 was seen by psychiatry. MD 1 stated Resident 31 will benefit from a dementia unit. 3. During a review of Resident 31's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/17/24, indicated Resident 31's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 31's score was 03 meaning poor cognition. Resident 31 had no potential (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 9 of 20 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 11/21/2024 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 indicators of psychosis, no hallucination, no delusions. Resident 31 exhibited wandering and rejection of care behavior. Resident 31's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 31's Order Summary Report dated 2/14/24, indicated the physician prescribed Resident 31 zyprexa oral tablet 2.5 mg give 2.5 mg by mouth at bedtime for schizophrenia manifested by disorganized thought process. Further review of Resident 31's physician order dated 7/4/24 indicated behavior monitoring for antipsychotic seroquel and zyprexa medication, document number of episodes per shift of target behavior; screaming, yelling, pacing, refusing care every shift for behavior monitoring for zyprexa. During a review of Resident 31's Medication Administration Record (MAR), dated 11/1/24 to 11/18/24 indicated Resident 31 was administered zyprexa 2.5 mg give 2.5 mg tablet by mouth at bedtime. During a review of Resident 31's Behavior Management care plan initiated 11/28/23, indicated use of psychotropic medication related to episodes of yelling out, refusal of care, pacing, unable to redirect, interventions included monitor/record occurrence of target behavior symptoms i.e. pacing, wandering, disrobing, inappropriate response to verbal communication. During an observation on 11/19/24 at 11:09 a.m. Resident 31 wandered up and down the hallways alert with incomprehensible conversation. During an interview on 11/20/24 at 1:14 p.m. Certified Nursing Assistant (CNA2), CNA2 stated Resident 31 wanders around goes to other residents' rooms and closet. CNA2 stated Resident 31 was very confused and difficult to redirect. During an interview on 11/20/24 at 2:39 p.m. DON stated despite interventions Resident 31 continued to wanders into other residents rooms. During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, revised 2022, the P&P indicated, Antipsychotic medications will not be used if the only symptoms are one or more of the following: a. Wandering; b. Poor self care; c. Restlessness; d. impaired memory; e. Mild anxiety; f. Insomnia; g. Inattention or indifference to surroundings; i. Fidgeting; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 10 of 20 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 11/21/2024 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 j. Nervousness; or Level of Harm - Minimal harm or potential for actual harm k. Uncooperativeness. Findings: Residents Affected - Some 4. During a review of Resident 145's admission record, the admission record indicated the resident was admitted on [DATE] with diagnoses that included Alzheimer's Disease (a brain disorder that gradually destroys memory and thinking skills) and Dementia (loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 145's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 11/11/24, indicated the resident had severe cognitive impairment. During a review of Physician's orders dated 11/9/24, indicated, an order of Seroquel oral tablet 25 milligrams (mg., a form of measurement), give 0.5 tablet by mouth every 12 hours as needed for Alzheimer's Dementia manifested by depression and anxiety for 14 days (Seroquel is an antipsychotic medication; an antipsychotic is a medication that is used for the mind to manage delusions, hallucinations, disordered thought. Antipsychotic medications can cause severe side effects; depression is a mood disorder that causes persistent feelings of sadness). A review of Physician's orders dated 11/9/24, indicated, no target behaviors were specified to be monitored for the use of the antipsychotic drug Seroquel (target behaviors for antipsychotics refer to the specific, undesirable behaviors that a patient is exhibiting which a doctor aims to reduce or manage with the use of antipsychotic medication, such as aggression, agitation, hallucinations, delusions, or other disruptive behaviors). During an interview on 11/21/24, at 10:00 a.m., with the Director of Nursing (DON), DON stated that there should be target behaviors to be monitored for the use of Seroquel. Also stated this would help in surveilling the medication's effectiveness in controlling the undesirable behaviors. During a telephone interview on 11/21/24 11:24 a.m., with the Consultant Pharmacist (CP), CP stated that there should be target behaviors to be observed for the use of Seroquel. Further stated the behavior monitoring would have helped to determine if Seroquel was effective and if the resident still needed this medication. During a telephone interview on 11/21/24, at 10:36 a.m., with the Medical Doctor (MD) 1, MD 1 stated there should be target behaviors specified to be monitored for the use of Seroquel. During a review of the resident's Pre-admission Screening Resident Review (PASRR) for serious mental illness screening dated 11/9/24 indicated, Resident 145 did not have a serious mental illness. During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 2001, the P&P indicated, . The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications . The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 11 of 20 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 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to label medications and properly dispose of a medication beyond the use by date for two of 14 sampled residents (Resident 36 and Resident 5), when while inspecting medication cart two (use by date is the date at which the manufacturer can still guarantee the full potency and safety of the drug): 1. Resident 36's one bottle of Latanoprost Ophthalmic Solution 0.005 % ( Latanoprost ) was not labeled with an open date. Another bottle Resident 36's Latanoprost was stored beyond the use by date in the medication cart (Latanoprost is an eyedrop used to treat a condition in which increased pressure in the eye can lead to gradual loss of vision). 2. A bottle of Atropine Sulfate Ophthalmic solution 1% was not properly labeled (Atropine Sulfate Ophthalmic solution is an eyedrop used to treat certain eye conditions). Findings: 1. Resident 36 was admitted on [DATE] with diagnoses including changes in retinal vascular appearance to the right eye (meaning changes in the light sensitive layer of tissue at the back of the right eyeball). During a concurrent observation and interview on 11/19/24, at 9:21a.m., with the Director of Staff Development (DSD), while inspecting medication cart two, Resident 36 had two opened bottles of Latanoprost eyedrops. One eyedrop bottle was not labeled with an open date and another eyedrop bottle had an open date of 9/10/24. Both boxes of the eyedrop bottles indicated, to dispose the eyedrops after 28 days from the opening date. DSD stated, the eyedrop without the open date should have been dated. The DSD further stated, the eyedrop with an open date of 9/10/24 should have been disposed after 28 days (the 28th day after 9/10/24 would have been 10/8/24, this observation was conducted on 11/19/24). During a review of Resident 36's Physician Order, dated 9/5/24, indicated an order, for Latanoprost Ophthalmic Solution 0.005 %, instill 1 drop in both eyes at bedtime for dry eyes and itching. During a review of Resident 36's Medication Administration Record (MAR),dated November 2024, the MAR indicated that Latanoprost eyedrops were last given to Resident 36 on 11/18/24 at 9:00 p.m. During an interview on 11/20/24 at 1015 a.m., with the Director of Nursing (DON), DON stated, the Latanoprost eyedrops with an open date of 9/10/24 should have been disposed after 28 days from the opening date and the other bottle of Latanoprost eyedrops with no open date should have been labeled with an open date to know when the eyedrop's use by date was. Stated the risk of giving the eyedrops past their use by date was that it would not be effective in treating the illness because they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 12 of 20 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 11/21/2024 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 have less potency. Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 11/21/24 11:24 a.m., with the Consultant Pharmacist (CP), stated Resident 36's Latanoprost eyedrops should have had an open date label and should have been disposed after the use by date because of the risk of eye infection and blindness. Residents Affected - Few 2. During a concurrent observation and interview on 11/19/24, at 9:21a.m., with the DSD, while inspecting medication cart two, observed an open Atropine Sulfate Ophthalmic Solution 1% eyedrop bottle in a box with no label. The box of the Atropine eyedrops had handwritten notes which read, 2 drop and L eye. DSD stated that the eyedrops belonged to Resident 5. Also stated Resident 5's Atropine should have been labeled with the resident's name and dosage, to prevent medication error. Resident 5 was admitted on [DATE]with diagnoses including ocular hypertension, unspecified eye (a condition when pressure within the eye increases). During a review of Resident 5's Physician Order, dated 3/21/24, indicated an order, for Atropine Sulfate Ophthalmic Solution 1%, instill two drops to left eye two times a day. During a review of Resident 5's Medication Administration Record (MAR), dated November 2024, the MAR indicated that Atropine was last given on 11/19/24 at 9:00 a.m. During an interview on 11/20/24 at 1015 a.m., with the DON, stated the Atropine eyedrops should have been labeled with the resident's name, dosage, open date and the initial of nurse who opened the medication. A review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2001, the P&P indicated, . Medication Labeling. 1.Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. the medication label includes at a minimum a. medication names b. prescribed dose c. strength d. expiration date, when applicable e. resident's name f. route of administration; and g. appropriate instructions and precautions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 13 of 20 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 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record review, the facility failed to ensure storage of food under sanitary conditions when the following food items in the refrigerator were not dated and labeled with received, open and use-by dates : - One bag of cauliflower with brownish black discoloration - One bag of parsley moist and withered - Three cut up watermelon not labeled with date - One chest freezer had no temperature log. - Refrigerator temperature log missing entries - Trash can lid with brownish discoloration - Kitchen floor tiles with brownish stain and discoloration These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 11/18/24 at 8:20 a.m. with Dietary Aide (DA)1, the following were observed in the refrigerator; one bag of cauliflower with brownish black discoloration, one bag of parsley moist and withered, three cuts up watermelon not labeled with use by date. DA 1 stated food items in refrigerator are labeled with use-by-date. DA 1 stated the bag of cauliflower and parsley were no longer good for use . DA 1 said she will disposed these food items. Further tour with DA 1 indicated refrigerator/freezer temperature log was missing entries from 11/13/24 to 11/17/24. Trash can located under hand washing sink lid had brownish discoloration. Kitchen floor tiles with brownish stain discoloration. During a follow up tour of kitchen on 11/19/24 at 12:24 p.m. with Dietary Supervisor (DS), one stand alone chest freezer had no temperature log, DS stated the temperature log for the chest freezer was missing and she will start a new log. DS stated she had new staff in the kitchen that are in training. During an interview on 11/19/24 at 2:34 p.m. with DA 2, DA 2 stated she received training on her job function including dating and labeling food in the refrigeration. During an interview on 11/19/24 at 2:42 p.m. with [NAME] (CK), CK stated he was a new hire. CK said he received training that included checking food temperature, dating and labeling of food in refrigerator and check and documentation of fridge and freezer temperature. During a review of the facility's policy and procedure (P&P) titled, Food receiving and storage of cold food, dated 2023, the P&P indicated, All perishable food items purchased by the department of food and dining services will be stored properly. All open food items will have an open date and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 14 of 20 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 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 use-by-date per manufacturer's guidelines. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 15 of 20 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 11/21/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure garbage and refuse storage area was maintained in a sanitary condition when the dumpster was overflowed with bags of trash and not properly contained with lid. Residents Affected - Some This failure had the potential of harborage and feeding of pest. Findings: During an observation on 11/19/24 at 7:12 a.m., with Dietary Services Manager (DSM) one dumpster located by the side of the facility overflowed with trash bags was not contained with lid. During an interview on 11/19/24 at 7:18 a.m. with Administrator (Admin) stated contracted company staff came and left without empty the dumpster. Admin stated house keeping staff assist with making sure dumpster was emptied. During an interview on 11/19/24 at 7:23 a.m. with Housekeeping Supervisor (HKS), HKS stated someone blocked the path to the dumpster and the dumpster was not emptied. During a review of the facility's policy and procedure (P&P) titled, Waste Disposal, revised January 2022, the P&P indicated, All infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 16 of 20 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 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alhambra Post Acute 331 Ilene Street Martinez, CA 94553 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective infection control program when the lid (cover) of Resident 144's suction machine cannister was not changed for 18 days (Suction machine is a device that is used for removing secretions like mucus, phlegm, saliva from a person's airway; the suction machine cannister is where the secretions are collected). Residents Affected - Few This failure placed the resident at increased risk of healthcare associated infections. Findings: During a review of Resident 144's admission record indicated the resident was admitted on [DATE] with diagnoses that included esophageal obstruction (a blockage or narrowing of the esophagus, the muscular tube that connects the mouth to your stomach). During a concurrent observation and interview on 11/18/24, at 2:22 p.m., with Licensed Vocational Nurse (LVN) 2, in Resident 144's room, the resident's suction machine cannister was observed to be filled with 100 milliliters (ml., a form of measurement) of phlegm. The lid of the suction machine cannister was observed to have a handwritten date of 11/1/24. LVN 2 could not specify the date when the suction cannister was last changed. During a concurrent observation and interview on 11/18/24 at 2:30 p.m., with Registered Nurse (RN) 1, in Resident 144's room, RN 1 also could not specify when the suction cannister was last changed. RN 1 further stated, the container jar (bottom part) of the suction cannister was changed frequently, but the upper part of the suction canister ( lid or cover ) was not changed regularly. During an interview on 11/18/24 at 2:30 p.m., with Infection Preventionist (IP), IP acknowledged that the suction cannister lid should have been changed before 11/18/24, stated the risk of not changing the cannister lid was for Resident 144 to have a respiratory infection. During an interview on 11/20/24 at 1015 a.m., with the Director of Nursing (DON), stated, the suction cannister and its lid should have been changed every 7 days. Further stated risk of not changing the lid every seven days was infection. During a review of Resident 144's Order Summary Report dated 11/19/24, indicated an order with a start date of 8/2/24 to change the suction cannister weekly every Wednesday and as needed. During a review of the facility's policy and procedure (P&P) titled, Policies and Practices - Infection Control ,revised October 2018,the P & P indicated .4. All personnel (staff ) will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 17 of 20 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 11/21/2024 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 - Some 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 resident rooms (Rooms 1, 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 11/20/24, at 10:00 a.m., the following rooms and corresponding sq. ft per bed were identified: room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 18 of 20 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 11/21/2024 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 room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. Residents Affected - Some room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. During random observations of care and services from 11/18/24 to 11/21/24, there were sufficient space for the provision of care for the residents in the rooms. There was no heavy equipment in the room that might interfere with residents' care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed the decreased space and/or safety concerns in the five rooms. Granting of room size waiver recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 19 of 20 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 11/21/2024 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 0920 Level of Harm - Minimal harm or potential for actual harm Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Based on observation and interview, the facility failed to provide a dining/activity room with adequate space for 42 residents. Residents Affected - Some This failure resulted in limiting the independent functioning and task performance of the residents during mealtime and activity time. Findings: The facility census on 11/18/24 was 42 residents. On 11/21/24 at 12:04 p.m., observation of dining/activity room was conducted. The room which served as the residents' dining room and activity room had three square tables and accommodated five residents in wheelchairs and two ambulatory residents who used a walker as an assistive device. The dining room was observed to be crowded for the seven residents. The dining room staff were observed to push the tables to the side to be able to push and position some of the residents in wheelchairs in the dining tables. During an interview on 11/21/24 at 8:17 a.m., with Certified Nursing Assistant (CNA) 2 , CNA 2 stated the dining room was crowded at mealtimes and stated some of the ambulatory residents could slip and fall due to the tight space in the dining room. During an interview on 11/21/24 12:16 p.m., with Resident 16, stated the dining room was small and sometimes she had to dine in her room because the dining room space was limited. During an interview on 11/21/24 at 8:30 a.m., with Resident 17, stated the dining room was congested at mealtimes. Also stated it was difficult for the staff to position the residents in wheelchairs in the dining tables because of the small space of the dining area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555292 If continuation sheet Page 20 of 20