Health inspection·April 22, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for one (Resident 45) of 11 sampled residents, the facility failed to develop a comprehensive care plan within seven days of completion of the Minimum Data Set (MDS, a resident assessment tool used to guide care). This failure had the potential to result in unmet care needs for Residents 45. Findings: A review of Resident 45's face sheet indicated Resident 45 was admitted to the facility on [DATE] with multiple diagnosis including obstructive sleep apnea (a blockage of the upper airway occurring during sleep which prevents normal breathing; common causes include swollen tonsils or excessive relaxation of the throat muscles causing collapse/narrowing of the airway). A review of Resident 45's MDS dated [DATE], indicated Resident 45 was able to understand others and be understood. The MDS also indicated Resident 45 was on oxygen therapy. During an interview on 04/19/22, at 10:35 a.m., Resident 45 stated since he had lung surgery a month ago, he had used oxygen regularly during the night and sometimes needed oxygen during the day. During an interview and concurrent record review on 04/19/22, at 9:55 a.m., with the Director of Nursing (DON), the DON stated Resident 45 should have had a nursing care plan for Resident 45's use of oxygen to ensure nursing staff knew Resident 45's care needs. The DON was unable to provide documentation of a care plan which included goals and interventions for Resident 45's need for oxygen use. A review of the facility's policy and procedure, Comprehensive Person-centered Care Planning, revised November 2018, indicated, Within 7 days from completion of the MDS assessment, the comprehensive care plan will be developed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055215 If continuation sheet Page 2 of 13 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 055215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide weekly showers to one of twenty residents (Resident 27) as requested by Resident 27's emergency contact. Residents Affected - Few This failure resulted in Resident 27's not receiving preferred bathing services (a weekly shower) and had the potential to result in decreased comfort and hygiene. Findings: A review of Resident 27's admission Record (AR), undated, indicated Resident 27 was originally admitted in 2017 with diagnoses of dementia (a chronic disorder marked by memory disorders, personality changes, and impaired reasoning), muscle weakness, and abnormalities of gait and mobility. The admission Record also indicated Resident 27 had a family member as an emergency contact, FAM 1. A review of Resident 27's Minimum Data Set (MDS, an assessment tool used to guide care), dated 1/20/22, indicated Resident 27 was rarely/never able to understand others and rarely/never was understood by others. The MDS indicated it was somewhat important for Resident 27 to choose between shower, tub, bed, or sponge bath. The MDS indicated Resident 27 had moderately impaired vision (could not read newspaper headlines but could identify shapes) and was totally dependent on physical assistance from one person for bathing. A review of Resident 27's care plan for ADL [activities of daily living] self-care performance deficit, dated 9/19/21, indicated an intervention of, Bathing/showering: The resident is totally dependent on staff to provide bath/shower and as necessary. A review of the facility's shower schedule for the 3:00 p.m.-11:00 p.m. shift, undated, indicated Resident 27 was scheduled for a shower every Tuesday and Friday. During a phone interview on 4/14/22, at 10:27 a.m., with FAM 1, FAM 1 stated she wanted Resident 27 to get at least a weekly shower to keep Resident 27 clean and make her feel better. During a concurrent interview and record review on 4/20/22, at 12:16 p.m., with Certified Nursing Assistant 2 (CNA 2), Resident 27's Activities of Daily Living (ADL) flowsheet, dated April 2022 was reviewed. CNA 2 stated Resident 27's ADL flowsheet under type of bathing, had no indication any showers had yet been given during the month of April 2022. During a concurrent interview and record review on 4/20/22, at 12:25 p.m., with CNA 2, the facility Resident Shower Binder was reviewed. CNA 2 was unable to provide documentation to show Resident 27 had received a shower during the month of April 2022. CNA 2 stated if Resident 27 had received or refused a shower during the month of April 2022, there would have been a Shower Sheet in the Resident Shower Binder for Resident 27. During an interview on 4/21/22, at 10:44 a.m., with the Assistant Director of Nursing (ADON), the ADON stated she was aware that FAM 1 wanted Resident 27 to be showered once a week, preferable on Friday, but was unable to provide documentation that Resident 27 had received any showers in April. The ADON stated certified nursing assistants were to provide residents showers according to the resident's shower schedule and document the shower on the ADL flowsheet and complete a Shower Sheet for the Resident Shower Binder each time a shower was given. The ADON stated if a resident refused a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055215 If continuation sheet Page 3 of 13 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 055215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete shower, the refusal should be documented, and the licensed nurse notified that a skin assessment was needed. During a review of the facility's policy and procedure (P&P) titled, Showering and Bathing, dated 1/1/12, the P&P indicated, A tub or shower bath is given to the residents to provide cleanliness, comfort, and to prevent body odors. Residents are given tub or shower baths unless contraindicated. Event ID: Facility ID: 055215 If continuation sheet Page 4 of 13 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 055215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, for one of twenty sampled residents (Resident 29), the facility failed to arrange for surgery for treatment of a left eye cataract. (A cataract is a cloudy area in the lens of the eye that leads to a decrease in vision.) Residents Affected - Few The failure to arrange for Resident 29's eye surgery resulted in delayed treatment to improve Resident 29's vision in his left eye for five months and 13 days. Findings: A review of Resident 29's admission Record, undated, indicated Resident 29 was admitted in 2020 with multiple diagnoses including diabetes mellitus (a chronic condition of uncontrolled blood sugar). During a review of Resident 29's care plan, dated 10/27/21, the care plan indicated, The resident has impaired visual function on the left eye. Goal: The resident will show no decline in visual function and . will maintain optimal quality of life . A review of Resident 29's Ophthalmology Consultation Record (OCR), dated 11/3/2021, the OCR indicated Resident 29's vision in the left eye was 20/200 (20/200 means a person with normal vision can stand 200 feet away from an object and see that object perfectly, but the person with impaired vision must stand within 20 feet of the same object to see it clearly.) The OCR indicated, Plans and comments: Refer for Cataract surgery . Goals of treatment: Quality of life enhancement. During an interview on 4/18/22, at 11:09 p.m., with Resident 29, Resident 29 stated he had cataract surgery on his right eye before the pandemic, but he had difficulty seeing from his left eye, and needed to have cataract surgery on his left eye so he could see from his left eye again. Resident 29 stated he had been seen by an ophthalmologist (a physician who specializes in treatment of eye diseases) and had discussed his need for cataract surgery with the Social Services Director (SS), but the surgery had not yet been arranged by the facility. During a review of Resident 29's form titled, Physician Referral for Surgery/Procedure and Referral to Specialist, dated 11/3/2021, the Physician Referral indicated a recommendation for Resident 29 to have cataract surgery on his left eye within three months. During a concurrent interview and record review on 4/21/22, at 10:39 a.m., with the Social Services Director (SS), Resident 29's social service progress notes were reviewed. The SS stated he knew Resident 29 needed cataract surgery on his left eye. SS was unable to provide documentation of any attempted arrangements for Resident 29's left eye cataract surgery. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055215 If continuation sheet Page 5 of 13 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 055215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, for one of eight sampled residents (Resident 74) with limited range of motion (ROM, a joint or body part with limited range of motion, cannot move through its normal range of motion; also known as contractures,), the facility failed to: 1. Apply knee immobilizer (a removable brace to maintain stability of the knee) daily to resident's right (R) knee as ordered by the physician. 2. Provide resident with ROM exercises three times a week as ordered by the physician, and according to the plan of care. These failures resulted in unmet care needs for Resident 74 and had the potential to result in decreased range of motion. Findings: 1. A review of Resident 74's admission Record, dated 4/21/22, indicated Resident 74 was admitted to the facility in February 2022, with diagnoses of Alzheimer's dementia, (a progressive disease that result in memory loss), history of fracture to the right femoral shaft (upper leg bone) and right humerus (upper arm), muscle weakness, and other abnormalities of gait and mobility. A review of Resident 74's Minimum Data Set (MDS, an assessment tool used to guide care), dated 2/27/22, indicated staff had assessed Resident 74 as moderately impaired memory skills. The MDS indicated Resident 74 had impairment of the right upper extremity and right lower extremity and required total physical assistance from one person for bed mobility, toilet use, and personal hygiene. The MDS indicated Resident 74 used a wheelchair for locomotion and required total physical assistance from two people for transfer between surfaces. A review of Resident 74's Medication Administration Record (MAR) dated 4/1/22-4/30/22, indicated a Physician Order with a start date of 2/20/22, for a knee immobilizer to be worn on Resident 74's right knee at all times until Resident 74 was seen by an orthopedic surgeon. During a concurrent observation and interviews on 4/21/22, at 10:14 a.m., with Certified Nursing Assistant 4 (CNA 4) and the Assistant Director of Nursing (ADON), Resident 74 lay in bed in her room with the head of the bed elevated. Resident 74 had her right leg constantly bent at the knee (contracted) and did not have a knee immobilizer on the right leg. CNA 4 stated she had not seen Resident 74's knee immobilizer for a while. The ADON searched Resident 74's room and stated she was unable to locate Resident 74's knee immobilizer. During an interview on 4/22/22, at 9:00 a.m., with the Director of Rehabilitation (DOR), DOR stated Resident 74 was admitted to the facility after right knee surgery and had a physician order for a knee immobilizer to keep the right knee from moving. A review of the policy and procedure (P&P) titled, Splinting, revised 1/1/21, indicated, Purpose: to prevent contractures or decreased tone and to protect joint alignment. It is the policy of this facility for the RNA staff to be responsible for applying and managing the splint application schedule for the residents under the supervision of the Nursing Department . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055215 If continuation sheet Page 6 of 13 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 055215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. A review of Resident 74's Order Summary, dated 4/5/22, indicated an order for Restorative Nursing Assistant (RNA) Program (exercises aimed towards improving or maintaining function) daily three times a week for 90 days for ROM exercises to left lower extremity until 7/5/22. During a concurrent interview and record review on 4/21/22, at 9:49 a.m., with Restorative Nursing Assistant 1 (RNA 1), Resident 74's Restorative Nursing Program documentation, dated April 2022, was reviewed. The document indicated the goal for Resident 74's was to prevent complications of contracture and skin breakdown, with a plan of providing RNA program three times a week of assisted ROM to left lower extremity, start date of 4/5/22. RNA 1 stated the document indicated Resident 74 had only received ROM by an RNA on three occasions in April so far: 4/10/22, 4/12/22, and 4/15/22. RNA 1 stated Resident 74 should have also received ROM by RNA staff on 4/8/22, 4/17/22, and 4/19/22. Review of the facility's policy and procedure (P&P) titled, Restorative Nursing Program Guidelines, revised date 11/8/16, indicated, .This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning unless a decline is unavoidable based on the resident's clinical condition .The RNA carries out the restorative program according to the Care Plan and documents daily .The Care Plan for each resident will be updated with any changes to the Restorative Nursing Program when they occur . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055215 If continuation sheet Page 7 of 13 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 055215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609 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 observations, interviews, and record reviews, the facility failed to ensure the two alarms on the South Station emergency exit were functional: the emergency exit alarm and the Wanderguard alarm. (Wanderguard is a system to alert caregivers when residents are attempting to exit a facility unsupervised. It is a two-part system: a bracelet worn by the resident, and a sensor installed on an exit. When the bracelet passes across the sensor, there is an audible alarm.) The failure to ensure the audible alarms worked on the South Station emergency exit door resulted in one (Resident 70) of 11 sampled residents entering the patio balcony without authorization or supervision and had the potential for unsafe wandering by other residents. Findings: A review of Resident 70's admission Record indicated she was admitted to the facility in 2017 with a diagnosis of vascular dementia (brain damage due to lack of oxygen to the brain). During a concurrent observation on 4/19/22, at 3:00 p.m., Resident 70 sat in a wheelchair in the South Station non-smoking balcony area and smoked. During a concurrent observation and interview on 4/19/22, at 3:20 p.m., with Resident 70, Resident 70 sat in a wheelchair in her room. Resident 70 stated she had smoked on the South Station balcony patio earlier that day, but she couldn't recall how she had gotten onto the balcony patio. During an interview on 4/21/22, at 7:10 a.m., the Activities Director (AD) stated Resident 70 must have used the South Station emergency exit to access the South Station balcony patio to smoke. AD stated Resident 70 was too weak to have wheeled herself around the facility to the South Station balcony patio from the pathway-connected North Station patio. During a concurrent observation and interview on 4/19/22, at 3:10 p.m., of the South Station emergency exit door with Housekeeping Supervisor (HS), the emergency exit door had three posted signs, two signs were posted paper, 8.5 inches wide by 11 inches long, the third sign was permanently affixed and indicated, EMERGENCY EXIT - KEEP DOOR CLOSED. Sign one was on white paper and indicated, DO NOT OPEN THIS DOOR - ALARM WILL SOUND! Sign two was on red paper and indicated, EMERGENCY EXIT ONLY. The door had a silver metal box affixed in the upper left area with a central keyhole and the word off on the top of the box, and the word on on the bottom of the box. On the doorjamb next to the doorknob was a white box with four numbered buttons. HS stated the silver metal box was the emergency exit door alarm and the white box was part of the Wanderguard alarm system. HS opened the emergency exit door; no audible alarm sounded. HS inserted a key into the silver metal box, turned the key, and stated he was resetting the alarm. HS opened the door and an audible door sounded. HS left the area and returned with a Wanderguard test unit and tested the Wanderguard alarm; no audible alarm sounded. HS stated he needed to reset the Wanderguard alarm and reset the alarm. During an interview on 4/20/22, at 8:30 a.m., Administrator (ADM) stated the emergency exit doors should not have the alarms turned off. During a concurrent interview and record review on 4/20/22, at 10:00 a.m., with the Maintenance Personnel (MP), the facility Wanderguard Door Module Testing Calendar, was reviewed. MP stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055215 If continuation sheet Page 8 of 13 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 055215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609 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 checked the Wanderguard alarms once each day, and documented the test on the form, Door Module Testing Calendar. MP stated the Door Module Testing Calendar did not indicate the Wanderguard module on the South Station emergency exit door was checked on 4/19/22. During a concurrent interview and record review on 4/20/22, at 12:15 p.m., with Central Supply (CS), the facility form, Monitored Doors and Gates Checklist, was reviewed. CS stated he checked emergency door exits three times a day: AM, Noon, and PM and documented the checks on the form, Monitored Doors and Gates Checklist. CS stated the Monitored Doors and Gates Checklist, did not indicate any of the emergency exits were checked on 4/19/22 PM, 4/20/22 AM, and 4/20/22 Noon. A review of the facility policy and procedure, Elopement Risk Reduction Approaches, dated November 2012, indicated, .Ensure that residents are able to move about freely, are monitored and remain safe Ensure that staff alert and elopement alarm/warning systems are the least intrusive and burdensome possible Install non-intrusive alarm systems that alert staff to resident exiting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055215 If continuation sheet Page 9 of 13 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 055215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609 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, interview, and record review, the facility failed to follow proper sanitation, food handling, and food storage practices when: Residents Affected - Some 1. Refrigerator 2 contained the following items: A container which held raw cucumbers, bell peppers and asparagus bunches: the cucumbers and bell peppers were nine days past the use by date on the container label; there was no label for the asparagus. A bag of cilantro leaves with part of the leaves discolored, and no use by date on the bag label. An unlabeled container with a discolored yellow bell pepper. An unlabeled container with a head of wilted cabbage. 2. The freezer had an undated sealed bag of French bread. 3. The freezer section of the freestanding white refrigerator had an undated bag of whipped topping. 4. [NAME] 2 did not perform hand hygiene in between tasks during tray line (serving and plating of food). These failures had the potential to result in food contamination and resident foodborne illnesses. Findings: 1. During a concurrent observation and interview with Registered Dietitian 1 (RD 1) on 4/18/22, at 10:38 a.m., Refrigerator 2 had a clear plastic container holding twelve cucumbers, two red bell peppers, and four bunches of asparagus. The outside of the container had three labels that indicated: cucumber prep date 4/4/22, use by date 4/9/22; bell pepper prep date 4/4/22, use by date 4/9/22. Five of the cucumbers were mushy and had scattered white fuzzy dots, with slimy white liquid beneath one of the cucumbers. A second container in Refrigerator 2 was unlabeled and had a yellow bell pepper with a half-dollar size dark discoloration on the side of the pepper. A plastic bag labeled, prep date 4/11/22, had green cilantro leaves in the top portion of the bag and yellow leaves in the bottom portion. A clear plastic container with a head of wilted cabbage was unlabeled. RD 1 stated the prep date on the labels indicated the date the vegetables were received. RD 1 stated the cucumbers, cilantro, yellow bell pepper, and cabbage were no longer edible and should be discarded. RD 1 stated raw vegetables should be separated and labeled with the name of the item and a use by date. 2. During a concurrent observation and interview with RD 1 on 4/18/22, at 10:45 a.m., Freezer 2 had a sealed bag of French bread with no received date or use by date. RD 1 stated the bread should have a received or use by date. 3. The freezer section of the freestanding white refrigerator had a sealed bag of whipped topping with no received date or use by date. RD 1 stated all food items and bags should be labeled with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055215 If continuation sheet Page 10 of 13 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 055215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609 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 received dates or use by dates. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2020, indicated, All food items in the store room, refrigerator, and freezer need to be labeled and dated .Food delivered to facility needs to be marked with a received date . Residents Affected - Some 4. During an observation on 4/19/22, at 12:10 p.m., [NAME] 2 plated food on the tray line with ungloved hands. [NAME] 2 stated the barbecue sauce was getting low and would need refilling. [NAME] 2 left the tray line and went to Refrigerator 1, opened the door, and removed a plastic container holding brown liquid. [NAME] 2 carried the container to the stove, poured the brown liquid into a pot on the stove, and left the container on the kitchen counter. [NAME] 2 returned to the tray line and resumed plating of the food, without any intervening hand hygiene. RD 1 and RD 2 stated kitchen staff should perform hand hygiene whenever changing tasks, such as when [NAME] 2 left the tray line to remove an item from the refrigerator. A review of the facility's policy and procedure (P&P) titled, Dietary Department, Infection Control for Dietary Employees, revised November 2016, indicated, To ensure that the dietary department is maintained in a sanitary condition in order to prevent food contamination and the growth of disease producing organisms and toxins. All dietary employees will follow Infection Control Policies as established and approved by the facility's Infection Control Committee .Proper Hand washing by Personnel will be done as follows: .During food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks .Before dispensing or serving food or handling clean tableware and serving utensils in the food service area. After engaging in any other activities that contaminate the hands . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055215 If continuation sheet Page 11 of 13 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 055215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609 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 follow policies and procedures for infection control for one (Resident 133) of 11 sampled residents when Certified Nurse Assistant 1 (CNA 1) entered Resident 133's room without wearing required personal protective equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury). Residents Affected - Few The failure to wear PPE necessary for a resident with contact and droplet precautions (Contact and droplet precautions are actions implemented to prevent the spread of infection based upon the transmission mode of direct or indirect contact with respiratory secretions from the resident or environmental surfaces contaminated with respiratory secretions) had the potential to result in transmission and spread of infection. Findings: A review of Resident 133's admission Record (face sheet) indicated Resident 133 was admitted to the facility on [DATE] with multiple diagnosis including cellulitis (inflammation of subcutaneous connective tissue) on both lower legs. During an interview on 4/21/22, at 12:45 p.m., with the Infection Preventionist (IP), IP stated Resident 133 was considered a Person Under Investigation (PUI, a person without symptoms or a positive lab test, but potentially infectious) for COVID-19 (a contagious respiratory disease). IP stated Resident 133 had only received one of two needed doses of the COVID-19 vaccination series before entry to the facility, so he had been placed in isolation with contact and droplet precautions. IP stated contact and droplet precautions required staff to wear full PPE when providing direct care to a resident. IP stated full PPE included: a gown, gloves, face shield, and an N95 mask (a type of PPE worn as a mask, used to protect the wearer from airborne particles or from liquid contaminating the face.) During an observation on 4/19/22, at 9:39 a.m., Certified Nursing Assistant 1 (CNA 1) entered Resident 133's room wearing only a surgical mask and gloves. During an interview on 4/19/22 at 9:45 a.m., with CNA 1, CNA 1 stated she had entered Resident 133's room to answer his call bell and had assisted Resident 133 don a T-shirt. CNA 1 stated Resident 133 was a PUI resident due to his new admission status and required use of full PPE, but Resident 133 was yelling and she forgot to don all necessary PPE as she hurried to answer his call bell. During an interview on 4/19/22 at 10:00 a.m., with the Director of Nursing (DON), the DON stated the facility's staff should wear full PPE when providing direct care to PUI residents. During a review of the facility's policy and procedure titled, COVID-19 Mitigation Plan, revised 3/24/22, indicated PPE needed when providing direct care to PUI residents included: eye protection in the form of a face shield or goggles, a gown, gloves, and an N95 respirator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055215 If continuation sheet Page 12 of 13 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 055215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, for one (Resident 70) of three sampled residents who smoked, the facility failed to ensure smoking policies and procedures were followed when Resident 70 smoked in an area designated as a non-smoking area. Residents Affected - Few The failure to ensure Resident 70 smoked in area with a readily available fire extinguisher, an ashtray made of a noncombustible material, and a metal container with a self-closing cover for emptying ashtrays, had the potential to result in a fire. Findings: A review of Resident 70's admission Record indicated she was admitted to the facility in 2017 with a diagnosis of vascular dementia (brain damage due to lack of oxygen to the brain). During an observation on 4/19/22, at 3:00 p.m., Resident 70 sat in a wheelchair in the South Station non-smoking balcony area and smoked. During a concurrent observation and interview on 4/19/22, at 3:20 p.m., with Resident 70, Resident 70 sat in a wheelchair in her room. Resident 70 stated she had smoked on the South Station balcony patio earlier that day, but she couldn't recall how she had gotten onto the non-smoking balcony patio. During an observation on 4/19/22 at 3:30 p.m., with the Activity Director (AD) on the South Station balcony patio, there was concrete flooring and two wooden planter boxes in the patio. On the ground, beneath the bottom edge of the planter box which held plants, was a cigarette butt; a second cigarette butt lay on the concrete flooring approximately four feet from the planter box which held only dirt. During an observation on 4/21/22 at 7:50 a.m., with AD, the North Station Dining Room patio had a permanently affixed sign posted on the wall which indicated, DESIGNATED SMOKING AREA. A continuation of a tour of the North Station patio area showed a connecting pathway to the South Station Patio with a sign posted on the pathway wall which indicated, NO SMOKING! DESIGNATED SMOKING AREA IS LOCATED AT THE DINING ROOM PATIO. A review of the facility policy and procedure, Smoking by Residents, revised January 2017, indicated, Smoking by residents is allowed outside the facility in designated, marked smoking areas with the following safety measures readily available: . Ashtrays made of combustible material and safe design; Metal containers with self-closing covers into which ashtrays can be emptied; Portable fire extinguisher FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055215 If continuation sheet Page 13 of 13