Health inspection·April 8, 2021

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 ensure safe and sanitary food preparation when: Residents Affected - Some 1. Dietary [NAME] (DC)1 did not perform hand hygiene while handling and preparing chicken puree. 2. Food preparation sink and ice machine did not have an air gap (a gap created to prevent back flow of contaminated water). These failures had the potential to cause food contamination and food born illnesses in residents. Findings: 1. During a observation and concurrent interview on 04/05/21, at 11:46 a.m., with DC 1, in the kitchen, a blender (mixer) filled with chicken was running on the kitchen countertop on the left side of the tray line. DC 1 was observed with blue colored gloves on both hands. DC1 touched the stove regulator (dials to control the stove heat temperature) with gloved hands, then picked up a glass measuring cup, proceeded to the dirty dish washing sink, turned on the faucet, half-filled the measuring cup with water from the sink faucet designated for washing dirty dishes, and then turned the faucet off. DC 1 proceeding to the tray line , turned off the blender, opened the blender lid, added water to the existing blended chicken, and closed the lid, without performing hand hygiene, and changing gloves, DC 1 went back to the dirty dish washing sink, turned on the faucet, half-filled the measuring cup with water designated for washing dirty dishes, and turned the faucet off, returned to the blender, opened the lid, added more water to the blender and added one spoon of a white powder to the blender. DC 1 stated it was a thickner. DC 1 picked a basting brush from a pot of butter sitting on the stove, brushed a quarter pan with butter, and poured the chicken puree into that quarter pan. DC 1 did not perform hand hygiene or change her gloves while completing these tasks During an interview on 4/5/21, at 12:35 p.m., with the DC1, in the kitchen, DC1 stated she should have washed her hands and changed her gloves while preparing the chicken puree. During an interview on 4/6/21, at 1:05 p.m., with the Registered Dietician (RD), RD stated kitchen staff should wash their hands in between handling food and then touching something else which is not food. The facility Policy and Procedure titled Food Handling, dated 2018, indicated All Food and Nutrition service personnel will wash their hands prior to handling all food. 2. During a concurrent observation and interview, on 4/5/21, at 12:25 p.m., with the Dietary Supervisor (DS)1 and the Maintenance Supervisor (MS)1, in the kitchen, the food preparation sink did not have an air gap. MS1 confirmed the food preparation sink did not drain through an air gap. During a record review of facility document titled, Contract Change Order (CCO), dated 4/7/21, the CCO indicated, Need to install airgap under the sink. During a concurrent observation and interview, on 4/8/21, at 12:30 p.m., with DS1 and MS1, in the kitchen, the ice machine did not have an air gap MS1 and DS 1 confirmed the ice machine did not drain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055775 If continuation sheet Page 2 of 6 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 055775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orinda Care Center, LLC 11 Altarinda Road Orinda, CA 94563 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 through an air gap. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/6/21, at 1:05 p.m., with the RD, the RD stated an air gap was needed to prevent cross contamination, food sanitation, and backlog of the dirty water. Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Accident Prevention-Safety Precautions, dated 2018, the P&P indicated, An air gap is the most reliable backflow prevention device. It is the physical separation of the potable and non-potable water supply systems by an air space. All steam tables, ice machines and bins, food preparation sinks, display cases, soda fountains, espresso machines and other equipment that discharge liquid waste or condensate shall be drained through an air gap into an open floor sink. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055775 If continuation sheet Page 3 of 6 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 055775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orinda Care Center, LLC 11 Altarinda Road Orinda, CA 94563 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents' food brought from outside was labeled and stored appropriately in one of one residents' food refrigerator and freezer. Residents Affected - Some This failure had the potential to cause food contamination and food borne illnesses in residents. Findings: During a concurrent observation and interview, on 4/6/21, at 11:37 a.m., with Certified Nursing Assistant (CNA 1) and the Director of Staff Development/Infection Control Preventionist (DIC), in facility's copy room, the facility's refrigerator and freezer designated for residents' food brought from outside stored the following items: a. An unlabeled, undated 12 (ounces) oz jar of organic apricot fruit spread, 16 oz of chunky blue cheese dressing, 6 oz of hot sauce. CNA 1 stated she did not know who these food items belonged to. b. A 20 oz coffee drink, CNA 1 stated the coffee drink belonged to her. CNA 1 stated she was not sure if staff could keep their food in resident's food refrigerator. c. An unlabeled, undated, partially eaten meat pizza slice, on a disposable plate and covered by another disposable plate, The (DIC) stated that was an all meat pizza and belonged to facility staff. DIC also stated staff should not use resident's food refrigerator to store their own food to prevent cross contamination. d. A 64 oz of diet orange Juice in a clear pitcher dated 4/1/21, DIC stated facility should discard the food items after three days from the open date. e. An unlabeled, 5.2 oz of bean and cheese burrito, and a 3.5 oz of vanilla pack, CNA1 stated she did not know who those two food items belonged to. During an interview, on 4/6/21, at 1:05 p.m., with the Registered Dietician (RD), the RD stated, it was important to label the food, so that resident's food did not get mixed with other residents' food, and staff's food. RD stated food should be labeled and dated to prevent confusion and to prevent cross contamination. During a review of the facility's policy and procedure (P&P) titled, Bringing in Food for a Resident, dated 2018, the P&P indicated, Food or beverages should be labeled and dated to monitor for food safety. Food or beverages in the original containers marked with the manufacturer expiration dates and unopened, need to be marked with resident's name Prepared foods, beverages, or perishable foods that require refrigeration will be marked with the date food was opened and resident's name FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055775 If continuation sheet Page 4 of 6 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 055775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orinda Care Center, LLC 11 Altarinda Road Orinda, CA 94563 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 Based on observation, interview, and record review, the facility failed to follow its policy in verifying the effectiveness of Spirit II disinfectant against the bacterial organism found in one (Resident 18) of 39 sampled residents . Residents Affected - Some This failure had the potential to result in the spread of Enterobacter Cloacae(member of the normal gut flora) which could result in the infection of additional residents, possible facility outbreak, and the possibility of resident death. Findings: Review of Resident's 18's face sheet dated 1/16/20, indicated Resident 18 was admitted to the facility with a diagnosis of chronic hepatitis C (infection caused by a virus that attacks the liver that can lead to an infection), cancer of the skin and gastro-esophageal reflux disease (a condition in which acidic gastric fluid flows backward into the esophagus (connects the throat to the stomach) causing heart burn without esophagitis. During an interview on 04/06/2021, at 9:30 a.m., with the Director of Staff Development/Infection Preventionist Consultant (DIC), the DIC stated that Resident 18 had bacteria which was categorized under CRE (Carbapenem-Resistant Enterobacteriacea (a family of infectious bacteria), and that the bacteria was currently colonized (an infectious process not currently active). The DIC stated that per the CRE policy, Resident 18 was allowed to be out of her room and may ambulate throughout the facility. During an interview on 04/07/2021, at 10:35 a.m., the Maintenance Supervisor (MS1), stated the spray disinfectant used on all public surfaces such as handrails in the hallways and the tabletops in the dining room was disinfectant one. During an interview on 04/07/2021, at 12:30 p.m., with the MS1, DIC and Infection Preventionist (IP), the DIC gave examples of Enterobacter bacteria that are killed by the disinfectant Spirit II, but MS1 and DIC could not locate the bacteria Enterobacter Cloacae on disinfectant one bottle. During an observation on 04/07/2021, at 1:30 p.m., Resident 18 was observed exiting the smoking patio by entering the facility through the sun room. During an observation on 04/07/2021, at 2:00 p.m., House Keeper (HK)1 disinfected the door handles to the sun room using disinfectant one. During an interview on 04/07/2021, at 2:30 p.m., the DIC stated that the manufacturer of the disinfectant disinfectant one confirmed that the disinfectant is a germicide and will disinfect against all germs. DIC stated she was waiting for the manufacturer to provide a complete list of bacteria that disinfectant one was effective against. During an observation on 04/08/2021, at 9:00 a.m., Resident 18 was observed entering the smoking patio through the sun room. The DIC was present in the sun room and requested the work surfaces and door handles to be disinfected. At 9:15 a.m. HK1 cleaned and disinfected Sun Room door handles and work surfaces using Spirit II. At 9:30 a.m. House Keeper (HK)2 came to the sun room and began cleaning and disinfecting the door handles and work surfaces with disinfectant one. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055775 If continuation sheet Page 5 of 6 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 055775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orinda Care Center, LLC 11 Altarinda Road Orinda, CA 94563 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 04/08/2021, at 2:00 p.m., the DIC stated that she was continuing to search for the complete list of bacteria that disinfectant one was effective against but did not have the list of bacteria at that time. During a review of the facility's policy and procedure (P&P) titled, CRE (Carbapenem-Resistant Enterobacteriacea) Management Policy (undated) the P&P indicated to Check the disinfectants used to clean environmental surfaces. Check that the products used have appropriate 'kill claim' or claim of effectiveness against the organism that is causing infection. Event ID: Facility ID: 055775 If continuation sheet Page 6 of 6