Health inspection·October 13, 2022

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the Social Services (SS) on 10/12/22 at 10:09 a.m., SS stated Resident 18's and Resident 23's clinical records had no documentation of a podiatry visit since the year prior. SS also stated residents that included Resident 18 and Resident 23 should have been seen by podiatrist every eight weeks. Review of the facility's policy and procedure titled, Foot Care last revised March 2020, had indicated residents will receive necessary foot care and treatment including treatment of foot disorders by qualified podiatrist, doctor of medicine, doctor of osteopathy including nail disorders and preventive care to avoid foot problems in diabetic residents and residents with circulatory disorders. Event ID: Facility ID: 055156 If continuation sheet Page 2 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for one of one (Resident 76) investigated for accident hazards, the facility failed to ensure Resident 76's environment was free from accident hazards when personal belongings were not within reach. This failure had the potential to result in another fall episode. Findings: Review of Resident 76's admission record indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (narrowing of the spinal canal resulting in pain, numbness, and muscle weakness) and osteoporosis (bone disease that leads to decrease in bone strength and increases the risk of fractures). Review of Resident 76's Baseline Care Plan with Summary dated 10/6/22 indicated Resident 76 was alert and oriented, able to understand, and communicated easily with staff. Review of Resident 76's fall risk assessment dated [DATE] indicated Resident 76 was identified as having a moderate risk of falling. Review of Resident 76's IDT (Interdisciplinary team-individuals from different departments of the facility) Post Event Review dated 10/10/22 indicated, on 10/9/22, Resident 76 was observed on the floor by the bed. Resident 76 stated the fall occurred while trying to reach for something at the bedside. The review indicated IDT interventions included placing Resident 76's personal items within reach and for staff to do anticipatory purposeful rounding. During an interview with Resident 76 on 10/12/22 at 12:40 p.m., Resident 76 stated fall happened while trying to reach the toothbrush that was inside the nightstand drawer. Resident 76 also stated not being able to call the staff for help because the call button was not on the bed and could not see where it was. During an observation of Resident 76's bedside and concurrent interview with Minimum Data Set Coordinator (MDSC) on 10/12/22 at 2:44 p.m., Resident 76's nightstand was still more than a foot from the edge of the bed. There was a black purse and two books on top and Resident's toothbrush and toothpaste were inside the drawer. Resident 76 stated she could not reach the items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 3 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to have a Registered Nurse (RN) coverage for at least 8 consecutive hours a day on 10/2/22, 10/8/22, and 10/9/22. Residents Affected - Few This deficient practice had the potential to cause delayed delivery of necessary assessment and treatment services for residents day-to-day care. Findings: Review of the nursing staffing assignment and sign-in sheet dated 10/3/22, 10/8/22 and 10/9/22 indicated facility did not use the services of an RN for at least 8 consecutive hours a day. During an interview and record review of the October staffing schedule on 10/11/22 at 10:59 a.m., the Director of Nursing (DON) stated there are some days the facility did not have an RN coverage for at least 8 consecutive hours a day on weekends. DON stated the facility had tried to recruit RNs, but did not have RN coverage on 10/2/22, 10/8/22, and 10/9/22. The Facility Assessment Tool updated 9/13/22 indicated, the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Staffing Plan; Our general staffing plan is developed to ensure that we have sufficient staff to meet the needs of the residents at any given time. Plan: RN full-time days and other times as needed, One RN for daily shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 4 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 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 Residents Affected - Few 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, for one of five residents (Resident 78) observed for medication pass administration, the facility failed to provide pharmaceutical services when calcium-citrate-magnesium tablets were not available for medication administration. This failure had the potential to result in low blood calcium levels for Resident 78. Findings: Review of Resident 78's Order Summary Report for October 2022 indicated an order for calcium citrate-magnesium-mineral tablet one tablet by mouth one time a day. During an observation and concurrent interview with the Licensed Vocational Nurse 2 (LVN 2) on 10/11/22 at 9:30 a.m., LVN 2 did not administer calcium citrate-magnesium-mineral tablet to Resident 78. LVN 2 stated the medication order would have to be clarified with the Attending Physician (AP) because the way it was written was confusing. LVN 2 pulled out all the drawers in the medication cart and could not show a bottle of calcium citrate. During an interview and concurrent review of Resident 78's Medication Administration Record (MAR) for October 2022 with LVN 2 and the Director of Nursing (DON) on 10/11/22 at 2:35 p.m., Resident 78's MAR had the order for calcium-citrate-magnesium signed off by LVN 2 for the 9:00 a.m. dose. Both DON and LVN 2 went to the medication cart to look for calcium-citrate-magnesium and did not find any. DON stated she would call AP to find out if AP would want to change the order with something that was available at the facility. During an interview with AP on 10/11/22 at 2:45 p.m., AP stated the multivitamin tablet and calcium citrate were two different medications. AP stated Resident 78 needed extra calcium and that was why the calcium-citrate-magnesium was ordered. AP stated the DON needed to get the calcium citrate from the pharmacy if it was not available in the facility's inventory of over-the-counter (OTC) medications. During an interview with DON on 10/11/22 at 2:48 p.m., DON stated she looked again in the facility's medication room OTC cabinet and did not find any calcium citrate. Review of the facility's policy and procedure titled, Non-Controlled Medication Orders last revised December 2012 indicated the prescriber shall be contacted by nursing for direction when delivery of a medication will be delayed or the medication is not available. Review of Resident 78's clinical record did not indicate AP was notified of the unavailability of the ordered medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 5 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 75's Order Summary Report for October 2022 indicated the physician's order dated 9/14/22 for Resident 75 to receive Cinacalcet (reduces calcium levels in the blood) hydrochloride tablet 30 milligrams (30 mg) and an order dated 9/30/22 for Atorvastatin Calcium (lowers blood cholesterol) tablet 40 mg. Review of the MRR dated 9/24/22 indicated CP's )recommendation to monitor the following: parathormone (PTH, hormone released by the parathyroid gland, plays a key role in controlling calcium in the blood) level, calcium, phosphorus and lipid panel (blood tests used to find abnormalities in lipids, such as cholesterol and triglycerides). The review signed by the Attending Physician (AP) on 10/4/22 indicated a recommendation to check Resident 75's Vitamin D level. During an interview and concurrent record review with the Director of Nursing (DON) on 10/12/22 at 12:58 p.m., DON stated Resident 75 was admitted on [DATE], the medication regimen review by CP was done on 9/24/22. DON stated Resident 75 was sent to the hospital on 9/26/22 and returned on 9/30/22. DON further stated, before Resident 75 returned to the facility on 9/30/22, some laboratory tests were done that included calcium and phosphorus levels. DON stated AP had signed the recommendation but there was no order to do the laboratory tests that AP agreed to. DON also stated Resident 75's clinical record did not indicate laboratory tests had been done for the lipid panel, Vitamin D, and PTH. Review of the facility's policy and procedure titled, Medication Monitoring Medication Regimen Review and Reporting last revised October 2007 indicated, Recommendations shall be acted upon within a reasonable time frame. Based on interviews and record review, the facility did not follow their policy and procedure for Medication Regimen Review (MRR) and failed to act upon the Consultant Pharmacist's (CP) report of the medication irregularities for two (Resident 20 and 75) sampled residents when; 1. Resident 20, had CP recommendations to taper and decrease or discontinue use of Metformin ER (extended release medication to treat diabetes, a blood sugar disorder), Jardiance (diabetes), Effexor ER, Wellbutrin (antidepressant) and Pramipexole (treats symptoms of Parkinson's disease, a disorder of the central nervous system that affects movement, tremors) did not include the physician's medical/clinical rationale for continuing or disagreeing with the MRR recommendations. 2. For Resident 75, the CP recommendation was not acted upon in a timely manner. This deficient practices had the potential for residents to receive unnecessary drugs and result in adverse effects. Findings: 1. Review of order summary report dated 9/12/22 indicated the physician prescribed Resident 20 to received the following medications: - Metformin HCL (hydrochloride) ER tablet Extended Release 24 hour 500 mg (milligram), one tablet by mouth two times a day related to Type 2 Diabetes Mellitus (DM 2) with Diabetic Chronic Kidney (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 6 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Disease (Longstanding disease of the kidneys leading to renal failure. The kidney filters waste and excess fluid from the blood. As kidney fails the waste builds up). -Jardiance 25 mg one tablet by mouth, one time a day for DM 2. -Bupropion HCL ER (Wellbutrin XL) 450 mg one tablet by mouth in the morning for Bipolar (a long term mental disorder associated with episodes of mood swings).with Major depression with situational flare. -Venlafaxine HCL (Effexor) ER tablet extended release 24-hour 150 mg, give 3 tablets by mouth one time a day for Bipolar with Major depression. Review of the Consultant Pharmacist (CP) report, Note to attending physician /prescriber dated 9/20/22, indicated Resident 20 currently receiving above medications. Please consider tapering and decreasing or discontinuing orders. Please provide clinical rationale. Further review of CP's Note To Attending Physician/Prescriber dated 9/20/22 indicated Resident 20's physician disagreed with the CP recommendation and did not provide the requested clinical rationale. Review of Resident 20's Medication Administration Record (MAR) for October 1, 2022 through April 12, 2022 indicated Resident 20 continued to receive Metformin ER, Jardiance, Effexor ER, Wellbutrin and Pramipexole as ordered by the physician. During an interview on 10/12/22 at 9:50 a.m., the Director of Nursing (DON) stated Resident 20's physician did not provide the clinical rationale for disagreeing with CP's recommendations for Resident 20's MRR. The facility's policy and procedure titled, Medication Regimen Review and Reporting, dated October 2007 indicated, The physician may accept and act on recommendation or reject recommendation and provide an explanation for disagreement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 7 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interviews and record review, the facility failed to ensure two sampled residents (Resident 13 and 20) were free from unnecessary drugs when; -Resident 13 was administered Olanzapine (Zyprexa-an antipsychotic) medication without appropriate indication for use. -Resident 20 was administered Rexulti and Bupropion HCL ER (antidepressants) without adequate monitoring of behavior manifestations. {Psychotropic drug is any drug that affects brain activities associated with mental processes and behavior} {According to the manufacturer, Zyprexa is not approved for use in older adult with dementia-related psychosis}. [Reference: https://www.drugs.com/pro/zyprexa.html]. This deficient practice had the potential for residents to receive unnecessary medications and adverse side effects. Findings: Review of Resident 13's order summary dated 8/19/22 indicated the physician prescribed Zyprexa 5 mg (milligram) give 0.5 mg tablet by mouth at bedtime for prevention of psychosis (thoughts and emotions are impaired so that contact is lost with external reality). During an interview on 10/12/22 at 11:41 a.m., the Licensed Vocational Nurse (LVN 1) stated Resident 13 wanted to talk with staff. LVN 1 stated Resident 13 sometimes liked to be left alone. Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 3/5/22 indicated Resident 13's Basic Interview of mental status (BIMS) score was 03 (meaning poor cognitive impairment). Resident 13 had no physical behavioral symptoms such as hitting, kicking, pushing and grabbing or verbal behavioral symptom such as threatening, screaming and cursing directed towards others. Resident 13 diagnoses included Non-Alzheimer's Dementia (a brain disease characterized by changes in memory, thinking and reasoning, feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). Review of the Medication Administration Record (MAR), for 10/1/22 through 10/11/22, in the presence of the Director of Nursing (DON), indicated Resident 13 was administered Zyprexa 5 mg give 0.5 tablet by mouth at bedtime for prevention of psychosis. During an interview on 10/12/22 at 12:10 p.m., DON stated Zyprexa is an antipsychotic medication not used for prevention of psychosis but for definitive diagnosis. DON stated resident was admitted with Zyprexa and without the appropriate indication for its use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 8 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Order Summary report dated 9/12/22 indicated the physician prescribed Resident 20 to receive the following medications: Rexulti 2 mg one tablet by mouth daily for Bipolar (mood swings) with major depression and Bupropion HCL ER (Wellbutrin XL) 450 mg one tablet by mouth in the morning for Bipolar with Major depression with situational flare. Review of Resident 20's MAR for October 1, 2022 through October 12, 2022 indicated Resident 20 was administered Rexulti 2 mg one tablet and Wellbutrin XL 450 mg one tablet by mouth daily. During a review of 20's MAR and concurrent interview, on 10/12/22 at 9:25 a.m., the Licensed Vocational Nurse (LVN 1) stated the behavior manifestations for use of Rexulti and Wellbutrin XL were not monitored. During an interview on 10/12/22 at 9:50 a.m., DON stated the behavior manifestations are expected to be monitored for use of antidepressants. The facility's policy titled, Psychotropic Drugs, revised 05/2020 indicated, A Psychotropic drug is any medication that affects brain activities associated with mental processes and behavior which includes but is not limited to drugs in the following categories: anti-psychotic; antidepressant; antianxiety or hypnotic (sleep-inducing). Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 9 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 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 the medication error rate did not exceed five percent (%) or greater when three medication errors were observed out of 25 opportunities for error that totaled 12%. The medication error rate was calculated as follows: three divided by 25, then multiplied by 100, which equaled 12%. Residents Affected - Few 1. a. For Resident 75, the Licensed Vocational Nurse (LVN) 5 did not give instructions on how to use Spiriva (an inhaler medication to treat asthma [a condition when a person's airways become inflamed, narrow and swell which makes it difficult to breathe]) prior to handing the medication to Resident 75 for administration. b. For Resident 75, LVN 5 administered three inhalation medications in an incorrect sequence when Spiriva and Symbicort (a corticosteroid inhalation medication) were administered before albuterol-ipratropium nebulizer (combination of bronchodilators, works by relaxing and opening the air passages to the lungs to make breathing easier) treatment. These failures had the potential to result in Resident 75 not receiving the full dose and maximum benefit of the medications. 2. For Resident 78, LVN 2 did not administer calcium citrate (a mineral, to increase blood calcium levels) as ordered by the physician. This failure had the potential to result in low blood calcium levels for Resident 78. Findings: 1. Review of the manufacturer's prescribing information for Spiriva indicated Instructions for Use Spiriva Handihaler (tiotropium bromide inhalation powder) .Important Information about using your SPIRIVA HANDIHALER. Taking your full daily dose of medicine requires 4 main steps .Step 4 taking your full daily dose (2 inhalations from the same SPIRIVA capsule). Breathe out completely in 1 breath, emptying your lungs of any air .with your next breath, take your medicine .Breathe in deeply until your lungs are full .Hold your breath for a few seconds . take HANDIHALER device out of your mouth. Breathe normally again. To get your full daily dose, you must again, breathe out completely and for a second time breathe in from the same SPIRIVA capsule. [Reference:https://www.drugs.com/pro/spiriva.html]. Review of the manufacture's prescribing information indicated Patient Information Instructions for Use SYMBICORT .How to use SYMBICORT. Using your SYMBICORT inhaler .7. Breathe out fully (exhale) .place mouthpiece fully into your mouth and close your lips around it .8. Breathe in (inhale) deeply and slowly through your mouth .9. Continue to breathe in (inhale) and hold your breath for about 10 seconds, or for as long as is comfortable . [Reference: https://www.drugs.com/pro/symbicort.html]. During an observation and concurrent interview with LVN 5, on 10/11/22 at 9:03 a.m., LVN 5 did not instruct Resident 75 to breathe out completely prior to the administration of the Spiriva. LVN did not follow the instruction or use Step 4 as indicated in the manufacturer's prescribing information instructions. Furthermore, LVN 5 did not give instructions for Resident 75 to follow the instructions for use according to the manufacturer's prescribing information for SYMBICORT. Additionally, LVN 5 administered a total of three medications inhalation in the following sequence: first- spiriva (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 10 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 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 - Few handihaler, second- symbicort, and third-ipratropium-albuterol solution. LVN 5 stated, sometimes, Resident 75 would take Symbicort first, then Spiriva and would take the ipratropium-albuterol last, depending on what Resident 75 wanted and preferred at that particular time. During a follow-up interview with LVN 5 on 10/11/22 at 12:03 p.m., LVN 5 stated, before giving the inhaler medications Spiriva and Symbicort, LVN 5 stated she should have instructed Resident 75 to breathe in and breathe out completely before taking the first puff and waiting at least one minute before taking the second puff. LVN 5 stated she did not give instructions to Resident 75 because Resident 75 would not listen anyway. Review of the facility's policy and procedure titled, Medication Administration Oral Inhalations last revised December 2012, indicated the procedures of oral inhalations included; 9. Ask resident to breathe out (not exhaling into the inhaler). 10. Place inhaler mouthpiece under the top teeth and above tongue with mouth closed around the mouthpiece 11. Breathe in slowly through the mouth. 12. Hold breath for 5-10 seconds or for as long as possible to allow medication to reach deeply into lungs. Under Inhaler Sequencing, if more than one inhaler is used for maximum drug effectiveness. The policy and procedure indicated that following the sequence below provides the most benefit to the resident: -Bronchodilators- administered first if more than one inhaler to be administered at the same medication pass time. Examples include ipratropium-albuterol inhalation solution - Anticholinergic Agents- antagonizes the action of acetylcholine with resulting bronchodilation. Maybe more useful than traditional bronchodilators. Examples include Spiriva. - Corticosteroids- administer last if more than one inhaler to be administered at the same medication pass time. Symbicort is a combination product containing corticosteroid and a beta2 adrenergic agonist, a log-acting bronchodilator. 2. Review of Resident 78's Order Summary Report for October 2022 indicated an order for calcium citrate-magnesium-mineral tablet one tablet by mouth one time a day. During an observation and concurrent interview with LVN 2 on 10/11/22 at 9:30 a.m., LVN 2 did not administer calcium citrate-magnesium-mineral tablet to Resident 78. LVN 2 stated the medication order would have to be clarified with the Attending Physician because the way it was written was confusing. During an interview with LVN 2 on 10/11/22 at 11:47 a.m., (two hours after medication pass with Resident 78), LVN 2 stated she had not followed up with the Director of Nursing (DON) or the Attending Physician (AP) to discuss the medication order. LVN 2 stated Resident 78 was already taking a multivitamin with mineral which also has calcium and magnesium and thought the order was redundant. During an interview and concurrent review of Resident 78's Medication Administration Record (MAR) for October 2022 with LVN 2 and DON on 10/11/22 at 2:35 p.m., Resident 78's MAR had the order for calcium-citrate-magnesium signed off by LVN 2 for the 9:00 a.m. dose. The signing off a medication in the MAR meant the medication was administered. LVN 2 stated she had signed off the calcium-citrate-magnesium because LVN 2 thought it was the same medication as the multivitamin tablet. Resident 78's MAR indicated both multivitamin tablet and calcium-citrate-magnesium were signed off. Both DON and LVN 2 went to the medication cart to look for calcium-citrate-magnesium and did not find any. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 11 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 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 During a joint interview with AP and LVN 2, on 10/11/22 at 2:45 p.m., AP stated the multivitamin tablet and calcium citrate were two different medications. LVN 2 stated that multivitamin tablets have calcium in them too. AP answered Resident 78 needed extra calcium and that was why the calcium-citrate-magnesium was ordered separately. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 12 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record review, the facility failed to follow proper sanitation and food storage practices when: Residents Affected - Some - The High temperature dishwasher was not within the required temperature range - Kitchen floor tiles had brownish residual discoloration - Juice dispenser had a brownish substance around the nozzle - Food prep refrigerator had brownish debris at the bottom shelf area. - One 5 LB (pound) can of creamy peanut butter was past the used-by-date 9/22/22 - Food steamer with brownish substance and crumbs at the bottom shelf area. These deficient practices had the potential to result in foodborne illness and did not ensure sanitary conditions. Findings: During the initial observation tour of the kitchen on 10/10/22 at 9:36 a.m., accompanied by the Director of Dietary Services (DDS) and Registered Dietician (RD), showed the following: Kitchen floor tiles had brownish black residual discoloration, Juice dispenser with brownish substance around the nozzle, prep Refrigerator had brownish debris at the bottom shelf area, one can of creamy peanut butter was past the used-by-date 9/22/22, food steamer with brownish substance and crumbs at the bottom and the high temperature dishwasher had the final rinse temperature of 140 degrees Fahrenheit. During an interview on 10/10/22 at 9:48 a.m., DDS stated the facility used a high temperature dishwasher machine. During an observation on 10/10/22 at 9:40 a.m., in the presence of Dietary staff (DS 1) the dishwasher was operated to wash plates. The final rinse temperature was at 140 degree and below. During an interview on 10/10/22 at 9:48 a.m., DS 1 stated that the dish washer's temperature gauges fluctuates from time to time and was reported to the managers. DS 1 stated DDS was aware of the dishwasher not holding the temperature. During an interview on 10/10/22 at 10:10 a.m., DDS stated he was aware the the dishwasher temperature gauges was not reading correctly last week. DDS said the facility had notified the maintenance contractor and waiting for a response. During an interview on 10/10/22 at 10:19 a.m., DDS stated the kitchen floor tiles were old and that was why they were discolored. The Dishwasher Installation & Operation Manual indicated the Final rinse temperature and flow pressure gauges are accurate only when a rack enters the final rinse area and water is flowing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 13 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Acceptable temperature range is 180 - 195 degrees Fahrenheit and pressure should be 20 psi (pounds per square inch). The facility's policy and procedure titled, Sanitation and Infection Prevention Control, revised 1/22' indicated the Director: Confirms the wash and rinse temperatures listed on the manufacturer's data plate on the dish machine. Modify the dish machine temperature record as necessary. Event ID: Facility ID: 055156 If continuation sheet Page 14 of 15 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 055156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Paul's Towers 100 Bay Place Oakland, CA 94610 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 and interview, the facility failed to ensure proper garbage and refuse disposal when bags of garbage were stored in a dumpster without lids outside the kitchen area. Residents Affected - Few This failure had the potential for foul odors and attract unwanted pests. Findings: During an observation on 10/11/22 at 8:50 a.m., in the presence of the Director of Dietary Services (DDS), bags of garbage were stored in an open dumpster that did not have lids located at the back of the kitchen area. The dumpster was full with garbage. During an interview on 10/11/22 at 8:50 a.m., DDS stated the dumpster had no cover. DDS said the garbage is removed on Mondays, Wednesday and Fridays. According to the United States Food and Drug Administration (FDA) Food Code 2017, under Outside Receptacles, receptacles and waste handling units for refuse with materials containing food residue and used outside the food establishment shall be designed to have tight-fitting lids or covers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055156 If continuation sheet Page 15 of 15