Health inspection·May 20, 2022

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed obtain a doctor's order and assess one of one resident (Resident 67) ability to self-administer medications when Resident 67 had a bottle of Sore Throat Oral Anesthetic Spray (medication to temporarily relieve sore throat pain) bottle at the bedside. Residents Affected - Few This deficient practice had the potential to result in Resident 67 using the Sore Throat Oral Anesthetic Spray against safe dosing recommendations. It also had the potential to result in the use of the medication by other residents, who could potentially obtain Resident 67's medication from the bedside table where it was stored. Findings: During a concurrent observation and interview on 6/16/22, at 11:35 a.m., with Resident 67, at Resident 67's bedside, a bottle of Sore Throat Oral Anesthetic Spray was observed on Resident 67's overbed table. Resident 67 stated she used the Sore Throat Oral Anesthetic Spray whenever she felt throat pain. Resident 67 further stated she did not remember how often she used the spray, nor how much spray she used. During a review of Resident 67's admission Record, dated 5/19/22, indicated Resident 67 was admitted to the facility on [DATE] and has medical diagnoses including stenosis of larynx, anxiety disorder, and other specified diseases of upper respiratory tract. During a review of Resident 67's minimum data set (MDS, a comprehensive assessment tool to guide care), dated 4/22/22, indicated Resident 67 had a Brief Interview for Mental Status (BIMS, a screening tool to assess cognitive function) score of seven which indicated severe cognitive impairment. During an interview with Registered Nurse (RN) 1, on 5/16/22, at 11:55 a.m., RN 1 stated the bottle of Sore Throat Liquid may stay at Resident 67's bedside because Resident 67 was alert and oriented. RN 1 further stated she was not aware an assessment was needed prior to allowing residents to self-administer medication(s). During a concurrent interview and record review, with the Interim Director of Nursing (IDON), on 5/18/22, at 10:45 a.m., the IDON stated the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their patients) must fill out the Assessment for Self-Administration of Medications form and review it prior to recommending a resident to self-administer medications. The IDON also stated the Assessment for Self-Administration of Medications form was not completed for Resident 67. Page 1 of 24 055876 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0554 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Medication-Self Administration, dated 1/1/12, the P&P indicated, The Facility will allow a resident to self-administer medications when determined capable to do so by the IDT [Interdisciplinary Team] and the resident's Attending Physician. Residents Affected - Few 055876 Page 2 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 27) preferences for showers were followed, when Resident 27's scheduled shower days were missed from April through May 2022. This failure resulted in Resident 27's request and preference for showers not being honored. Findings: During an interview on 5/16/22, at 12:30 p.m., with Resident 27, Resident 27 stated he does not receive showers as scheduled. Resident 27 stated he told the Administrator (ADM) and the Interim Director of Nursing (IDON) about missed showers. Resident 27 stated he was scheduled to have showers twice a week on Tuesdays and Fridays and prefers to take them on his scheduled days. Resident 27 stated his scheduled shower last Friday was missed because of short staff and had to wait until Monday for a shower. Resident 27 further stated it makes him feel annoyed and agitated when his showers are missed because he wants to be clean. During a review of Resident 27's admission Record, dated 5/18/22, indicated Resident 27 was admitted on [DATE]. The admission Record indicated Resident 27 has medical diagnoses including hemiplegia (paralysis of one side of the body) of left non-dominant side, major depressive disorder, anxiety disorder, dependence on wheelchair, and traumatic arthropathy (arthritis or joint disease) of left shoulder. During a review of Resident 27's minimum data set (MDS, a comprehensive assessment tool to guide care), dated 3/16/22, indicated Resident 27 had a Brief Interview for Mental Status (BIMS, a screening tool to assess cognitive function) score of 15 which indicated intact cognition. During an interview on 5/17/22, at 11:52 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated there were days when the facility was short staffed, and showers were missed. CNA 1 stated residents receive showers twice a week. CNA 1 stated completed showers are recorded on the residents' Skin Assessment form and Activities of Daily Living (ADL, activities related to personal care) Flowsheet. During a review of Princeton Manor Shower Schedule PM Shift, updated 4/7/20, indicated Resident 27 has scheduled showers on Tuesday and Friday. During a record review of Resident 27's comprehensive health assessment, dated 9/7/21, indicated Resident 27 responded very important to the question How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? During a record review of Resident 27s comprehensive health assessment, dated 3/9/22, indicated Resident 27 has supervision for bathing. During a concurrent interview and record review on 5/19/22, at 10:30 a.m., in the IDON's office, with the IDON, Resident 27's ADL Flowsheet, dated April through May 2022, were reviewed. The IDON stated showers and sponge baths were documented in the ADL Flowsheets. The IDON stated Resident 27's 055876 Page 3 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0561 Level of Harm - Minimal harm or potential for actual harm scheduled showers were on Tuesdays and Fridays. The IDON stated the P indicated sponge bath and the S indicated shower on the ADL Flowsheet. The IDON confirmed there were no S's or showers documented for Resident 27 in the April and May 2022 ADL Flowsheets. The IDON stated she does not know why there were only sponge baths documented for Resident 27. The IDON stated there needs to be education on showers and documentation. Residents Affected - Few During a review of the facility's policy and procedure (P&P), titled, Showering and Bathing, revised 1/1/12, the P&P indicated, A tub or shower bath is given the residents to provide cleanliness, comfort, and to prevent body odors. 055876 Page 4 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure the comprehensive care plan for falls were updated and implemented for one of one sampled resident (Resident 67), when Resident 67 was identified as a high risk for falls and experienced multiple falls. This failure resulted in Resident 67 experiencing a fractured left femoral neck (hip bone), requiring a left hemiarthroplasty (hip replacement surgery) from the fall, and was transferred to the acute care hospital for treatment. Findings: A review of Resident 67's admission Record, dated 5/19/22, indicated Resident 67 was admitted to the facility on [DATE] with diagnoses that included paralysis (the loss of the ability to move (and sometimes to feel anything) in part or most of the body and weakness of the left side of the body. A review of Resident 67's Minimum Data Set (an assessment tool to guide care), dated 7/21/21, indicated Resident 67's Brief Interview for Mental Status (BIMS, a screening tool to assess cognitive function) score was seven which indicated moderate impaired cognition. A review of Resident 67's Fall Risk Assessment, dated 10/21/21, indicated Resident 67's fall risk score was 18 which indicated a high risk for falls. The assessment also indicated Resident 67 experienced multiple falls within the last six months. The assessment further indicated Resident 67 exhibits loss of balance while standing, requires hands on assistance to move from place to place, uses an assistive device, and has decrease in muscle coordination. A review of Resident 67's medical records from 8/11/2021 through 4/8/3022 indicated Resident experienced a fall on 8/11/21, 10/21/21, and 4/8/22. A review of Resident 67's fall risk care plan, initiated 4/20/21, indicated Resident 67 is high risk for falls related to gait and balance problems, incontinence, and left sided hemiparesis. The care plan interventions included: -ensuring call light within reach -educating resident about safety reminders -encouraging resident to participate in activities -ensuring resident is wearing appropriate footwear -following facility fall protocol -evaluating and treating resident as ordered or as needed -reviewing information on past falls and attempt to determine cause of falls and record possible root causes. 055876 Page 5 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 67's fall care plan, initiated 8/11/21, indicated resident has had an actual fall with no injury, poor balance, unsteady gait on 8/9/21. The care plan interventions included: -Continue interventions on the at risk plan -Monitor, document, and report as needed to doctor for signs and symptoms of pain, bruises, and change in mental status, new onset of confusion, sleepiness, inability to main posture, and agitation for 72 hours -Neuro checks for 72 hours -PT [physical therapy] consult for strength and mobility -Vital signs every shift for 72 hours. A review of Resident 67's Progress Notes, dated 10/21/21, indicated [Resident 67] told staff that she fell and it's suspected that she was self transferring to her bedside commode .Her roommate reports that she heard a noise at night and woke up to see [Resident 67] on the floor . [Resident 67] was reporting leg pain . IDT [interdisciplinary team] will safety measures when she returns such as bed in low position, floor mat, side rail, etc . A review of Resident 67's acute care hospital (ACH) History and Physical record, dated 10/21/21, indicated Resident 67 Presents from SNF [skilled nursing facility] secondary to fall out of bed, found to have L [left] femoral neck fracture. Per patient she uses a wheelchair at baseline . L sided paresis [partial paralysis] but had a dream that she could walk and tried to step out of bed this morning .remembers nurse helping her off the floor and into bed . Per nursing staff at her SNF, her fall was unwitnessed. She had been complaining of pain to her L hip. Nursing staff did not document finding her out of her bed, and the nursing staff that I spoke with was unaware of the event. They state that she has otherwise seemed to be at her baseline mental status and with normal vitals. The only complaint that she has had is the pain to her L hip. A review of Resident 67's ACH imaging record, dated 10/21/21, indicated Resident's 67 left hip x ray indicated a left femoral neck fracture and There is a superior and lateral displacement of the distal fracture component. A review of Resident 67's ACH Orthopaedic Surgery Progress Note, dated 10/23/22, indicated Resident 67 presenting with L [left] femoral neck fx [fracture] now s/p [status/post, refers to a treatment and often a surgical procedure] L hemiarthroplasty [a surgical procedure that involves replacing half of the hip joint] on 10/21, pt [patient] remains stable since surgery. A review of Resident 67's ACH Discharge summary, dated [DATE] indicated resident was admitted to ACH from 10/21/21 to 10/26/21 due to a left displaced femoral neck fracture. A review of Resident 67's fall care plan initiated on 10/21/21, indicated Resident 67 has had an actual fall with L femur fx d/t [due to] poor balance, unsteady gait. The care plan interventions included: -bed in low position, call light in reach 055876 Page 6 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0656 Level of Harm - Minimal harm or potential for actual harm -continue interventions on the at risk plan for no apparent acute injury, determine and address causative factors of the fall -monitor, document, and report as needed to doctor for signs and symptoms of pain, bruises, and change in mental status, new onset of confusion, sleepiness, inability to main posture, and agitation for 72 hours Residents Affected - Some -pharmacy consult to evaluate medications -provide activities that promote exercise and strength building where possible -PT consult for strength and mobility -vital signs every eight hours for 72 hours. During observations on 5/17/22, at 11:00 a.m. and 5/18/22, at 10:00 a.m., Resident 67 was observed using a wheelchair to propel herself throughout the facility. There was no fall mat observed located at Resident 67's bedside. During a concurrent interview and medical record review on 5/20/22 at 9:30 a.m., with Registered Nurse 1 (RN 1), Resident 67's fall history was discussed. RN 1 stated she was on morning duty on 10/21/22 when RN 1 received a phone call from an ACH doctor informing RN 1, Resident 67 was discovered with a fracture. RN 1 stated the assigned nurse for Resident 67 during the night shift did not report the fall incident to RN 1. RN 1 stated the night shift nurse reported to RN 1 that Resident 67 was transferred out to hospital. The multiple fall care plans were reviewed with RN 1 and RN 1 was requested to comment about Resident 67's nursing interventions. RN 1 stated a care plan was created after each fall incident, not revised, was vague and not detailed to appropriately care for Resident 67. RN 1 stated she would have added frequent monitoring, an example of a nursing intervention, to update or revise the care plan to prevent additional falls for Resident 67. A review of Resident 67's fall care plan, initiated on 4/8/22, indicated Resident 67 has had an actual fall (no injury) poor balance, unsteady gait on 4/8/22. The care plan interventions included: -continue interventions on the at risk plan for no apparent acute injury, determine and address causative factors of the fall -PT consult for strength and mobility -vital signs (FREQ). During an interview on 5/19/22, at 11:30 a.m., with the Interim Director of Nursing (IDON), the IDON stated she assessed Resident 67 and determined Resident 67 was independent. The IDON stated Resident 67 removed the armrest on her wheelchair and the wheel brake was not long enough to prevent Resident 67 from scooting out of the chair. The IDON stated she would notify the PT to evaluate the Resident 67 to add a longer handbrake to the wheelchair. The IDON stated the interdisciplinary team was going to implement frequent checks on the resident, every hour. The IDON further stated these interventions would be added to Resident 67's care plan. 055876 Page 7 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review, on 5/20/21, at 10:11 a.m., with the PT, the Therapy Post Fall Screen, dated 4/11/22 was reviewed. The Therapy Post Fall Screen, indicated Resident 67 did not require physical therapy. The PT stated he educated Resident 67 to use the call light to get out of bed and for assistance when items are out of reach. Review of the facility's policy and procedure (P&P), titled, Fall Management Program, revised on 3/13/21, indicated, The Facility will implement a Fall Management Program that supports providing an environment free from fall hazards .A .the licensed nurse will complete a fall risk evaluation. If a fall risk factor is identified, document interventions on the Resident's care plan .B. A licensed nurse will conduct a new fall risk evaluation .upon identification of a significant change of condition, post fall and as needed .C. The Interdisciplinary Team (IDT) and/or the licensed nurse will develop a care plan according to the identified risk factors and root cause(s) per Care Area Assessment (CAA) guidelines. The P&P further indicated, for a resident who is identified as high risk for falls, the IDT will meet monthly to review the fall risk interventions for appropriateness and effectiveness until the frequency of their falls diminishes and The Residents' care plans will be updated with the IDT's recommendations. 055876 Page 8 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure that its medication error rate was not five percent or greater. During the medication pass (med pass) observation, there were six medication errors observed out of 36 opportunities which resulted to a med pass error rate of 16.6 percent. Residents Affected - Some This failure had the potential for Resident 54 not getting the full therapeutic benefit of the medications. Findings: During a medication pass observation on 5/17/22 at 8:40 a.m., Registered Nurse 1 (RN1) crushed six medications of Resident 54: Metoprolol 25mg (used to treat high blood pressure), Lovastatin 20mg (used to lower cholesterol), Tamsulosin 0.4mg (for the treatment of enlarged prostate), Metformin 500mg (used to treat high blood sugar levels), Memantine 10mg (for dementia), Lisinopril 40mg (used to treat high blood pressure and heart failure). A review of Resident 54's admission Record, dated 5/19/22, indicated Resident 54 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), high blood pressure and dysphagia (difficulty swallowing). During a concurrent interview and record review, with the Interim Director of Nursing (IDON) on 5/17/22, the IDON was not able to find physician's orders for the medications of Resident 54 to be crushed. The IDON stated there should be a physician's order stating nurses may crush the medications. The facility's policy and procedure titled: Medication Administration dated 1/1/12 indicated, if the resident has difficulty swallowing pills, the licensed nurse will notify the physician to discuss possibility of a different form of the medication i.e. crushed, liquid or suspension. If the medication is to be crushed, a physician's order is required. 055876 Page 9 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0760 Ensure that residents are free from significant medication errors. 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 ensure one of one sampled resident (Resident 54) was free of significant medication error, when Resident 54's oral medications were all crushed and administered together without a physician's order. Residents Affected - Some This deficient practice had the potential for Resident 54 not receiving the full benefits of the medications. Findings: During a medication pass observation on 5/17/22, at 8:40 a.m., Registered Nurse 1 (RN1) crushed all of Resident 54's prescribed medication in a plastic pouch: Metoprolol 25mg (used to treat high blood pressure), Lovastatin 20mg (used to lower cholesterol), Tamsulosin 0.4mg (for the treatment of enlarged prostate), Metformin 500mg (used to treat high blood sugar levels), Memantine 10mg (for dementia), Lisinopril 40mg (used to treat high blood pressure and heart failure) poured them in a medicine cup, mixed it with apple sauce, then served it to Resident 54, followed by a teaspoonful of Medpass Plus 2.0 (a medication pass drink which delivers more nutrition than water). RN1 stated she crushed the medications because she feared Resident 54 might choke if given whole medication tablets. A review of Resident 54's admission Record, dated 5/19/22, indicated Resident 54 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), high blood pressure and dysphagia (difficulty swallowing). During a concurrent interview and record review, with the Interim Director of Nursing (IDON) on 5/17/22, the IDON was not able to find physician's orders for the medications of Resident 54 to be crushed. The IDON stated there should be a physician's order stating nurses may crush the medications. During a review of the facility's policy and procedure (P&P) titled, Medication-Administration, dated 1/1/12, indicated, If the resident has difficulty swallowing pills, the licensed nurse will notify the physician to discuss the possibility of a different form of the medication i.e crushed, liquid or suspension. If the medication is to be crushed, a physician order is required. 055876 Page 10 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, facility failed to follow its policy and procedure on Oxygen Therapy when there was no date on the oxygen tubings of Resident 62. This deficient practice had the potential of delivering oxygen in an unsafe and unsanitary condition to resident. Findings: During the initial tour of the facility on 5/16/22 at 11:55 a.m., Resident 62 had two (2) oxygen concentrators ( a device that concentrates oxygen by removing nitrogen to supply oxygen-enriched gas), and two(2) small oxygen tanks in her room. The two(2) concentrators each had 25 feet tubings connected by a Y tube to deliver a high dose of oxygen to Resident 62. The two(2) oxygen tanks were set up with tubings and were a back up source of oxygen, in case of a power outage. The oxygen tubings connected to the two(2) concentrators and two(2) oxygen tanks were not dated. In an interview with Registered Nurse (RN)1 on 5/16/22 at 12:10 p.m., she stated she was not sure when the tubings were changed. She stated there were no labels indicating the date the tubings were changed. Review of the facility policy titled: Oxygen Therapydated November 2017 indicated:Oxygen tubing, mask, and cannulas will be changed no more than every seven (7) days and as needed. The supplies will be dated each time they are changed. 055876 Page 11 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and facility document review, the facility failed to provide adequate oversight of the kitchen when multiple issues were identified with kitchen safety and sanitation; equipment was not maintained; food was not served so it was palatable and cooked to maintain nutritive value; and staff were not trained and competent for calibrating thermometers and cooking food to a safe temperature. These failures had the potential to result in food being served to residents in a safe and sanitary manner resulting in food borne illness; attract pests to the kitchen resulting in contamination of food, utensils, and equipment; and decrease the amount of food intake for residents resulting in nutritional related medical issues, for 71 residents who received food from the kitchen out of a facility census of 71. Findings: Review of the undated job description provided for the Dietary Supervisor (DS), titled, Director of Nutritional Services, indicated this position ensured the preparation of nutritious meals to all residents, maintained a safe and sanitary work environment, and monitored staff performance through coaching, evaluated quality of services accomplished by staff. During the Federal Re-certification survey conducted from 5/16/22 to 5/20/22, multiple issues were identified, including: 1.) food was not stored in a safe and sanitary environment when food stored inside a freezer was not frozen; door screens had rips, holes, and were not securely fitted; pans used for cooking were in poor condition; an ice scoop used for scooping ice was not protected from pests and other contaminants; ice was not stored in an area where staff could wash their hands before scooping ice; staff did not demonstrate proper hand hygiene when serving food; and oven mitts were soiled and came into contact with food (Cross-reference F812); 2.) a leaking drainpipe from a 2-compartment sink was not fixed after staff reported it to the DS (Cross-reference F-809); and 3.) food was not prepared in a manner to conserve nutritive value and vegetables served were not palatable (Cross-reference F804). In addition, it was identified that a cook was not competent and not trained on 1.) safe cooking temperatures for meat; and 2.) calibrating thermometers. 1. An observation on 5/18/22, at 12:02 p.m., showed [NAME] 2 removed a pan with multiple meatloaves from the oven. She placed a thermometer in the meatloaf and stated the meatloaf had to be at least 140 degrees Fahrenheit (F). She continued to take the temperature of the meatloaf then stated the meatloaf should be 145 degrees F. Then she placed the thermometer in several other spots in the meatloaf and said the meatloaf had to be 150 degrees F. She showed the temperature of the meatloaf taken in the various spots were 142 degrees F, 155 degrees F, and 175 degrees F. [NAME] 3 and Diet Aide 1 (DA 1), told [NAME] 2 the temperature was not okay so [NAME] 2 placed the meatloaf back in the oven. After speaking with [NAME] 3 and DA 1, [NAME] 2 stated the temperature of the meatloaf had to be 165 degrees F. In an interview on 5/19/22, at 11:50 a.m., DS stated she did not know if [NAME] 2 was trained on cooking temperatures for meat and she did not have in-service documentation indicating she was trained. Review of the policy and procedure titled, Meat Cookery and Storage, dated July 1, 2014, showed 055876 Page 12 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0801 ground beef had to be cooked to an internal temperature of 155 degrees F for at least 15 seconds. Level of Harm - Minimal harm or potential for actual harm Review of the recipe titled, Garden Fresh Meatloaf, dated Week 3 Wednesday, and provided for the meatloaf served for lunch on 5/18/22, indicated ground beef was an ingredient and the internal temperature of the meatloaf must register at least 165 degrees for 15 seconds. Residents Affected - Many 2. In an observation and concurrent interviews with [NAME] 2 and the DS, on 5/18/22, at 10:30 a.m., [NAME] 2 stated thermometers were usually calibrated by cooks on Mondays and she was one of the cooks that calibrated thermometers. [NAME] 2 demonstrated how to calibrate thermometers by placing two, bi-metallic food thermometers (dial thermometers) in a glass filled with ice and some water. The thermometers read 28- and 30-degrees F, and she said they were okay. [NAME] 2 said if thermometers were not at the correct reading, she just discarded them. [NAME] 2 stated she did not know the thermometers were calibratable. [NAME] 2 said she wanted to learn how to calibrate the thermometers, so the DS demonstrated. The DS took the thermometer out of the ice water and turned the dial, so it read 32 degrees Fahrenheit (F). Then the DS placed the thermometer back in the ice water and the thermometer read 5 degrees F. The DS said the temperature was not right. The DS repeated the steps by removing the thermometer from the ice water and turned the dial on the thermometer and placed it back in the ice water, this time the thermometer read 20 degrees F. Review of the policy and procedure titled, Calibrating a Thermometer, dated July 1, 2014, indicated how to calibrate a bi-metallic food thermometer. The procedure indicated to fill a glass with ice and add water then place the thermometer in the glass of ice water. Then wait until the thermometer stabilizes and the thermometer should be 32 degrees F. If the thermometer is not 32 degrees F, then leave it in the ice water and turn the thermometer dial until the needle reads 32 degrees F. In an interview on 5/19/22, at 11:50 a.m., DS stated she did not know if [NAME] 2 was trained on calibrating thermometers and she did not have in-service documentation showing she was trained. Review of an undated, written statement provided by the ADM, titled [Name of [NAME] 2] - Cook indicated, Competency evaluation was not done at the time of hire. However, the Dietary Supervisor will provide 90 days evaluation for the employee. 055876 Page 13 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure vegetables were palatable and cooked in a manner to conserve nutritive value for 71 residents who received food from the kitchen out of a facility census of 71. Residents Affected - Many This failure had the potential for residents to not consume the amount of nutrients planned for the menu. Findings: An observation and concurrent interview with [NAME] 1, on 5/16/22, at 10:30 a.m., [NAME] 1 was observed pureeing food in a food processor. [NAME] 1 stated she was pureeing the turkey for lunch. [NAME] 1 said she just put the pureed green beans and pureed bread on the oven. [NAME] 1 stated the regular green beans were in the oven too. Inside the oven, was one large pan covered with foil and two smaller pans covered with foil. [NAME] 1 lifted the foil off the large pan to show it held green beans. [NAME] 1 stated she had to heat them up and planned to take them out at 11:45 a.m. to place on tray-line which started at 12 p.m. [NAME] 1 confirmed the oven was set at 450 degrees F. Review of the recipe titled, Green Beans with Garlic, dated Week 3 Monday, and provided for the recipe used for the green beans served for lunch on 5/16/22, indicated the recipe called for frozen green beans and to heat green beans . The recipe did not indicate how long to cook the green beans for and at what temperature. In an interview on 5/16/22, at 11:30 a.m., Resident 15 stated the food was horrible and said the vegetables were too watery. A record review for Resident 15, indicated she was [AGE] years old, she had a Brief Interview of Mental Status (BIMS; a test used to get a quick snapshot of how well a person is functioning cognitively) score of 15 (a BIMS score of 15 indicates intact cognition meaning there is no sign of dementia or cognitive impairment), and she was on a Regular diet. In an interview on 5/18/22, at 2:20 p.m., Dietary Supervisor (DS) stated the green bean prepared for lunch on Monday, were canned green beans. DS stated the green beans might take 30 - 40 minutes to heat-up in an oven at 450 degrees Fahrenheit (F). In an interview on 5/19/22, at 10:19 a.m., Registered Dietitian 1 (RD 1) stated vegetables cooled too long could become too soft and mushy and might lose nutrients. RD 1 said residents might not think the overcooked vegetables were appealing and refuse to eat them. RD 1 stated sometimes canned green beans were substituted for frozen green beans if frozen green beans were not available from the supplier. RD 1 confirmed the cooking time and temperature for the green beans were not on the recipe. In an interview on 5/19/22, at 2:28 p.m., RD 1 stated cooking canned vegetables for over an hour was way too long. RD 1 said cooking the vegetables that long would make them too mushy and the residents may not like them, and it would likely decrease the nutrient value. 055876 Page 14 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

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 facility document review, the facility failed to ensure a safe and sanitary environment in the kitchen when: Residents Affected - Many 1. Food was not frozen when stored in a reach-in freezer; 2. Two door screens were not intact and sealed properly to help prevent insects and rodents from entering the kitchen; 3. Cooking pans were in poor condition; 4. The ice machine was not stored in an area to help prevent contamination of the ice; 5. There were no air-gaps for the food preparation sink and the 2-compartment warewashing sink; 6. Staff did not practice appropriate hand hygiene; and 7. Soiled oven mitts came into contact with food. This failure had the potential to cause contamination of food resulting in food borne illness for 71 residents who received food from the kitchen out of a facility census of 71. Findings: 1. An observation and concurrent interview with the Dietary Supervisor (DS), on 5/16/22 at 10 a.m., showed food stored in the 2-door, reach-in freezer number 2 was not frozen solid when the food was pressed, and it was soft. Foods that were not frozen solid in the freezer included a plastic bag filled with plain doughnuts; a box of plain doughnuts, three loaves of packaged garlic bread, a large, full container of ice cream, over 20 frozen nutritional supplements, and three bags of packaged hashbrown potatoes. The built-in temperature display screen located on the outside of the freezer, read negative 1 degrees Fahrenheit (F). Two thermometers located on the shelves inside the freezer, read 10 055876 Page 15 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many degrees F. DS stated she recorded the temperatures of the freezer onto the temperature log the last two mornings. DS stated she used the thermometer reading located on the outside of the freezer to document the freezer temperature and did not look at the internal thermometers. In a concurrent observation and interview with DS, on 5/16/22, at 1:58 p.m., DS stated she figured out why the food was getting soft in the freezer. DS demonstrated when the right door was opened then pushed closed, the left door opened and stayed ajar a half inch. An observation and concurrent interview with DS, on 5/17/22, at 12:42 p.m., showed single serving plastic containers of ice cream served on the lunch trayline (a system of food preparation in which trays move along an assembly line). The ice cream cups were stored in a metal container filled with melting ice, so the cups were partially floating in the ice water. The ice cream cups were not solid and the sides of the plastic cups easily pressed in. DS confirmed the ice cream was melted. DS also stated it was difficult to keep the ice cream cups in freezer number 2 during trayline because the door was not closing properly to keep the food frozen. Review of the Refrigerator/Freezer Temperature Log, dated May 2022, indicated written instructions, . Freezer temperatures should be 0 degrees F or below. If temperature is not within this range, report to supervisor-on-duty immediately or contact Maintenance for correction. Document corrective actions taken in appropriate column as necessary. According to the 2017 Federal Food Code, frozen food is to be maintained frozen. 2. An observation and concurrent interview with [NAME] 1 and DS, on 5/16/22, at 10:35 a.m., showed the back doors were open and a magnetic bug screen was attached to the doors. The magnetic screens were two screen panels with a magnetic strip down the middle for the purpose of closing the two screen panels. On the door located closer to the stove, the screen magnets were not connected so the two sides of the screen door were not closed leaving an open gap to the outside. The bottom of the screen was not attached to anything, so it laid loose on the ground. In addition, the screen was ripped in the middle creating a hole over 1 inch by 3 inches long; and it was ripped at the bottom creating a hole over 3 inches by 5 inches long. [NAME] 1 stated she kept the back door open at times because the kitchen was hot due to the majority of the air conditioning vents in the kitchen not working. DS confirmed the magnetic screen door was open and was ripped. DS stated flies could come in through the holes. Three flies were flying around inside the kitchen. In an interview on 5/17/22, at 10:25 a.m., the Environmental Manager (EM) stated the procedure for communicating maintenance needs in the kitchen was for staff to log the issues in the maintenance logbook located in station 1. EM stated he was not aware of the ripped screen door because kitchen staff did not report it. EM confirmed the magnetic strips that held the two sides of the screen door together near the bottom of the screen door, did not connect which left a gap in the screen. EM stated flies could come in through the gaps and the rips in the screen. An observation on 5/18/22, at 12:15 p.m., showed the back door located next to the 2-compartment sink, was open. The two screen panels of the magnetic door screen were not closed, leaving a gap in the screen the entire height of the door. Toward the top, the gap between the screens was one inch and toward the bottom the gap was over four inches. The bottom of the screen was not attached to anything, so it laid loosely on the ground. Staff were preparing food at the food preparation table next 055876 Page 16 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0812 to the open door. Level of Harm - Minimal harm or potential for actual harm An observation and concurrent interview with EM and the Administrator (ADM), on 5/19/22, at 9:15 a.m., showed the back door near the 2-compartment sink was open and the magnetic screen was not fully closed which left a gap in the screen. The administrator agreed that rodents could potentially enter the kitchen because the bottom of the screen was not attached and laid loosely on the ground. Residents Affected - Many According to the 2017 Federal Food Code, if doors of a food establishment are kept open for ventilation, or other purposes, the openings shall be protected against the entry of insects and rodents by mesh screens (16 mesh per 1 inch), properly installed air curtains, or other effective means. 3. An observation on 5/16/22, at 10:42 a.m. showed cooking pans hanging from a rack in the stove area. The cooking surface of one pan had black residue build-up on the inside cooking surface. The cooking surfaces of five pans had cooking surfaces with black and orange residue build-up, and scratches. [NAME] 1 stated she did not use the pan with the most orange residue build-up, but she did use the other pans. DS stated she ordered two new pans to replace the worst pans but did not receive them yet. DS stated she was going to replace all the pans eventually. According to the 2017 Federal Food Code, food-contact surfaces are to be easily cleanable, smooth and free of chips, inclusions, pits and similar imperfections. Also, food-contact surfaces are to be clean to sight and touch; and the food contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulation. 4. An observation and concurrent interview with Nourishment Staff 1 (NS 1), on 5/16/22, at 2:08 p.m., showed an ice machine located in an outdoor patio area outside of the activity room. An ice scoop was inside a scoop container attached to the wall. The lid on the scoop container was open, leaving the scoop uncovered. When the lid was closed, there was a gap at the area where there was a hole cut out for the scoop handle. NS 1 opened the door to the activity room, then unlocked the door to the patio and opened the door to the patio, then handled the lock on the ice machine. Then NS 1 removed the ice scoop from the container on the wall and scooped ice into an ice cooler. NS 1 stated the ice was for the kitchen and there was only one ice machine at the facility. There was no handwashing sink in the patio area where the ice machine was located to allow staff to clean their hands before scooping ice. In an interview on 5/17/22, at 8:18 a.m., DS stated a kitchen staff retrieved ice from the outdoor ice machine before each meal and the ice was used to keep milk and juices cold during meal service. DS stated nurses also retrieved ice from the outdoor ice machine which was used for ice water for residents. In an observation and interview with EM, on 5/17/22, at 10:14 a.m., EM stated he was responsible for cleaning the inside of the ice machine. EM opened the top of the machine, so the internal parts were visible. The plastic that covered the condenser had black residue on the surface. EM stated it was a little dust. In an interview on 5/18/22, at 10:45 a.m., Registered Nurse 1 (RN 1) stated some residents liked 055876 Page 17 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many ice in their water. RN 1 said any nursing staff filled coolers with ice from the outside ice machine, to have ice available for residents. In an interview with the Registered Dietitian (RD) and a concurrent observation of the ice machine, on 5/19/22, at 10:58 a.m., RD stated staff could wash their hands in the kitchen before getting ice, but in order to get ice, they would contaminate their hands between the kitchen and scooping ice because they had to open doors and handle the lock on the ice machine. RD also agreed the ice scoop was not fully protected from insects even when the scoop container was closed since there was a gap in the lid when it was closed. RD said she thought the scoop was cleaned daily but insects could come into contact with the scoop between cleanings. According to the policy and procedure titled, Ice Machines & [and] Ice Storage Chests, dated October 1, 2014, indicated the ice scoop was to be in a covered container when not in use. According to the 2017 Federal Food Code, hand washing is to occur when working with exposed food, clean equipment and utensils, and after engaging in other activities that contaminate the hands. According to the 2017 Federal Food Code, cleaned equipment and utensils are to be stored where they are not exposed to dust or other contamination. In addition, during pauses in food dispensing, dispensing utensils such as ice scoops, are to be stored in a clean protected location. 5. During an observation on 5/17/22, at 8:32 a.m., in the facility kitchen, the Food Preparation and the 2-Compartment Ware Washing sinks were observed. Both sinks were plumbed directly to the floor without an air gap (space that separates a water line from a sink to a sewer). During an interview on 5/17/22, at 10:52 a.m., with Dietary Aid 1 (DA 1), DA 1 stated the 2-Compartment Ware Washing sink was for washing items used for food preparation. During an interview on 5/17/22, at 10:33 a.m., with EM, EM stated the Food Preparation and the 2-Compartment Ware Washing sinks were plumbed directly into the sewage system and did not have an air gap. According to the 2017 Federal Food Code, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. 6. During an observation on 5/17/11, at 12:00 p.m., in the facility Kitchen, [NAME] 2 was observed. Before [NAME] 2 started trayline, [NAME] 2 did not wash her hands before she put gloves on. During an observation on 5/17/11, at 12:33 p.m., in the facility Kitchen, [NAME] 2 was observed during trayline. [NAME] 2 prepared resident lunch plates and did not wash her hands after [NAME] 2 removed her gloves and before she put new gloves on. During an interview on 5/17/22, at 12:42 p.m., with DS, DS stated [NAME] 2 did not wash her hands when she changed gloves during trayline. DS stated staff need to wash their hands before they put on gloves. 055876 Page 18 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, dated 9/1/20, the P&P indicated, The following situations require appropriate hand hygiene . Before and after food preparation . Before donning (putting on) and after doffing (removing) Personal Protective Equipment (PPE). According to the 2017 Federal Food Code, food employees are to wash their hands and exposed portions of their arms before donning gloves to initiate a task that involves working with food. 7. During an observation on 5/17/22, at 11:51 a.m., in the facility Kitchen, [NAME] 2 was observed during trayline. [NAME] 2 poured two pans of cooked baked chicken into a container, on the steam table. [NAME] 2's oven mitts came into contact with the chicken and sauce that when into the pan on the steam table. [NAME] 2 placed the chicken and sauce from the pan onto plates for resident lunches. During a concurrent observation and interview on 5/18/22, at 9:28 a.m., in the facility Kitchen, with DS, 4 oven mitts were observed. The oven mitts were observed with orange residue on outer surface. DS stated the residue on the oven mitts were from food. DS stated oven mitts were not cleaned or laundered. DS stated that the oven mitts should not come into contact with food because it is a risk for cross contamination. During an observation on 5/18/22, at 12:19 p.m., in the facility Kitchen, [NAME] 3 picked up an oven mitt she dropped on the kitchen floor and placed it on the food preparation counter. The oven mitt came into contact with an opened bag of breadcrumbs, and a plastic container of onion powder. During an interview on 5/19/22, at 10:19 a.m., with RD, RD stated staff should not use an oven mitt that fell on the floor, they should use a clean oven mitt. RD stated oven mitts that fell on the floor should be washed because oven mitts have the potential to contact food. During an interview on 5/20/22, at 8:25 a.m. with Regional Registered Dietitian (RRD), RRD stated oven mitts that fell on the floor should immediately be placed in the soiled linen bin so housekeeping clean and sanitize it with chemicals. RRD stated If an oven mitt fell on the floor, it should not be placed on the counter or near the food prep area. RRD stated the floor is not sanitary and it is a risk for cross contamination. According to the 2017 Federal Food Code, cloth gloves may not be used in direct contact with food unless the food is subsequently cooked. 055876 Page 19 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to follow infection control policies and procedures when the Infection Preventionist (IP) did not properly disinfect and store reusable ice bags. Residents Affected - Few This deficient practive had the potential to place residents at risk for spread of infection and cross contamination. Findings: During a concurrent observation and interview on 5/17/22, at 11:20 a.m., at the medication room in Nurses Station 1, with Licensed Vocational Nurse 1 (LVN 1), the Nurses Station 1 resident food refrigerator was observed. The refrigerator did not have food inside. There were four re-useable ice packs in the refrigerator compartment and five re-useable ice packs in the freezer compartment. LVN 1 stated the ice packs were for residents, for issues such as pain, and residents needed a doctors order for them. During an interview on 5/18/22, at 9:45 a.m., with LVN 1, LVN 1 stated the ice packs in the Nurses Station 1 fridge were from physical therapy. During an interview on 5/18/22, at 9:52 a.m. with Physical Therapist (PT), PT stated the ice packs were reusable, and shared between residents. PT stated the ice packs contained a chemical that kept them cold, longer. PT stated after residents used the ice packs, they were bleached for about five minutes, allowed to dry, wiped with alcohol, then placed in Nurses Station 1 refrigerator. PT stated the ice packs stored in the food refrigerator was a risk for cross contamination. During an interview and record review on 5/18/22, at 10:01 a.m., at the medication room in Nurses Station 1, with IP, IP stated after residents used the ice packs, they were rinsed in the sink, then placed back in the refrigerator. IP stated the Nurses Station 1 refrigerator was designated as a food refrigerator. The Medication Room Temperature Log, dated May 2002, posted on the Nurses Station 1 fridge was reviewed. IP stated staff took fridge temperatures to make sure it was the proper temperature for food. IP stated they must get another refrigerator for ice packs. During an interview on 5/18/22, at 1:03 p.m., with Physical Therapy Aide (PTA), PTA stated after residents used ice packs, they were sanitized for four minutes per manufacturer's instruction and placed back in the refrigerator. During an interview on 5/19/22, at 12:30 p.m., with Interim Director of Nursing (IDON), IDON stated the Nurses Station 1 refrigerator was designated for food only. IDON stated the ice packs were not supposed to be reused or kept in the refrigerator. IDON stated ice packs should not be in the refrigerator because of cross contamination. IDON stated all the ice packs were discarded. During a concurrent interview and record review on 5/20/22, at 10:24 a.m., with IP, the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident Care Equipment, revised 1/1/2012, was reviewed. The P&P indicated, Reusable items are cleaned and disinfected or sterilized between residents . IP stated reusable items were disinfected with a chemical and allowed to dry, according to manufacture's instruction to prevent cross contamination. 055876 Page 20 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0880 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's job description titled Infection Control Coordinator, undated, the job description indicated, Principal Responsibilities . Promotes and maintains infection control guidelines and standards. Residents Affected - Few 055876 Page 21 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for two of five (Resident 26 and 34) sampled resident vaccination record, the facility failed to follow their immunization policy and procedure when the pneumococcal vaccine was not offered or documented for Resident 26 and 24 as recommended by the Advisory Committee on Immunizations Practices (ACIP, group of medical public health experts). Residents Affected - Some This deficient practice had the potential to increase the risk for Resident 26 and 34 to acquire, transmit or experience complications from pneumococcal disease. Findings: During a concurrent interview and vaccine record review, on 5/18/22, at 10:55 a.m., Resident 26 and 34's pneumococcal vaccination records were reviewed with the Infection Preventionist (IP). The vaccination record indicated Resident 26 received the pneumococcal vaccine on 6/10/16. The vaccination record did not indicate which pneumonia vaccine was administered to Resident 34. The newly appointed IP stated she would search through records for Resident 26 and 34. Review of Resident 26's admission Record, dated 5/19/22, indicated Resident 26 was [AGE] years old with an autoimmune disease (body does not make enough cortisol to help break down fats, proteins, and carbohydrates in the body). Review of Resident 34's admission Record, dated 5/19/22, indicated Resident 34 was [AGE] years old with diagnoses that included diabetes and high blood pressure. Review of the facility's policy and procedure (P&P), titled Pneumococcal Disease Prevention, revised on 2/18/21, indicated the pneumococcal vaccination is recommended for the following residents: adults [AGE] years old and older, anyone 2 - [AGE] years old who has long term health problems such as diabetes and residents of nursing homes or long-term care facilities and those who are immunocompromised. The Resident's medical record shall include documentation that indicates, at a minimum, a date vaccine was administered and whether the Resident received the PCV13 (Prevnar 13,Pfizer) or the PPSV23 (Pneumovax 23) vaccine, or did not receive either because of medical contraindications or refusal. 055876 Page 22 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and document review, the facility failed to ensure one of four staff (Dietary Aide 1 [DA 1]) followed the COVID-19 (an infectious respiratory disease) vaccination policies and procedures when DA 1 did not complete COVID-19 vaccine series with a booster dose. Residents Affected - Few This failure had the potential to result in the spread of COVID-19 infections to residents, staff, and visitors in the facility. Findings: During a concurrent interview and document review on 5/18/22, at 10:55 a.m., the Employee COVID-19 Vaccination Log, was reviewed with Infection Preventionist (IP). The vaccination log indicated DA 1 received the Pfizer vaccine (a COVID-19 vaccine) on 8/13/21 and 10/20/21. A COVID-19 vaccine booster result was not recorded for DA 1. IP confirmed DA 1's booster was due and not logged. IP stated, DA 1 received the COVID-19 booster vaccine, however, DA 1 has not brought in the vaccine record for verification. IP stated DA 1 still worked in the facility and last worked sometime last week. During a follow-up interview and concurrent document review on 5/19/22, at 12:00 p.m., with IP, IP stated she was waiting for DA 1 to send a copy of the COVID-19 booster vaccination record. IP then provided DA 1's COVID-19 vaccination record card. DA 1's vaccination card indicated DA 1 received the booster on 5/19/21 (same day as the current interview). Review of the facility's policy and procedure (P&P), titled, COVID-19 Staff Vaccination Program, revised on 9/2/21, indicated all personnel providing services or performing work at the facility are required to be vaccinated against COVID-19. Only those who have a medical or religious reason will be granted an exemption. The P&P also indicated, If additional doses of COVID-19 vaccines (i.e., boosters) become recommended by federal, state, or local health authorities . the Facility may require personnel to receive additional vaccine doses in alignment with those recommendations. 055876 Page 23 of 24 055876 05/20/2022 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure a drainpipe from the 2-compartment kitchen sink was in good repair. Residents Affected - Many This had the potential to attract pests resulting in contamination of food and utensils for 71 residents who received food from the kitchen out of a facility census of 71. Findings: An observation and concurrent interview with Dietary Aide 1 (DA 1) and [NAME] 2, on 5/17/22, at 8:32 a.m., showed a drainpipe under the 2-compartment sink, used for manual warewashing, was plumbed into the floor. When the sink was drained, water leaked from the pipe, which was caught in a plastic dome plate cover on the floor under the sink and drainpipe. DA 1 and [NAME] 2 stated, there was a terrible odor that came from the drainpipe area under the sink, especially when the 2-compartment sink drained. [NAME] 2 said the drain was like that since she started working at the facility six months ago. In an interview on 5/17/22, at 10:25 a.m., Environmental Manager (EM) stated there was a maintenance logbook in station 1. EM said kitchen staff were supposed to log things in need of maintenance in the kitchen. EM said he was not aware of the leak or the smell from the drainpipe under the 2-compartment sink. EM said staff did not notify him. In an interview with EM and Administrator (ADM), on 5/19/22, at 1:02 p.m., EM stated the dripping pipe could be a possible contamination and ADM said it was a sanitation concern. In an interview on 5/20/22, at 12:04 p.m., Dietary Supervisor (DS) stated staff told her about the dripping drainpipe from the 2-compartment sink about two weeks ago. DS said she notified maintenance verbally and did not document it in the maintenance logbook. DS stated she was not aware staff were catching the water from the dripping pipe with plate dome covers. DS also said she did not follow-up with maintenance to find out if the dripping drainpipe was fixed. Review of the policy and procedure titled, Maintenance - Work Orders, dated January 1, 2012, indicated department directors/supervisors were responsible for completing work orders and forwarding them to the Director of Maintenance. According to the 2017 Federal Food Code, a plumbing system shall be maintained in good repair. 055876 Page 24 of 24