Health inspection·March 14, 2024

F 0727 Level of Harm - Minimal harm or potential for actual harm During a review of the document titled, PBJ Staffing Data Report, for 1/1/23 through 3/31/23, printed 3/6/24, the report indicated the facility did not have an RN on duty on the following dates: 1/1/23, 1/2/23, 1/3/23, 1/4/23, 1/7/23, 1/8/23, 1/14/23, 1/15/23, 1/16/23, 1/22/23, 1/28/23, 1/29/23, 2/4/23, 2/5/23, 2/11/23, 2/12/23, 2/18/23, 2/19/23, 2/20/23, 2/25/23, 2/26/23, 3/4/23, 3/5/23, 3/11/23, 3/12/23, 3/18/23, 3/19/23, 3/23/23, 3/24/23, 3/25/23, and 3/26/23. Residents Affected - Many During a review of the document titled, PBJ Staffing Data Report, for 4/1/23 through 6/30/23, printed 3/6/24, the report indicated the facility did not have an RN on duty on the following dates: 4/1/23, 4/2/23, 4/8/23, 4/9/23, 4/15/23, 4/16/23, 4/21/23, 4/22/23, 4/23/23, 4/29/23, 4/30/23, 5/6/23, 5/7/23, 5/13/23, 5/14/23, 5/20/23, 5/21/23, 5/27/23, 5/28/23, 5/29/23, 6/3/23, 6/4/23, 6/10/23, 6/11/23, 6/17/23, 6/18/23, 6/24/23, and 6/25/23. During a review of the document titled, PBJ Staffing Data Report, for 7/1/23 through 9/30/23, printed 3/6/24, the report indicated the facility did not have an RN on duty on the following dates: 7/1/23, 7/2/23, 7/4/23, 7/8/23, 7/9/23, 7/10/23, 7/15/23, 7/16/23, 7/21/23, 7/22/23, 7/23/23, 7/24/23, 7/29/23, 7/30/23, 8/5/23, 8/6/23, 8/12/23, 8/13/23, 8/19/23, 8/20/23, 8/26/23, 8/27/23, 9/2/23, 9/3/23, 9/4/23, 9/9/23, 9/10/23, 9/16/23, 9/17/23, 9/23/23, 9/24/23, and 9/30/23. During a review of the document titled, PBJ Staffing Data Report, for 10/1/23 through 12/31/23, printed 3/6/24, the report indicated the facility did not have an RN on duty on the following dates: 10/1/23, 10/7/23, 10/8/23, 10/14/23, 10/15/23, 10/21/23, 10/22/23, 10/28/23, 10/29/23, 11/4/23, 11/5/23, 11/10/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23, 12/2/23, 12/3/23, 12/9/23, 12/10/23, 12/15/23, 12/16/23, 12/17/23, 12/23/23, 12/24/23,12/25/23, 12/30/23, and 12/31/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 2 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store controlled medications (medications with a high potential for abuse and addiction) in a secure manner to limit potential for diversion, ensure two emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were replaced timely after being opened or contents used/expired, and medication cart controlled drug accountability sheets (a record used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were signed for the outgoing and incoming nursing shifts. The facility failed to develop and implement a policy and procedure (P&P) to secure chain of custody of discontinued controlled medications, and ensure controlled substance medications were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR) for one of five randomly selected residents (Residents 35). These failures resulted in the facility not having accurate accountability of controlled medications, potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: During a concurrent observation and interview with the Director of Nursing (DON) in the medication room on [DATE] at 9:45 a.m., the medication refrigerator was observed with an unlocked padlock on it. When inspecting the contents inside, a small e-kit containing a vial of injectable lorazepam (a medication to treat anxiety) was found. The DON stated all the licensed nurses had a key to the refrigerator padlock, which should have been locked at all times. During a review of the facility's Policy and Procedure (P&P) titled, Medication Storage-Controlled Medication Storage, dated 11/2017, the P&P indicated, Medications listed in Schedule II, including those requiring refrigeration, are stored separately, under separately locked permanently fixed compartments. During a concurrent observation and interview with the DON in the Medication Storage Room on [DATE] at 10:06 a.m., an unlocked IV (intravenous-solutions injected into the vein) e-kit was observed. The contents list affixed to the outside of the e-kit was compared with the physical contents which indicated three bags of saline solution (salt water used to replace bodily fluids) were removed and unaccounted for. The DON stated the e-kit should have contained a completed log indicating which items were removed and locked for replacement by the pharmacy. One of two SPS (sodium polystyrene sulfonate, a medicine used to treat excessive potassium in the body) e-kits was also identified and expired on 2/2024. The DON stated expired e-kits should have been given to the pharmacy when the replacement was brought to the facility. During a review of the facility's P&P titled, Emergency Pharmacy Service and Emergency Kits, dated 9/2010, the P&P indicated, Emergency medications and supplies are kept secure, checked periodically for integrity and dating and stored in accordance with State Board of Pharmacy and federal regulations . upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit log. One copy of this information should be immediately faxed to the pharmacy with the original prescriber order or refill request form and placed within the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 3 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resealed emergency kit until it is scheduled for exchange . when the replacement kit arrives, the receiving nurse gives the used kit to the pharmacy personnel for return to the pharmacy. During a concurrent record review and interview with the DON on [DATE] at 11:00 a.m., the [DATE] controlled drug sign-in/sign-out sheet for both medication carts were reviewed. The controlled drug sign-in/sign-out sheets indicated missing signatures by the outgoing and incoming nurse for each shift (7 a.m., 3 p.m., and 11 p.m.). The DON acknowledged and confirmed the records were missing signatures between nursing shift changes. A review of both controlled drug sign-in/sign-out sheets, dated [DATE] to [DATE], indicated a total of 82 missing signatures (for the dates indicated) between nursing shift changes. The DON stated nursing staff were expected to do a controlled medication reconciliation count with each shift change, and to sign once completed. During a review of the facility's P&P titled, Controlled Medication Storage, dated 11/2017, the P&P indicated, At shift change or when keys are surrendered, a physical inventory of all Schedule II controlled medications is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report. During a concurrent observation, interview and record review on [DATE] at 1 p.m. in the DON's office, the DON reviewed the facility's process for destruction of controlled medications. A green filing cabinet with four legs on top of rolling wheels was observed. The filing cabinet had a lock on the outside. The DON unlocked the cabinet with a key and inside were several discontinued controlled medication bubble packs, along with the CDR for each. The DON stated she removed discontinued controlled medications from the medication carts herself and transferred them to the metal cart in her office for later destruction with the pharmacist. When asked if there were any witnesses to confirm the removal from the medication cart and placement into the rolling cabinet in her office she answered, no. The DON acknowledged and confirmed the process did not limit the potential for diversion because of lack of accountability and documentation for processing controlled medications for destruction. During a review of the facility's P&P titled Medication Administration - Controlled Substances, dated 11/2017, the P&P indicated, 'Controlled Medications' are substances that have an accepted medical use (medications which fall under U.S. Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical and psychological dependence. These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal state laws and regulations. According to the 42 eCFR (electronic Federal Code of Regulations) §483.45(b)(2), the facility must establish .a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation . Resident 35 had a physician's order dated [DATE], for lorazepam 0.5 milligrams (mg, a unit of measurement), one tablet by mouth every six hours as needed for anxiety manifested by restlessness. The CDR indicated 30 lorazepam 0.5 mg tablets were received by the facility on [DATE]. The first two tablets (tablet count 30 and 29) were signed out by nursing staff, however the date and time of administration to Resident 35 was not documented. Four tablets were documented as removed on the CDR (two tablets on [DATE] and two tablets on [DATE]) but were not documented as administered to Resident 35 on the MAR. During a concurrent interview and record review on [DATE] at 1:30 p.m. with the DON, the DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 4 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm reviewed the discrepancies between the MARs and CDRs for Resident 35. The DON confirmed the two doses (count 30 and 29) were signed out but not documented on the CDR, and stated the nurse who gave the medications did not document correctly. The DON reviewed the discrepancies between the CDRs and MARs and stated nursing staff were expected to document on the CDR as soon as a controlled medication was removed for administration and in the MAR immediately after administration. Residents Affected - Some During a review of the facility's P&P titled, Medication Administration - Controlled Substances, dated 11/2017, the P&P indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information in the accountability record when removing dose from controlled storage: date and time of administration, amount administered, and signature of the nurse administering the dose . administer the controlled medication and document dose administration in the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 5 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility had a 10.34% error rate when three medication errors out of 29 opportunities were observed during a medication pass for seven residents (Residents 7, 28, and 29). Residents Affected - Some This failure resulted in medications not being given in accordance with the prescriber's orders and the manufacturer's specifications, with the potential to affect the residents' clinical conditions. Findings: During a medication pass observation on 3/11/24 at 11:30 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed preparing Humulin N insulin (a medication to treat diabetes, the body's inability to regulate blood sugar) 10 units for Resident 28. LVN 1 removed the vial from medication cart and drew up the medication into the syringe without mixing/rolling the vial first. A review of Resident 28's medical record indicated a physician's order, dated 1/5/24, for Humulin N 100 units/milliliter (u/ml, a unit of measurement) pen, inject 10 units subcutaneously (under the skin) every day with 12 p.m. medication. During an interview on 3/11/24 at 11:22 a.m. with LVN 1, LVN 1 stated intermediate-acting, or cloudy insulin vial should be shaken prior to administration. During a review of an article from the Mount [NAME] Hospital Health Library titled, Giving an Insulin Injection, dated 8/12/22, the article indicated, Intermediate-acting insulin (N or NPH) is cloudy and must be rolled between your hands to mix it. Do not shake the bottle. This can make the insulin clump . insulin should not have any clumps on the sides of the bottle. If it does, throw it out and get another bottle. A review of the manufacturer's specifications for Humulin N indicated, Humulin N - Instructions for Use . Gently roll the vial between the palms of your hands at least 10 times . Carefully invert the vial at least 10 times. Mixing is important to make sure you get the right dose. Humulin N should look white and cloudy after mixing. https://www.mountsinai.org/health-library/selfcare-instructions/giving-an-insulin-injection, accessed 3/14/24). A review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 9/2018, the P&P indicated, Medications are administered in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. During a medication pass observation on 3/12/24 at 8:22 a.m. with LVN 1, LVN 1 was observed preparing two oral medications for Resident 7, including lactulose (a medication used to treat constipation, the inability to pass stool) 10 grams/15 milliliter (gm/ml, a unit of measurement). LVN 1 poured 30 ml of thick lactulose into a calibrated plastic medication cup, then poured the liquid into a small paper cup. She continued to prepare other oral medications and gave them to Resident 7. When Resident 7 took his medications, he drank the lactulose from the paper cup, then gave the cup back to LVN 1 who disposed of it in the trash. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 6 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm A review of Resident 7's medical record indicated a physician's order, dated 3/8/21, for lactulose 10 gm/15 ml solution, take 30 ml (20 gm) by mouth daily. During an interview on 3/12/24 at 12:10 p.m. with LVN 1, LVN 1 agreed the lactulose was a thick liquid medication and Resident 7 did not receive the full 30 ml dose. Residents Affected - Some During a review of the facility's P&P titled, Medication Administration - General Guidelines, dated 9/2018, the P&P indicated, For suspensions and thick liquids that may coat calibrated measuring cups, use water to rinse medication residue and administer to the resident to ensure entire dose is given. During a medication pass observation on 3/12/24 at 9 a.m. with LVN 1, LVN 1 was observed preparing seven oral medications for Resident 29, including one tablet acetaminophen (a medication used to treat mild to moderate pain) 325 milligrams (mg, a unit of measurement). LVN 1 prepared the remaining oral medications and administered them to Resident 29. A review of Resident 29's medical record indicated a physician's order, dated 9/20/23, for acetaminophen (a medication to treat pain) 325 mg, 2 tablets by mouth twice daily. During a concurrent interview and record review on 3/12/24 at 1:50 p.m. with LVN 1, LVN 1 stated she could not recall how many acetaminophen tablets she administered to Resident 29 during the observed medication pass. LVN 1 looked at Resident 29's MAR (medication administration record) and the physician's orders and confirmed the correct dosage was two tablets, not one. During a record review of facility's P&P titled, Medication Administration - General Guidelines, dated 9/2018, the P&P indicated, Medications are to be administered in accordance with written orders of the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 7 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - 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, the facility failed to monitor and log medication refrigerator temperatures twice daily, to store food items separately from medications in the medication storage room refrigerator, to timely dispose of refused/unused medications, to remove an expired insulin (a medication for the regulation of blood sugar) pen from the medication cart, to ensure nursing staff locked medication carts when unattended, and to store discontinued controlled substances in a permanently affixed storage space. The deficient practices had the potential for unauthorized staff and residents to access medications, for residents to receive medications with unsafe and reduced potency, and for residents to suffer hazardous cross-contamination to their medications. Findings: During a concurrent observation and interview with the Director of Nursing (DON) in the medication room on 3/11/24 at 10 a.m., the medication refrigerator temperature logs dated March 2024 were reviewed. The logs indicated on seven occasions in March 2024, both a.m. and p.m. temperatures were not monitored and recorded. An inspection of the refrigerator identified two vials Tubersol (an injectable used for testing of tuberculosis, a contagious infection that usually affects the lungs). The DON stated nursing staff monitored the temperature twice daily and confirmed the incomplete log. During a review of the facility's Polciy and Procedure (P&P) titled, Storage of Medications, dated 9/2018, the P&P indicated, The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. During a concurrent observation and interview with the DON in the medication storage room on 2/11/24 at 10:10 a.m., a can of soda was identified in the unlocked medication room refrigerator, alongside patient medications. The DON confirmed the finding and stated the soda should be stored separate from medications. During a review of the facility's P&P titled, Medication Storage, dated 9/2018, the P&P indicated, Refrigerated medications should be . segregated from fruit juice, applesauce and other foods . During a concurrent observation and interview with the DON while inspecting one of two medication carts on 3/11/24 at 10:55 a.m., a small paper medication cup with approximately seven tablets/capsules were observed in the top drawer of the medication cart. The DON stated they were refused medications and should not have been left in the cart. She stated the nurse should have destroyed the medications at the completion of the medication pass. During a review of the facility's P&P titled, Medication Administration General Guidelines, dated 9/2018, the P&P indicated, Once removed from the package/container, unused medication doses shall be disposed of . During a concurrent observation and interview on 3/11/24 at 10:56 a.m. with the DON, an injectable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 8 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some insulin glargine (a long-acting medication to treat diabetes) pen was found in the top drawer of one of two medication carts. The expiration date of the insulin pen was 3/11/24. The DON confirmed the finding and stated the medication was expired and should have been removed from the cart. During a review of the facility's P&P titled Medication Storage, dated 9/2018, the P&P indicated, Outdated, contaminated discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . and reordered from the pharmacy. During two separate observations (3/12/24 at 8:22 a.m. and 1:05 p.m.) Licensed Vocation Nurse 1 (LVN 1) left a medication cart unlocked and unattended. On both occasions, residents and unlicensed staff were present and had access to the unlocked medication carts. During a review of the facility's P&P titled, Storage of Medications, dated 9/2018, the P&P indicated, In order to limit access to prescription medications . Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. During an interview on 3/12/24 at 1:30 p.m. with LVN 1, LVN 1 stated it was her usual practice to lock the medication cart when she walked away from it. She stated that she was busy and that was why they were unlocked and unattended. During a concurrent observation and interview on 3/12/24 at 1 p.m. with the DON in the DON's office, the discontinued controlled medications removed for destruction were observed in a locked rolling metal cabinet. The DON stated discontinued controlled medications were not stored in a permanently affixed storage cabinet because it was not a requirement in the facility's P&P. According to 42 eCFR (electronic Federal Code of Regulations) §483.45(h)(2), The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs . and other drugs subject to abuse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 9 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0801 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. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interviews, and review of facility documents, the facility failed to: Residents Affected - Many 1. Comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. 2. Ensure the Registered Dietitian (RD) provided sufficient consultation to the Food and Nutrition Services department. The lack of full-time, competent oversight of food and nutrition staff and lack of sufficient consultation from the RD placed 35 residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or decreased nutrient intake which had the potential to result in death and/or nutritional related medical complications. Findings: 1. There was no full-time, qualified oversight of the Food and Nutrition Services Department. According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Subdivision (b) includes the following: The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 10 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision. (7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6). An observation and interview with [NAME] 1 during the initial tour of the kitchen on 3/11/24 at 9:48 a.m., showed [NAME] 1 and Diet Aide 1 (DA 1) working in the kitchen. [NAME] 1 stated the kitchen supervisor was on his way from another facility. He stated there was no full-time supervisor for the kitchen since August 31. He said the current supervisor usually came to this facility on Tuesdays and Thursdays when the food delivery came in. [NAME] 1 stated the kitchen needed a full-time supervisor because it was too much work for him. During an observation and interview on 3/11/24 at 12:34 p.m., a test-tray was sampled, and the food was noted to be cold and bland (Cross-reference F804). At this time FNSD stated the facility really needed a full-time kitchen supervisor and he told the facility this. In an interview on 3/12/24 at 9:20 a.m., the Administrator (ADM) confirmed FNSD was the kitchen supervisor and was not full time. He stated the Registered Dietitian (RD) came into the facility once a week. He also stated the last full-time kitchen supervisor's last day was on 8/31/23. ADM stated he might have a candidate for the kitchen supervisor, but he did not offer the job to this person yet. Review of the consulting agreement contract between RD1 and the facility, titled Nutrition Professional Services, signed by RD1 and ADM on 2/1/23, showed RD1's allotted time at the facility was 8 hours a month. Review of the facility's Time & Attendance - Employee Timecard Report for FNSD showed his hours at the facility ranged from 13.5 hours to 26.5 hours every two weeks from 9/1/23-3/15/24. In an interview on 3/14/24 at 10:30 a.m., ADM stated he did not consider hiring a full-time RD to supervise the kitchen while the facility was recruiting for a kitchen supervisor. He continued to say, the facility's budget had to be considered. In an interview on 3/14/24 at 12 p.m., FNSD stated he was only at the facility three to four hours on the days he came in which did not give him time to address issues RD 1 noted in her reports such as cleaning. 2. Lack of sufficient consultation by the RD to the Food and Nutrition Services Department. Review of the consulting agreement contract between RD1 and the facility, titled Nutrition Professional Services, signed by RD1 and ADM on 2/1/23, showed her duties included but were not limited to: developing and conducting in-service education programs for Food Service Personnel, as requested; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 11 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0801 and conducting monthly food safety and sanitation audits. Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated job description titled Registered Dietitian, showed the RD responsibilities included but were not limited to: assume the administrative authority, responsibility and accountability of directing the Food Service Department; plan, organize, implement, evaluate, and direct the facility's Food Services Department, its programs and activities; ensure staff is aware of and follows established departmental policies; assist the food service staff in the development and use of departmental procedures governing food service activities, equipment, supplies, etc.; Assist in developing methods for determining quality and quantity of food served; meet with food service personnel, on a regularly scheduled basis, and solicit advice from staff concerning the operation of the Food Services Department; Ensure menus are maintained and filed in accordance with current industry standards of practice as well as established policies and procedures; visit residents periodically to evaluate the quality of meals served, likes and dislikes, etc.; Involve the resident/family in planning dietary objectives and goals for the resident; Assist in developing diet plans for individual residents; Assist the Director of Food Services in planning menus as required; Review therapeutic and regular diet plans and menus to assure they are in compliance with physician's orders; Review the dietary requirements of each resident admitted to the facility and assist the attending physician in planning for the resident's prescribed diet plan; Assist in identifying and correcting problem areas, and/or improvement of services; ensure the food service personnel are performing required duties and that appropriate food service procedures are being rendered to meet the needs of the facility; develop and participate in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on how to do the job, to ensure a well-educated food services department; ensure the food service work areas are maintained in a clean and sanitary manner; and ensure all food storage rooms, preparation areas, etc., are maintained in a clean, safe, and sanitary manner. Residents Affected - Many During the Re-certification Survey from 3/11/24-3/14/24, multiple issues were identified regarding kitchen staff competency (Cross-reference F802); not following the planned menu as well as not having a vegetarian menu for a resident who was vegetarian (Cross-reference F803); food was not palatable including taste and temperature (Cross-reference F804); pureed food was not an appropriate texture (Cross-reference F805); physician's diet orders were not followed for fortified diets (Cross-reference F808); and food was not stored, prepared, and served in a safe and sanitary manner (Cross-reference F812). During an interview with RD1 on 3/12/24 at 10:15 a.m., RD1 stated she said she did spot checks in the kitchen when she came into the facility. RD1 stated the spot checks mainly included looking at cooler (refrigerator/freezer) temperatures and making sure food items were labeled and dated. RD 1 said she had a sanitation checklist to complete when she did rounds in the kitchen but did not do one since July of last year. She also stated the sanitation checklists should be completed monthly. RD 1 said she gave the administrator reports containing what she did when she was at the facility. RD1 stated she did not conduct any in-service trainings for the kitchen staff. In an interview with RD1 on 3/12/24 at 11:30 a.m., kitchen sanitation checklists for the past year were requested. RD1 stated for the past year she only did a sanitation checklist in March 2023 and July 2023. In an interview on 3/12/24 at 12:40 p.m., RD 1 stated she did not think the prior kitchen supervisor did any in-service trainings for kitchen staff. She stated she did not think the kitchen supervisor addressed the issues on her sanitation checklist, so she stopped doing the sanitation checklists. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 12 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0801 Level of Harm - Minimal harm or potential for actual harm Review of two documents titled Nutrition Professional Services Food Safety/Sanitation Evaluation completed by RD1 and dated March 15, 2023 and July 26, 2023, showed a detailed nine paged checklist with items listed related to kitchen sanitation, maintenance of equipment, using recipes, and menus and meal planning. There were checkboxes which indicated if items/procedures were met or not met. In addition, there were comments and recommendations coinciding with the items/issues which were not met. Residents Affected - Many Review of the Review of the Consultation Dietitian Report written by RD 1, showed the report contained a summary of her visit to the facility. The report showed she was monitoring/documenting weekly weight variance and monthly weight variance, working on quarterly and annual assessments, monitoring/documenting enteral feeding (a method of supplying nutrients directly into the gastrointestinal tract). In relation to the kitchen, eight of the most recent reports from 1/17/24 - 3/7/24, showed RD1 gave feedback and recommendations for labeling and dating food items. The report did not indicate she looked at other areas throughout the kitchen. Twenty-nine consecutive Consultation Dietitian Report written by RD 1 from 8/31/23 to 3/7/24 delegated tasks to the kitchen supervisor but there was no detail to indicate specific issues she observed. All the reports from 8/31/23 to 3/7/24 repeated the same verbiage: a. DSS [Dietary Services Supervisor] will focus on bringing the kitchen up to par with cleanliness, labeling and dating food items, etc. b. DSS will conduct multiple in-services to educate dietary staff on food staff on food safety, labeling and dating all food items with RD/OD/UBD [receive date, open date, use-by-date], monitoring and recording of food temps [temperatures], refrigerator/freezer temps, dishmachine washing temps/sanitizer ppm [parts per million], hierarchy of freezer/refrigerated storage, etc. All of the reports from 8/31/23 to 3/7/24 showed the last Food Safety/Sanitation Evaluation was completed 7/26/23. In an interview on 3/12/24 at 1:14 p.m., FNSD stated since he worked at the facility, he only had time to do two in-service trainings for staff. One was regarding labeling and dating, and the other was for storing personal items. In an interview on 3/14/24 at 12 p.m., FNSD 1 stated the communication/consultation from RD1 was mainly through reports he found in his box. He stated he and RD1 did not really talk to each other. He said RD1's reports always said the same thing, and it was not clear what she felt needed to be cleaned. FNSD stated he was only at the facility three to four hours on the days he came in which did not give him time to address issues RD 1 noted in her reports such as cleaning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 13 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and facility document review, the facility did not ensure proper kitchen staff competency for testing sanitizer strength, checking the dish machine temperature, and the use of the 2-compartment ware washing sink. The failure to ensure staff competency for kitchen tasks related to safety and sanitation in the kitchen placed 35 residents who received food from the kitchen at risk for illness from cross contamination of utensils, as well as food borne illness. Findings: 1. During a concurrent observation and interview with [NAME] 1 on 03/12/24 at 1:26 p.m., [NAME] 1 demonstrated how to test the strength of the quaternary ammonia (quat) sanitizer solution used for sanitizing surfaces in throughout the kitchen, including food contact surfaces. [NAME] 1 filled the red sanitizer bucket from a quat sanitizer dispensing hose by the dirty side of the dish machine. The dispensing hose was connected to a box labeled Quaternary. The sanitizer in the red bucket was very foamy. [NAME] 1, dipped sanitizer test strip into bucket for 5 seconds. It could not be determined if the test strip was dipped into the foam or the actual solution. After 5 seconds, [NAME] 1 pulled out the test strip and it was very dark green. [NAME] 1 stated it was good and stated the strip read 200. [NAME] 1 was asked on how he knew that this number was ok and [NAME] 1 stated that there was a chart he compare it to. [NAME] 1 located a color chart inside a test strip container which was located in a drawer of a preparation table. [NAME] 1 compared his test strip to the color chart and again stated the dark green showed it was 200, when in fact, the test strip color chart showed very dark green matched 400 ppm (parts per million). On the color chart showed a mustard yellow color equaled 200 ppm. When [NAME] 1 was if he was sure a dark green test strip showed 200 ppm, [NAME] 1 stated it was actually 400 and was too high. [NAME] 1 stated that when the test strip showed the strength of the sanitizer was too high, the sanitizer company had to be contacted. [NAME] 1 tested the sanitizer again, with a second test strip. This time he held the test strip in the foam at the top of the solution for about 3 secs. The test strip turned a dark green and mustard yellow color. [NAME] 1 stated the test strip showed the sanitizer strength was okay. During an observation in the kitchen and interview on 03/12/24 at 1:26 p.m., it was determined Diet Aide 1 (DA1) did not follow appropriate procedures for filling the red bucket with sanitizer and checking for an appropriate strength, when the quat sanitizer she placed in the red bucket, along with added water, did not have any strength when she tested it with a test strip (Cross-reference F812). Review of the manufacturer's instructions inside the Quaternary Test Strip container, showed to Dip the paper in the quat solution, NOT FOAM SURFACE, for 10 seconds .Compare [to the color chart] at once .Testing solution should have a neutral pH [a measure of how acidic or basic a solution is]. Review of the manufacturer's label on the container of Food Contact Quat Sanitizer showed articles to large for immersing, apply a solution of 150-400 ppm to precleaned hard surfaces thoroughly wetting surfaces with a cloth. Review of the facility's policy and procedure titled Quaternary Ammonium Log Policy, dated 2023, showed the concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution. The Food and Nutrition Services worker will place the solution in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 14 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many appropriate bucket labeled for its contents and will test the concentration of the sanitation solution. The concentration will be tested at least every shift or when solution is cloudy. The solution should be replaced when the reading is below 200 ppm. Review of the facility's policy and procedure titled Sanitation dated 2023, showed the FNS (Food Nutrition Services) Director is responsible for instructing employees in the fundamentals of sanitation in food service and training employee to use appropriate techniques. 2. An observation in the kitchen on 3/12/24 at 1:14 p.m., showed DA 1 washed dishes from the lunch meal service in the dish machine. During a concurrent observation and interview with DA 1 on 03/12/24 at 2:02 p.m., DA1 demonstrated how she determined the dish machine was working properly. She stated that the dish machine was chemical machine (chemicals were used to sanitize items cleaned in the machine). DA1 demonstrated how she used a test strip to check the sanitizer strength. When DA 1 was questioned if the dish machine water had to be a certain temperature, DA1 stated she thought it was 200. When she was asked how she determined the temperature of the dish machine, she stated there use to be test strips. There was a dial on the front of the dish machine which showed the temperature of the dish machine water. DA 1 never stated she looked at the dial to determine the temperature. When DA 1 was asked if she logged dish machine sanitizer strength and temperature, she retrieved the logbook and the areas to document the afternoon dish machine values was blank. She stated she did not check the dish machine sanitizer strength or temperature yet this afternoon. Review of the information plate attached to the dish machine, showed the dish machine showed the minimum temperatures during wash cycle was to be120 degrees F and minimum temperature during the rinse cycle was 120 degrees F. During a record review of the facility's policy and procedure titled Sanitation dated 2023, showed the FNS Director is responsible for instructing employees in the fundamentals of sanitation in food service and training employee to use appropriate techniques. The FNS Director is responsible for instructing FNS personnel in the use of equipment. Each employee shall know ow to operate equipment in their specific area. No FNS employee shall operate any major piece of equipment without know to operate it correctly. 3. During a concurrent observation and interview with [NAME] 1 on 03/12/24 at 1:46 p.m., [NAME] 1 stated if dish machine did not function, the 2-compartment sink would be used to manually clean dishes and utensils. [NAME] 1 described the procedures for using the 2-compartment sink. [NAME] 1 stated the last sink was used for sanitizing the dishes. He said the sink would be filled with a sanitizer solution. He showed he would use the sanitizer dispensed from a hose above the sink (which was connected to a container of quat sanitizer stored below the sink). When asked how long the items needed to stay in the sanitizer solution, she stated he did not know, and no one ever told him about that. The sink use guidelines posted on the wall above/behind showed step-by-step directions for cleaning items in the sink, but it did not show how long to keep items in the sanitizer. Review of the facility policy and procedure titled 3-Compartment Procedure for Manual Dishwashing dated 2023, showed three compartment sink washing procedures are to be initiated when the dishwasher is inoperable. In the section of the P&P where it describes the third compartment is for sanitizing, it read Immerse all washed items for ___ (note time). The P&P had a blank space where it should show how long items are to be submerged in the sanitizer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 15 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the manufacturer's label on the container of Food Contact Quat Sanitizer showed to immerse pre-cleaned glassware, dishes, silverware, cooking utensils and other similar size food processing equipment in a solution mixed to 150-400 ppm, for at least 60 seconds. During a record review of the facility's policy and procedure titled Sanitation dated 2023, showed the FNS Director is responsible for instructing employees in the fundamentals of sanitation in food service and training employee to use appropriate techniques. The FNS Director is responsible for instructing FNS personnel in the use of equipment. Each employee shall know ow to operate equipment in their specific area. No FNS employee shall operate any major piece of equipment without know to operate it correctly. Event ID: Facility ID: 055892 If continuation sheet Page 16 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure: Residents Affected - Many 1. A Vegetarian menu was available for a Vegetarian resident; and 2. Residents received what was on the lunch menu including: a. Broccoli Salad b. Tropical Fruit Mold c. Oven Roasted Potatoes d. Green Beans with Red Peppers These failures had the potential to result in decreased nutrient intake resulting in weight loss and/or malnutrition for 35 residents who received food from the kitchen. Findings: 1. Review of the admission Record for Resident 22, showed she was admitted to the facility on [DATE] with diagnoses including but not limited to prediabetes, and deficiency of B group vitamins. A record review of Resident 22's physician's orders showed her current diet was Regular, no meat, no chicken, no seafood, only vegetarian. The record showed the diet order was started on 12/27/21. A record review of Resident 22's Nutrition Care Plan, dated, 11/05/21, showed the physician prescribed diet was Regular Vegetarian Diet Allergy - tomato. A record review for Resident 22, showed an Annual Registered Dietitian Nutrition Assessment, dated 11/10/22, which read under intervention Continue Diet Order Regular diet. Vegetarian . A record review for Resident 22 showed Quarterly Nutrition Progress Record, dated 02/14/23, 05/10/23 showed the diet order was Regular Vegetarian. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 17 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many A record review for Resident 22, showed a Registered Dietitian Nutrition Assessment, signed by Registered Dietitian 1 (RD 1) on 11/15/23, showed the physician prescribed diet was Regular, No meat, No Chix [chicken], No seafood, only Vegetarian. A record review for Resident 22 showed Quarterly Nutrition Progress Record, dated 2/14/24 and signed by RD 1 showed the diet order was Regular Vegetarian no meat, chicken, seafood, tomato. Review of the Cooks Spreadsheet Spring Cycle Menu, dated Week 2 Monday 03/11/24, 04/08/24 and 05/06/24, and used as the menu for lunch on 3/11/24, showed a variety regular and therapeutic diets. It was noted Vegetarian was not one of the diets listed on the spreadsheet. The Regular diet for the day included but was not limited to Tarragon Chicken with sauce, oven roasted potatoes, green beans with red peppers, broccoli salad, tropical fruit mold. An observation of trayline foodservice and concurrent interview with [NAME] 1 on 03/11/24 at 11:40 a.m., showed [NAME] 1 placed a scoop of mashed potatoes and a scoop of green beans on a plate for Resident 22. When [NAME] 1 was asked if there was a Vegetarian entrée, he stated the vegetarian resident received chili beans today. [NAME] 1 stated sometimes the vegetarian received grilled cheese sandwiches. The tray ticket on Resident 22's tray showed the diet was Regular Vegetarian **No Tomato** An observation and concurrent interview with Resident 22 on 03/11/24 at 12:42 p.m., Resident 22 was in her room, in her bed. Her lunch tray was on her bedside table. Her tray included bowl of refried beans, green beans and mashed potatoes. When Resident 22 was asked how her food was, she replied she did not get an entrée and did not like refried beans. The bowl of beans was still full. Resident 22 stated she did not like mashed potatoes or green beans. Both the mashed potatoes and the green beans were barely touched. Resident 22 stated she received potatoes for almost every meal. She said they receive grilled cheese sandwiches very frequently. She said she received grilled cheese sandwiches and potatoes too often. She stated she even received grilled cheese and mashed potatoes together at times. Resident 22 stated she told the kitchen she did not like the food she was served but still gets it. Resident 22 stated she liked foods such as tofu and veggie burgers. She said for the veggie burgers, she ordered her own from a fast-food restaurant. She also stated she ate her own cup of noodle soups she kept at her bedside. During an interview with RD 1 on 03/12/24 at 10:15 a.m., RD 1 stated, she did not recall a resident on a Vegetarian Diet at this facility. She stated the facility should have a Vegetarian menu. She said if she was told there was a resident on a Vegetarian diet, she would have made sure a Vegetarian menu was available. RD 1 stated she did not consider a bowl of refried beans an entrée. During an interview on 03/13/24 at 3:00 p.m. the Food and Nutrition Services Director (FNSD) stated a cook made him aware there was a resident was on a Vegetarian diet about 2 months ago. FNSD stated he was responsible for getting resident food preferences and when he was not at the facility, it up to the Nursing staff to get resident preferences. FNSD stated he was not sure if anyone asked Resident 22 her food preferences. FNSD confirmed there was no vegetarian menu. Review of the consulting agreement contract between RD1 and the facility, titled Nutrition Professional Services, signed by RD1 and ADM on 2/1/23, showed a duty for RD1 was to review and interpret diet orders and modify menus to meet the special (individualized) diet needs of the residents. Review of the facility's undated job description titled Registered Dietitian, showed the RD was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 18 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many responsible for ensuring menus were maintained and filed in accordance with current industry standards of practice. In addition, the RD was responsible for planning regular and special diet menus as prescribed by the attending physician, as well as reviewing therapeutic and regular diet plans and menus to assure they are in compliance with the physician's orders. 2. During a review of the facility's Diet Manual for Long Term Care Facilities dated 2023, showed the Diet Manual is intended for use along with the menu system and its corresponding products. The diets included within the manual were assessed for nutritional adequacy based on the Dietary Reference Intakes (a set of scientifically developed reference values for nutrients), specifically the Recommended Dietary Allowance (RDA; the average daily intake level that is sufficient to meet the nutrient requirement of nearly all healthy individuals in a particular gender and life stage group). Review of the facility job description titled FNS Director dated 2023, showed the FNS Director is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed. a. Review of the Cooks Spreadsheet Spring Cycle Menus dated Week 2, 3/11/24, showed the menu for lunch included Broccoli Salad. All diets were to receive Broccoli Salad except for residents on a Renal diet (a diet typically prescribed for a person with kidney disease), Low Fat/Cholesterol diet, and Finger Foods diet. During an interview and observation of trayline lunch service on 3/11/24 which started at 11:40 a.m., [NAME] 1 placed food on plates and Diet Aide 1 (DA 1) placed the food on trays, including hot and cold foods. The trays of food were loaded onto a food delivery cart. No trays included a Broccoli Salad or any type of salad. Review of the lunch tray tickets showed 28 residents were on a diet which allowed Broccoli Salad according to the Cook's Spreadsheet Menu dated 3/11/24. [NAME] 1 stated he forgot to make the Broccoli Salad. There was no substitute provided in place of the Broccoli Salad. b. Review of the Cooks Spreadsheet Spring Cycle Menus dated Week 2, 3/11/24, showed the menu for lunch included Tropical Fruit Mold. The spreadsheet showed all diets received the tropical fruit mold except for Renal diets. Consistent Carbohydrate diets (CCHO; typically prescribed for regulating blood sugar) received Diet Tropical Fruit Mold. The spreadsheet also showed small and regular portions received the same sized serving for the dessert. Review of the facility's recipe titled Tropical Fruit Mold, dated 2024, showed ingredients included strawberry gelatin, crushed pineapple, mandarin orange sections, and bananas. The recipe also showed for CCHO diets to prepare the fruit mold with diet gelatin. During an interview and observation of trayline lunch service on 3/11/24 which started at 11:40 a.m., with DA 1 scooped canned fruit into bowls. DA 1 stated the fruit was the dessert. DA 1 scooped smaller portions into some bowls and stated she made smaller portions for the small portion diets. Review of the lunch tray tickets showed 35 residents were on a diet which allowed Tropical Fruit Mold or Diet Tropical Fruit Mold according to the Cook's Spreadsheet Menu dated 3/11/24. During an interview on 03/11/24 at 11:44 a.m. with [NAME] 1, [NAME] 1 stated Tropical Fruit Mold (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 19 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many was not served for lunch today because it was not made yesterday (03/10/24) and he was not sure why because he did not work yesterday. [NAME] 1 stated the Tropical Fruit Mold should be made with Jello and stated that the cooks were responsible for making the desserts. During an interview on 03/12/24 at 1:14 p.m. FNSD stated the Jello dessert should have been made for lunch yesterday (3/11/24) because gelatin and all the ingredients were available for the recipe. He said to [NAME] 1, who stood nearby, he should have prepared the Tropical Fruit Mold in the morning (of 3/11/24) for the lunch menu. c. Review of the Cooks Spreadsheet Spring Cycle Menus dated Week 2, 3/11/24, showed the menu for lunch included Oven Roasted Potatoes. The spreadsheet showed all diets received oven roasted potatoes, except residents on a Renal diet. The spreadsheet showed pureed diets received pureed oven roasted potatoes, and mechanical soft diets received soft oven roasted potatoes. Review of the facility's recipe titled Oven Roasted Potatoes dated 2024, showed ingredients included fresh Russet potatoes, chopped onions, salt, pepper, vegetable oil, and parsley flakes. The instructions showed how to prepare the ingredients which including roasting in the oven. The recipe showed for the mechanical soft, to make sure the potatoes served were soft. For the pureed, the recipe showed to follow the pureed recipes in the Food Safety/Misc. section of Book #1 Review of the facility's undated recipe titled Pureed Starch (Rice, Pasta, Potatoes), showed to complete the regular recipe, measure out portions needed for pureed diets. Then puree on low speed and gradually add liquid if needed to achieve desired consistency. During an interview and observation of trayline lunch service on 3/11/24 which started at 11:40 a.m., [NAME] 1 placed white, instant mashed potatoes on trays for residents who received a pureed diet, mechanical soft diet, and on a tray for a resident who received a regular textured Vegetarian diet. [NAME] 2 placed browned, oven roasted potatoes on the trays for residents on a Regular diet. [NAME] 1 stated pureed and mechanical soft diets received mashed potatoes because he ran out of the potatoes used for the oven roasted potatoes. Review of the lunch tray tickets showed 19 residents who received a pureed, mechanical, soft, or regular vegetarian diet who did not receive Oven Roasted Potatoes but were allowed Oven Roasted Potatoes according to the according to the tray tickets and the Cook's Spreadsheet Menu dated 3/11/24. During an interview with RD 1 on 03/12/24 at 10:15 a.m. the Cooks Spreadsheet Spring Cycle Menu dated Week 2 Monday 03/11/24 was reviewed. RD 1 stated according to the menu, Mechanical Soft diets should have received soft Oven Roasted Potatoes and the and Pureed diets should have received pureed Oven Roasted Potatoes, not mashed potatoes. During an interview on 03/12/24 at 1:14 p.m. FNSD stated he was responsible for ordering food and [NAME] 1 took inventory of the food and made a list of foods needed ordering to meet the needs of the menu. Review of the facility's policy and procedure titled Purchasing Food and Supplies dated 2023, showed the FNS Director will observe that food purchasing begins with a planned menu. Supplies shall be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 20 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0803 appropriate to meet the requirements of the menu and therapeutic diets ordered. Level of Harm - Minimal harm or potential for actual harm Review of the facility job description titled FNS Director dated 2023, showed the FNS Director is responsible for maintaining weekly inventory of food assuring that sufficient supplies are on hand. Residents Affected - Many d. Review of the Cooks Spreadsheet Spring Cycle Menus dated Week 2, 3/11/24, showed the menu for lunch included [NAME] Beans with Red Peppers. During a review of the facility's recipe titled Green Beans with Red Peppers dated 2024, showed and ingredient included was chopped red peppers. During an interview and observation of trayline lunch service on 3/11/24 which started at 11:40 a.m., [NAME] 1 placed green beans on resident lunch trays. The green beans did not appear to have red peppers mixed in. [NAME] 1 confirmed there were no red peppers added to the green beans. During an interview on 03/12/24 at 1:14 p.m. FNSD stated he was responsible for ordering food and [NAME] 1 took inventory of the food and made a list of foods needed ordering to meet the needs of the menu. [NAME] 1 stated he did not add red peppers to the green beans when he prepared the vegetables for lunch yesterday (3/11/24) because red peppers were not available. [NAME] 1 stated he did not ask FNSD to order red peppers. Review of the facility's policy and procedure titled Purchasing Food and Supplies dated 2023, showed the FNS Director will observe that food purchasing begins with a planned menu. Supplies shall be appropriate to meet the requirements of the menu and therapeutic diets ordered. Review of the facility job description titled FNS Director dated 2023, showed the FNS Director is responsible for maintaining weekly inventory of food assuring that sufficient supplies are on hand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 21 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 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 Based on observation, interview, and facility document review, the facility failed to ensure food was palatable in regard to taste and temperature. This failure had the potential to result in decreased food consumption for 35 residents who received food from the kitchen. Residents Affected - Many Findings: During and interview on 3/11/24 at 9:44 a.m., Resident 5 stated food should be hotter. Resident 5 further added breakfasts especially comes cold. During an interview on 3/11/24 at 1:16 p.m., Resident 10 stated all the food was bland. During an observation of trayline food service and a concurrent interview with [NAME] 1 on 3/11/24 at 11:40 a.m., [NAME] 1 stated he did not measure the temperature of the chicken when it was removed from the oven, and he did not measure the temperature of any food on trayline. [NAME] 1 stated he took the temperature of food sometimes. The temperature of three random pieces of chicken on trayline were measured with a calibrated thermometer and were 100.2 degrees Fahrenheit (F), 127 degrees F, and 129.4 degrees F. On 3/11/24 at 12:28 p.m., a test-tray was sampled in the presence of the Food and Nutrition Services Director (FNSD). Only pureed food was sampled because the kitchen did not have enough regular textured food to sample. The pureed food temperature was measured with a calibrated thermometer and was as follows: pureed chicken 108 degrees F, mashed potatoes 111.6 degrees F, and pureed green beans 107.8 degrees F. All of the pureed felt lukewarm (only slightly warm) the mouth when it was sampled. In addition, the pureed green beans had very minimal flavor. FNSD stated all hot food on trayline should be held at a minimum of 145 degrees F. He also stated he thought the food should be close to 145 degrees F at the point of service to the residents. FNSD stated he felt the temperature of the food on the test tray was too low. FNSD also stated the green beans needed seasoning. In an interview on 3/12/24 at 10:15 a.m., Registered Dietitian 1 (RD1) stated she did not taste the food at the facility very often because she was on a strict diet. In an interview on 3/12/24 at 12:40 p.m., RD1 stated the last time she monitored food temperatures on trayline was in July 2023. She also stated she did not measure any food temperatures at the point of service to residents, so she did not know what the temperature of food was when it was served to the residents. She stated she never did test trays. Review of the facility's policy and procedure titled Meal Service dated 2023, showed the Food and Nutrition Services staff member will take the food temperature prior to service of the meal. will be served on trayline at the recommended temperatures and recorded on the daily therapeutic menu in the temperature column of the regular food and next to the food item under the therapeutic diet column of each food served. The temperatures may also be recorded on a temperature log. The service temperature of meat is 160 degrees F - 180 degrees F. Hot food serving temperature must be at or above minimum holding temperature of 140 degrees F. The P&P showed the recommended temperatures at delivery to residents for hot entrees, starch, and vegetables were at or above 120 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 22 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. The facility failed to prepare pureed food in a form appropriate for a pureed diet. This failure had the potential for four residents who received a pureed therapeutic diet to aspirate (to inhale food into the lungs resulting in choking and/or aspiration pneumonia) while their eating food. Findings: An observation during trayline food service on 3/11/24 at 11:40 a.m., showed [NAME] 2 placed all pureed diets on divided plates (a plate divided into 3 sections by raised dividers; a divided plate can separate food as well as provide additional surfaces to push against when trying to get food on a fork or a spoon). The tray tickets for Residents 4, 14, 16, and 19 showed they were on a pureed diet and the tray tickets did not indicate the residents required a divided plate. On 3/11/24 at 12:28 p.m., a test-tray was sampled in the presence of the Food and Nutrition Services Director (FNSD). The texture of the pureed green beans was very thin and runny. In an interview on 3/12/24 at 10:15 a.m., RD1 stated pureed food should be firm and hold its shape. RD1 also stated pureed food should be placed on regular plates when it was served to the resident, not divided plates, unless there was a physician's order for a divided plate. In an interview on 3/13/24 at 11:28 a.m., [NAME] 1 stated he used divided plates for pureed diets, so the food did not run together. [NAME] 2 stated she also used divided plates for pureed diets to keep the food separate and so it did not run together. Review of the facility's Diet Manual for Long Term Care Facilities dated 2023, showed the pureed diet is a regular diet that has been designed for residents who have difficulty with chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 23 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview and record review, the facility failed to ensure residents (Residents 4, 6, 8, 12, 16, 19, 21, 25, 29, 30, 31, 34) received physician prescribed Fortified Diets. Residents Affected - Some The failure to ensure 12 residents received Physician prescribed Fortified Diets placed them at potential risk for decreased caloric intake and possible malnutrition and/or weight loss. Findings: A record review showed Physician's Order Sheets showed the following residents were prescribed a diet including Fortified and the date the diet was prescribed: Resident 4 - Fortified ordered 11/8/23 Resident 6 - Fortified ordered 2/13/24 Resident 8 -Fortified, ordered 12/19/23 Resident 12 Fortified ordered 3/27/23 Resident 16 - Fortified, ordered 6/19/23 Resident 19 Fortified, ordered 1/30/24 Resident 21 - Fortified, ordered 7/9/23 Resident 25 Fortified, ordered 12/9/22 Resident 29 - Fortified, ordered 2/13/24 Resident 30 - Fortified ordered 8/18/22 Resident 31 - Fortified ordered 3/5/24 Resident 34 - Fortified ordered 9/29/23 During an observation of lunch tray line food service on 03/11/24 at 11:40 a.m., [NAME] 1 plated food for residents and DA (Dietary Aide) 1 verbally communicated to [NAME] 1 how many trays were needed for the different resident diets. DA 1 did not communicate trays requiring fortification for the Resident's who's tray tickets indicated they were on a physician prescribed fortified diet. Resident tray tickets which indicated a physician prescribed fortified diet were for Residents 4, 6, 8, 12, 16, 19, 21, 25, 29, 30, 31, and 34. During an interview with [NAME] 1 on 03/11/24 at 12:09 p.m., [NAME] 1 stated fortified diets usually received extra gravy and/or extra butter with their meal. He stated fortified diets did not receive extra gravy or extra butter for lunch today because gravy was part of the menu and all residents received gravy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 24 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0808 Level of Harm - Minimal harm or potential for actual harm Review of the Cooks Spreadsheet Spring Cycle Menus dated 3/11/24, showed all diets received 1-2 ounces of sauce along with the chicken. During interview on 03/11/24 at 12:09 p.m. the Food and Nutrition Services Director (FNSD) stated residents on a Fortified Diet should get extra gravy in addition to the gravy on the menu. Residents Affected - Some Review of the facility's policy and procedure Fortified Diet dated 2023, showed the fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. The goal is to increase the calorie density of the foods commonly consumed by the residents by adding calories such as extra margarine or butter to food items such as vegetables, potatoes and/or extra gravy and sauces to meats, potatoes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 25 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 interview, record review and observation, the facility did not ensure that food was stored, prepared, and served in a safe and sanitary manner when the following was noted: Residents Affected - Many 1. Time Temperature Control for Safety (TCS; food which requires time and temperature controls to limit the growth of illness causing bacteria) food temperatures were not measured after food was cooked. 2. The food thermometers were not sanitized. 3. The food thermometers were not calibrated. 4. Fish was not thawed safely. 5. The kitchen cabinets, shelving, drawers, and walls were not clean and had peeling paint. 6. The floor in the dry storage room was not clean. 7. The kitchen ceiling lights were not in clean condition. 8. Food preparation utensils and equipment were not cleaned and/or maintained in good condition. 9. A kitchen microwave was not maintained in clean condition. 10. A wooden countertop was not in clean condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 26 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 11. Level of Harm - Minimal harm or potential for actual harm An industrial can opener was not maintained in clean condition. 12. Residents Affected - Many Two cutting boards were not maintained in clean or good condition. 13. Coolers (refrigerator and freezers) were not maintained in clean condition. 14. A food scale was not in clean condition. 15. A toaster was not maintained in clean condition. 16. One knife handle was poor condition. 17. Dessert bowls and sheet pans were not air dried and were stacked wet. 18. Proper hand hygiene procedures were not followed. 19. The sanitizer strength was low for sanitizer meant to clean surfaces and items in the 2-compartment sink. 20. Containers of breadcrumbs and food thickener did not have appropriate tight-fitting lids. 21. Cooler temperatures storing food were not monitored. 22. There was expired pureed food stored in a freezer and available for use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 27 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many These failures placed 35 residents who received food from the kitchen at potential risk for food borne illnesses and/or illness related to use of contaminated utensils. Findings: 1. During a concurrent interview and observation on 03/11/24 at 11:40 a.m. with [NAME] 1 in facility kitchen, [NAME] 1 was setting up food for lunch trayline foodservice. [NAME] 1 did not take the temperature of the food when he placed it on trayline and before he started serving the food. [NAME] 1 stated he sometimes took food temperatures and confirmed he did not take any temperatures of food today. One item being served was chicken. [NAME] 1 stated he did not take the temperature of the chicken when it came out of the oven. During observation on 03/11/24 at 12:02 p.m. in facility kitchen, temperatures were measured of different three random pieces of chicken on tray line, with a calibrated thermometer, and were as follows: 100.2 degrees Fahrenheit (F); 127 degrees F; 129.4 degrees F. Temperature of pureed chicken on tray line was 124 degrees F. During an interview on 03/11/24 at 12:28 p.m., the Food and Nutrition Services Director (FNSD) stated tray line food should be held on trayline at or above 145 degrees F. During any interview on 03/12/24 at 12:50 p.m. with RD 1, RD 1 stated that last time she took temperatures of food on tray line was in July 2023. RD 1 stated chicken on tray line should be at least 165 degrees F. Review of the facility's policy and procedure titled, Meal Service dated 2023, showed the food and nutrition services staff member will take the food temperatures prior to service of the meal; the food will be served on tray line at the recommended temperatures (hot food serving temperature must be at or above minimum holding temperature of 140 degree and meat should be 160-170 degrees F. According to the 2022 Federal Food Code, poultry is to be cooked to 165 degrees F or above for over one second. 2. During an observation in the kitchen and interview with [NAME] 1 on 03/11/24 at 11:40 a.m., [NAME] 1 stated he measured the temperature of food with thermometers sometimes. [NAME] 1 stated he did not have sanitizer wipes to clean the food thermometers. [NAME] 1 stated that the kitchen was out of sanitizer wipes, and he did not get around to ordering more. When [NAME] 1 was asked how he sanitized the food thermometers, he stated the thermometers were not sanitized and he was not sure the last time they were sanitized. Review of the facility's policy and procedure titled, Meal Service dated 2023, showed the food and nutrition services staff member will take the food temperatures prior to service of the meal. A review of the facility's policy and procedure titled Thermometer Use and Calibration dated 2023, showed food thermometers are to be used properly. Thermometers are to be cleaned and sanitized after use. When using the same thermometer on multiple different foods during one meal, wipe thermometer with an alcohol swab between different food items. 3. During an observation and interview on 03/13/24 at 12:53 p.m., [NAME] 1 stated thermometers were calibrated every Monday. FNSD stated the cooks were responsible for calibrating the thermometers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 28 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Dial food thermometers were in a container on the preparation table across from the stove. [NAME] 1 demonstrated how to calibrate (adjust) one of the dial thermometers. [NAME] 1 filled a plastic cup with ice and placed some water in the cup with the ice. [NAME] 1 placed the thermometer in the ice water. When asked if temperature reading was okay, looked at thermometer and stated no and that had to do it again. The thermometer read about 40 degrees F. when it was in the ice water. [NAME] 1 filled the plastic cup with ice and some water again, this time the cup contained more ice. [NAME] 1 placed the thermometer in the cup of ice water. After over 1 minute, [NAME] 1 did not say anything regarding the thermometer so the Surveyor asked if the thermometer reading was okay. [NAME] 1 then stated he needed his glasses because could not see. [NAME] 1 retrieved a pair of reading glasses and put them on and stated the temperature of the thermometer looked okay. He stated the thermometer read 32 degrees F. The dial on the thermometer was below 32 degrees F. FNSD looked at thermometer and stated that it was about 20 degrees F. The Surveyor's thermometer was placed in the ice water, and it read 32.4 degrees F. [NAME] 1 was asked if he was able to calibrate the thermometer to 32 degrees F. [NAME] 1 stated he did not know how. [NAME] 2, who was also present, stated did not know how to calibrate the thermometer to 32 degrees F. Another dial thermometers wad placed in the ice water. The thermometer showed temperature of about 15 degrees F. FNSD confirmed that the thermometer temperature was too low and stated he did not think kitchen staff calibrated it correctly. Review of the facility's policy and procedure titled, Thermometer Use and Calibration dated 2023, showed food thermometers are to be calibrated to ensure accurate temperature reading. Checking the accuracy and calibrating: food thermometers are to be calibrated each week, after one is dropped or when a thermometer is new. It is recommended to put thermometer calibration on a cook's duties/sanitation list that must be initialed upon completed. If a thermometer does not read 32 degrees F, then the thermometer must be calibrated or discarded. 4. An observation on 03/12/24 at 1:27 p.m. in facility kitchen, over ten fillets of raw fish were in a plastic container, in standing water, in a food preparation sink. Parts of the fish were not submerged in the water. An observation and concurrent interview on 3/12/24 at 1:59 p.m., showed the fish was still sitting in the container of standing water. [NAME] 1 stated he placed the fish in the water about 1:30 p.m. this afternoon for these evening's dinner. [NAME] 1 stated he did not know water had to be running over thawing meat that no parts of the fish should be sticking out of the water. FNSD observed thawing fish and stated that fish should have running water over it. [NAME] 1 then stated asked the Surveyor if all meat had to be thawed under running water. FNSD walked back to his office. During interview an observation with FNSD on 03/12/24 at 2:04 p.m., FNSD was asked if the fish was safe to use. FNSD walked back out to where the fish was being thawed and the fish was in the standing water without the water running over the fish. FNSD turned the water on, so it was running over the fish. FNSD walked away. The temperature of the running water was measured with a calibrated thermometer and the temperature of the water was 80 degrees F and one minute later the running water over the fish was 85 degrees F. During a review of the facility's policy and procedure titled Thawing of Meats dated 2023, showed to when thawing meat using water, submerge the meat under running, potable water at a temperature of 70 degrees F or lower with pressure sufficient to flush away loose particles. 5. During an observation in the kitchen during the initial tour on 03/11/24 at 10:04 a.m., the kitchen shelving and cabinets above the food preparation area, had a rough painted surface with chunks (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 29 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many paint peeling from the surface. There were areas on the shelving where paint was peeled off and the wood surface of the shelving was exposed. In addition, there were brownish, orange residue marks on the underside of the outside surface of the shelving. As the initial tour continued on 03/11/24 at 10:04 a.m., and observation showed a light switch on the wall above a preparation table and below the cabinets. The metal light switch box cover plate and the surrounding wall area around the light switch box had black grime and pinkish residue build-up. On the wall below the light switch box there was a two plug outlet. There was black grime build-up in the crevice between the wall and the outlet cover. Next to the outlet was the top of the preparation table metal backsplash. There was black grime build-up where the metal backsplash came into contact with the wall. As the initial tour continued on 3/11/24 at 10:23 a.m., and observation showed shelving in the coffee station area. On the shelving surface dark brown, light brown, and white dried debris resembling coffee grounds and food crumbs. The inside wall where the shelving was attached also had black residue build-up on the surface. Uncovered coffee filters were stored on the shelving with the debris. As the initial tour of the kitchen continued, observation and a concurrent interview with Diet Aide 1 (DA1) on 3/11/24 at 10:24 a.m., showed a drawer, under the preparation table in the coffee station area which held items such as small paper cups. The wood drawer had a paper liner at the bottom which did not cover the entire bottom surface of the drawer. There were dark black bits and brown residue on the paper lining. In addition, there was an unwrapped band aid inside the drawer. Some of the small paper cups were not fully enclosed in their plastic storage sleeve, and loose paper cups came into contact with the drawer surface. DA 1 stated the small paper cups were used for condiments such as ketchup and mustard. As the initial tour continued on 3/11/24 at 10:46 a.m., a shelving area under a preparation table across from the stove and steam table was observed. The wood frame around the shelving area had rough peeling paint, with exposed wood in places, as well as brown and black residue on the rough, painted surface. Shelving, which held cooking equipment and some shelf stable food items such as breadcrumbs and food thickener, had a significant amount of brown residue and particles, as well as black grime build-up on the surface of the shelves. During an interview on 03/12/24 at 10:15 a.m. with RD 1, RD 1 stated that last sanitation checklist was done July 2023. RD 1 stated, normally these rounds should be done monthly (Cross-reference F801). She stated the Administrator (ADM) received copies of her sanitation checklists, but she did not think things were being addressed such as peeling paint, so she stopped doing them. During an interview on 03/12/24 at 11:42 a.m. with EVS, EVS stated he was aware of the peeling paint in the kitchen. He also stated housekeeping staff were responsible for cleaning areas in the kitchen once a month, however kitchen staff were responsible for cleaning shelving, drawers, and cabinets. In an interview on 3/12/24 at 1:14 p.m., FNSD stated he did not work at the facility full-time to supervise staff. He stated he was at the facility approximately two days a week, three to four hours a day (Cross-reference F801). FNSD stated a cleaning schedule was not posted. He stated he gave staff a cleaning schedule, but he did not know what they did with it. He stated there was not documentation to show when staff cleaned and/or cleaning was completed. He stated staff cleaned when they had time to clean. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 30 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 During an interview on 03/13/24 at 2:35 p.m. with FNSD, FNSD confirmed shelving was not clean and stated that shelving should be clean. A review of the facility's policy and procedure titled Walls, Ceilings, and Light Fixtures dated 2023, showed walls must be free of chipped and/or peeling paint. Residents Affected - Many During a review of the facility's policy and procedure titled Cabinets and Drawers dated 2023, showed clean cabinet and drawers on a weekly basis. During a review of the facility's policy and policy titled Sanitation dated 2023, showed the FNS [Food and Nutrition Services] Director will write a cleaning schedule in which he designates by job title and/or employee who is to do the cleaning task. The P&P also showed all shelves shall be kept clean. According to the 2022 Federal Food Code, physical facilities shall be cleaned as often as necessary to keep them clean. 6. An observation on 03/11/24 at 10:27 a.m., showed a dry-food storeroom located in the kitchen. Large metal racks in the storeroom stored shelf-stable food. On the floor under the racks there were small and large debris resembling pieces of food such as dried cereal, there were several plastic lids, an ink pen, single serve condiment packets, and gray fluffy residue resembling dust. During an interview on 03/12/24 1:14 p.m. with FNSD, FNSD stated kitchen staff were supposed to sweep under the kitchen racks every day. FNSD stated a cleaning schedule was not posted. He stated he gave staff a cleaning schedule, but he did not know what they did with it. During a review of the facility's policy and policy titled Storeroom dated 2023, showed the general cleanliness and care of the Storeroom and supplies are important to ensure safe, wholesome food. Floors must be kept clean by setting up, maintaining, and monitoring a regular cleaning schedule and routine inspections must be made to ensure cleanliness and high standards of sanitation. A review of the facility's policy and procedure titled Storage of Food and Supplies dated 2023, showed the storeroom should be clean at all times. Routine cleaning procedures should be developed and followed. A review of the facility's policy and policy titled Sanitation, dated 2023, the FNS Director will write a cleaning schedule in which he designates by job title and/or employee who is to do the cleaning task. 7. During an observation in the kitchen on 03/11/24 at 10:45 a.m., the ceiling fluorescent bulbs and light fixtures had black/gray fluffy looking residue on the surface. The lights were located above food preparation and serving areas as well as utensil/equipment storage areas. During a concurrent observation in the kitchen and interview with Environmental Supervisor (EVS) on 03/12/24 at 11:42 a.m. EVS stated that the black/gray fluffy residue on the lights and light fixtures was dust. He stated that lights were not very clean. According to the 2022 Federal Food Code, physical facilities shall be cleaned as often as necessary to keep them clean. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 31 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 8. During an observation on 03/11/24 at 9:47 a.m. hanging from a rack above a preparation table by the stove, were three small frying pans with scratches covering the majority of the cooking surface. These pans were also discolored with orange and black residue. In addition, two larger frying pans had orange and black residue on the inside surface. The silicone cover on the handle of one of the pans was mostly gone creating a jagged surface on the remaining silicone. The surface where the silicone was missing was a very rough and dark brown in color. One saucepan, also hanging from the rack, had orange and brown residue on the inside surface resembling dried food residue. A cheese grater hanging from the rack had rough, dried, white residue on the surface. Two strainers were stored hanging from the rack. One small strainer had a small chunk of light-pink residue on the surface resembling a piece of food and the other strainer had a brown residue on the surface. An observation on 03/11/24 at 10:07 a.m. showed a plastic container filled with utensils such as scoops, ladles, measuring spoons, measuring cups, and a potato masher stored on a shelf beneath a preparation table. The majority of the utensils had residue on the surface resembling food residue. The bottom inside of the container was wet with debris on residue that resembled food. During observation on 03/11/24 at 10:50 stored on a shelf under a preparation table, there were two large sheet pans with black residue build up on cooking surface and one smaller sheet pan with scratches white/black residue resembling food residue on the cooking surface. Also stored on the shelf were In muffin pans. A gray plastic bus tub with scratches imbedded with black residue on the outside bottom surface rested on top of the muffin pans. In addition, the muffin pans had brown residue inside surface resembling food residue. Review of the facility's policy and procedure titled Sanitation dated 2023, showed all utensils and equipment shall be kept clean, maintained in good repair, and shall be free from corrosion. According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulation. 9. An observation on 03/11/24 at 10:19 a.m. showed when the kitchen microwave door was opened, it appeared clean at eye level. However, when the upper surfaces were viewed, the microwave had yellowish/orange residue splatter residue over entire inside upper surface and some on the upper side surfaces. In an interview on 3/12/24 at 1:14 p.m., FNSD stated a cleaning schedule was not posted. He stated he gave staff a cleaning schedule, but he did not know what they did with it. An observation and interview on 3/12/24 at 1:54 p.m., showed the kitchen microwave was in the same condition when it was observed the day prior and had yellowish/orange residue splatter residue over entire inside upper surface and some on the upper side surfaces. FNSD confirmed there was residue splatter inside the microwave and stated to [NAME] 1 that microwave needed to be cleaned daily. During a review of the facility's policy and policy titled Sanitation, dated 2023, showed all equipment shall be kept clean. In addition, the FNS [Food and Nutrition Services] Director will write a cleaning schedule in which he designates by job title and/or employee who is to do the cleaning task. According to the US Food and Drug Administration (FDA) Food 2022 the cavities and door seals of microwave ovens are to be cleaned at least every 24 hours by using the manufacturer's recommended (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 32 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 cleaning procedure. Level of Harm - Minimal harm or potential for actual harm 10. An observation in the kitchen on 03/11/24 at 9:57 a.m., showed a large wood butcher block table being used as a storage space for equipment such as the blender and an electric cooking pot. This area was also used as a preparation table. There were cut marks throughout the surface, so the surface was not smooth. There was also black residue imbedded in the surface. Residents Affected - Many Review of the facility's policy and policy titled Sanitation, dated 2023, showed all counters and equipment shall be kept clean, maintained in good repair, and shall be free from corrosion, and open seams. According to the US Food and Drug Administration (FDA) Food 2022, food-contact multiuse surfaces are to be smooth and clean to sight and touch. Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. In addition, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning are to be constructed of a corrosion-resistant, nonabsorbent, and smooth material. Nonfood-contact surfaces are to be free of unnecessary crevices and designed and constructed to allow easy cleaning and to facilitate maintenance and are to be kept free of an accumulation of dust dirt, food residue, and other debris. 11. During a concurrent observation in the kitchen and interview with [NAME] 1 on 03/11/24 at 10:09 a.m., an industrial can opener was in a holder attached to kitchen preparation table had black/dark brown, thick residue on the blade and around the blade. Black residue transferred to white paper towel when the blade was wiped. In addition, there was black, sticky, thick residue build-up in the crevices of the can opener holder attached to the table. During review of the facility's policy and procedure titled Can Opener and Base dated 2023, indicated, proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. The can opener must be thoroughly cleaned each work shift and when necessary, more frequently. Review of the facility's policy and policy titled Sanitation, dated 2023, showed all equipment shall be kept clean. According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. Nonfood-contact surfaces are to be kept free of an accumulation of dust dirt, food residue, and other debris. 12. An observation in the kitchen on 3/11/24 at 9:57 a.m., showed a long white, plastic, cutting board surface attached to the area in front of the steam table. The surface of the plastic board was covered in cut marks and black/brown residue imbedded in the surface. An observation in the kitchen on 03/11/24 at 10:19 a.m., showed cutting board rack filled with cutting boards. One of five of the plastic cutting boards (white) had black residue imbedded on surfaces where there were cut marks. During a review of the facility's policy and policy titled Sanitation, showed all counters and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 33 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 equipment shall be kept clean and in good repair. Level of Harm - Minimal harm or potential for actual harm According to the US Food and Drug Administration (FDA) Food 2022, cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. In addition, food-contact multiuse surfaces are to be smooth and clean to sight and touch. Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning are to be constructed of a corrosion-resistant, nonabsorbent, and smooth material. Nonfood-contact surfaces are to be free of unnecessary crevices and designed and constructed to allow easy cleaning and to facilitate maintenance and are to be kept free of an accumulation of dust dirt, food residue, and other debris. Residents Affected - Many 13. During an observation in the kitchen on 03/11/24 at 10:16 a.m. reach-in freezer number one was filled with frozen food. There were white debris/particles resembling food crumbs on the bottom inside surface. In an interview on 3/12/24 at 1:14 p.m., FNSD stated a cleaning schedule was not posted. He stated he gave staff a cleaning schedule, but he did not know what they did with it. An observation in the kitchen and concurrent interview with FNSD on 3/12/24 at 1:54 p.m., showed the reach-in freezer number one had white debris/particles on the bottom inside surface, the same as the day before. FNSD confirmed the debris/particles inside the freezer and stated the freezer had to be cleaned. An observation on 03/13/24 at 11:32 a.m. showed a full sized refrigerator/freezer cooler located downstairs in the staff break room. The freezer compartment stored a box of individual containers of pureed meat, and multiple blocks of butter. There was a significant amount of particles resembling food crumbs, on the entire inside bottom surface. A carton of milk was stored in the refrigerator compartment. In an interview on 3/13/24 at 11:40 a.m., [NAME] 2 stated the refrigerator/freezer located downstairs stored butter and milk and was the kitchen overflow refrigerator. During an observation and concurrent interview with FNSD on 3/13/24 at 11:48 a.m., FNSD confirmed there was food for the kitchen stored in the refrigerator/cooler in the downstairs refrigerator/freezer. The rubber gasket attached to the inside surface of the refrigerator door had black residue imbedded in the long crevices. There was also orange residue on the freezer door in addition to the particles resembling crumbs inside the freezer. FNSD stated the cooler was not clean. Review of the facility's policy and procedure titled Refrigerator and Freezer, dated 2023, indicated, maintaining a clean refrigerator and freezer can improve the safety and quality of your food and the refrigerator and freezer should be cleaned on a weekly basis. During a review of the facility's policy and policy titled Sanitation, dated 2023, showed all equipment shall be kept clean. In addition, the FNS [Food and Nutrition Services] Director will write a cleaning schedule in which he designates by job title and/or employee who is to do the cleaning task. According to the US Food and Drug Administration (FDA) Food 2022, food-contact multiuse surfaces (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 34 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many are to clean to sight and touch. Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning are to be constructed of a corrosion-resistant, nonabsorbent, and smooth material and are to be kept free of an accumulation of dust dirt, food residue, and other debris. 14. An observation in the kitchen on 03/11/24 at 10:49 a.m., showed a food scale stored on a shelf below the food preparation table. The top surface of the scale was covered in foil and had spots of residue which appeared greasy as well has particles resembling food crumbs on the foil surface. In addition, the base of the scale had a layer of residue and particles on the surface. During an observation and concurrent interview with FNSD on 3/12/24 at 1:54 p.m., FNSD stated the scale was not clean and it appeared to have grease or gravy on the surface of the foil. Review of the facility's policy and procedure titled Sanitation, dated 2023, showed all equipment shall be kept clean. According to the US Food and Drug Administration (FDA) Food 2022, food-contact multiuse surfaces are to clean to sight and touch. Nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust dirt, food residue, and other debris. 15. An observation in the kitchen and concurrent interview with [NAME] 1 on 03/11/24 at 10:46 a.m., showed four-slot toaster stored in open on a shelf under the preparation table across from the stove. The toaster was covered in particles resembling food crumbs, and brown/tan residue on top surface. There was also a significant amount of particles inside the toaster slots. Review of the facility's policy and procedure titled Sanitation, dated 2023, showed all equipment shall be kept clean and maintained in good repair. 16. During a concurrent observation in the kitchen and interview with FNSD on 03/12/24 at 1:52 p.m., one knife stored in a knife rack attached to wall close to the stove, had a handle in which the silicone coating was split, torn, and cracked. The silicone was also discolored. FNSD stated the knife should be used and thrown away. During a review of the facility's policy and procedure titled, Healthcare titled Sanitation dated 2023, showed all utensils shall be kept clean, maintained in good repair and free from breaks, corrosions, and cracks. 17. An observation in the kitchen and interview with [NAME] 1 on 03/11/24 at 10:50 a.m., showed a plastic tub stored on a shelf on the food preparation table across from the stove. The container held clear plastic bowls stacked/nested together. The bowls were wet and had moist beige, black, or orange residue on the surface resembling food residue. [NAME] 1 stated the bowls were used for desserts. A consecutive observation on 3/11/24 at 10:51 a.m., showed two large sheet located on a shelf under a preparation table across from the stove. The pans had black residue build up on the surface and were stacked wet. Review of the facility's policy and procedure titled 3-Compartment Procedure for Manual Dishwashing dated 2023, showed after cleaning and sanitizing, all items are to be air dried, which means no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 35 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 droplets are present. Level of Harm - Minimal harm or potential for actual harm According to the 2022 Federal Food Code, after cleaning and sanitizing, equipment and utensils are to be air-dried or used. Residents Affected - Many 18. An observation in the kitchen on 03/11/24 at 9:58 a.m., showed [NAME] 1 wore gloves and was pureeing food. Then [NAME] 1 proceeded to the two-compartment dishwashing sink that was filled with soiled utensils and equipment and were not filled with water and/or sanitizer solution. [NAME] 1 turned on the water at the sink using his gloved hands to turn the water handle. He then, rinsed gloves under the water, and turned the water off. [NAME] 1 picked up a wet rag that was stored inside the sink (not in the red bucket). [NAME] 1 placed the rag back in the sink and back to pureeing food. [NAME] 1 did not change his gloves or wash his hands. During a review of the facility's policy and procedure title Glove Use Policy dated 2023, showed the appropriate use of gloves is essential in preventing food borne illness. Gloved hands are considered a food contact surface that can get contaminated or soiled. Disposable gloves are a single use item and should be discarded after each use, and especially before handling clean food items. Gloves must never be used in place of handwashing. Gloves need to be changed before beginning a different task and as soon as they become soiled such as when doing cleaning. According to the 2022 Federal Food Code, food employees are to clean their hands and exposed portions of their arms immediately before engaging in food preparation, after handling soiled equipment, before donning gloves to initiate a task that involves working with food, and after engaging in other activities that contaminate the hands. 19. During an observation in the kitchen and interview on 03/12/24 at 1:26 p.m. a red bucket filled with a clear liquid and[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 36 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 facility document review, the facility failed to safely store food brought in by family and visitors for residents. This failure had the potential to result in decreased intake of food as well as result in foodborne illness for 35 residents who ate food by mouth. Residents Affected - Many Findings: Review of the facility's undated policy and procedure titled Foods Brought by Family/Visitors, showed perishable foods must be stored in re-sealable containers with tight fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. The nursing staff is responsible for discarding perishable foods on or before the use by date. Home-prepared and home-preserved foods are permitted if brought by the family or visitors for the individual resident. This P&P did not provide guidance regarding timeframes for use-by dates. An observation and consecutive interview with [NAME] 1 on 3/11/24 at 10:41 a.m., showed a paper bag with Resident 16's name and room number were handwritten on the outside of the bag stored in the reach-in refrigerator in the kitchen. The bag contained a re-useable plastic container filled with a cooked rice mixture with what appeared to be mixed with chopped meat such as chicken, a re-useable plastic container filled what appeared to be a soup containing [NAME] 1 stated he knew the food for Resident 16 was stored in the refrigerator. He stated the food was already in the refrigerator when he arrived in the morning and did not know when it was placed in the refrigerator. In an interview on 3/12/24 at 11:35 a.m., Licensed Vocational Nurse 1 (LVN 1) stated some families brought food in for residents. She stated she asked families to take any food home if the resident did not want to eat the food right away. LVN 1 stated she did not store food brought in by families intended for residents. LVN 1 stated if food from outside was stored, she did not know how long it could be stored for. In an interview on 3/12/24 at 1:09 p.m., Certified Nursing Assistant 1 (CNA1) stated if a resident wanted to store food brought in by a visitor, she put the food in the refrigerator downstairs. She said she thought food could be stored up to two days. CNA1 stated she cared for three residents with families who brought in food for them. An observation on 3/13/24 at 11:30 a.m., showed two full sized refrigerator/freezer coolers in the staff breakroom. One refrigerator was filled with staff food. In addition to staff food was a plastic bag with a resident name and room number hand-written on the outside of the bag. Inside the bag was an unlabeled plastic re-usable container filled with pasta and what resembled meat sauce. There was no date on the food container or the bag to show when the food was to be used-by or when it was placed in the refrigerator. In an interview on 3/13/24 at 11:51 a.m., the Director of Nursing (DON) stated food brought in by family and visitors for residents was not stored. She stated anything perishable or that needed to be reheated and/or chilled was not safe to store. She said resident food should not be in the refrigerator downstairs or in the kitchen. When she was informed of the food stored in the staff refrigerator downstairs, she confirmed the resident was Resident 14. In an interview on 3/13/24 at 11:55 a.m., Resident 14 was alert and sitting up in bed. He stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 37 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 the food stored in the food downstairs was his spaghetti with meat sauce. He said a staff member placed it in the refrigerator for him a few days ago. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 38 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 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 essential equipment was maintained when there were no stopper/plugs available for the two-compartment sink. This failure did not allow for one piece of equipment to used for dishwashing as intended. Residents Affected - Few Findings: During and interview and observation on 3/12/23 at 1:46 p.m., [NAME] 1 described how he would use the two-compartment sink for warewashing in the case the dish machine was out of order. He stated the sinks would be filled, one with water for washing, and one with a sanitizer solution for sanitizing. However, he stated there were no stoppers to plug the drain holes for the sinks to be filled. Review of the facility policy and procedure titled 3-Compartment Procedure for Manual Dishwashing dated 2023, showed three compartment sink washing procedures are to be initiated when the dishwasher is inoperable. Supplies needed included but were not limited to drain stoppers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 39 of 40 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 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when ants were observed in the the residents ' dining/ activity room on 3/12/24 through 3/14/24. Residents Affected - Some This failure had the potential to result in the transfer of bacteria and placed a risk for food-borne illness to the residents who used the dining/ activity room. During multiple observations on 3/12/24, and 3/13/24, in the resident dining/activity room, multiple ants were observed crawling on the walls and tables. During an interview on 3/13/24, at 10:28 a.m., with Administrator (ADM), ADM was notified there were ants in the resident dining/activity room. ADM stated pest control comes monthly. During a concurrent observation and interview on 3/14/24, at 11:00 a.m., with Certified Nursing Assistant (CNA) 2, in the resident dining/activity room, CNA 2 stated residents used the room for dining and activity. CNA 2 stated there was a good amount of ants on the walls and residents may not like it. During a concurrent observation and interview on 3/14/24, at 11:05 a.m., with Environmental Supervisor (EVS), in the resident dining/activity room, EVS confirmed there were ants on the walls and dining tables. EVS stated they were not previously aware of the ants. EVS stated pest control services the facility monthly and as needed. EVS stated they called pest control immediately for urgent needs. EVS stated the ants were an urgent situation and they needed to call pest control right away. EVS stated it was important for the residents. During a concurrent observation and interview on 3/14/24, at 11:18 a.m., with Licensed Vocational Nurse (LVN) 1, in the resident dining/activity room, LVN 1 confirmed there were ants on the walls and dining tables. LVN 1 stated the ants in the dining/activity room was a risk to the residents because it could have caused them to have negative feelings, was not homelike for the residents and could have got in their food. During an interview on 3/14/24, at 11:51 a.m., with Director of Nursing (DON), DON stated ants were a nuisance and were not a good to have. During a review of the facility's undated policy and procedure (P&P) titled, Pest Control, the P&P indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 40 of 40