Health inspection·May 2, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for three out of 25 final sampled residents (Residents 4, 47 and 94). This had potential for the facility to provide treatment and services against the residents' wishes. Findings: 1. Review of Resident 4's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (Muscle wasting, also known as muscle atrophy, refers to the loss of muscle mass and strength). During a review of Resident 4's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/25/25 under Section C, indicated a score of 15, meaning Resident 4 was cognitively intact . During a review of Resident 4's Physician Orders for Life-Sustaining Treatment (POLST) form, dated 1/3/16, under information and signatures, it showed the resident had no adv directives. (A POLST is a form that gives instructions for the resident's care in life-threatening medical situations). 2. Review of Resident 47's Facesheet indicated, Resident 47 was admitted to the facility on [DATE] with diagnoses that included depression ( a mood disorder that causes persistent feelings of sadness), and adult failure to thrive (a syndrome where an adult experiences a decline in overall health, often marked by weight loss, decreased appetite, reduced energy, and a progressive decline in their ability to perform daily activities). During a review of Resident 47's MDS dated [DATE] under Section C, it indicated a score of 7, meaning Resident 47 had severe cognitive impairment . Review of Resident 47's medical records showed a POLST dated 2/18/22, under information and signatures, it showed the resident had no advanced directive. Page 1 of 39 056103 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0578 Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident 94's Facesheet indicated, Resident 94 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity). During a review of Resident 94's MDS dated [DATE] under Section C, it indicated a score of 6, meaning Resident 94 had severe cognitive impairment . Residents Affected - Some During a review of Resident 94's POLST form, dated 12/20/23, under information and signatures , it showed the resident's advanced directives was not available. During a concurrent interview and record review on 4/29/25, at 11:24 a.m., with the Social Service Director Assistant (SSDA), SSDA reviewed Resident 4,47 and 94's medical records and there were no documentation found that indicated the advance directives were discussed with Residents 4, 47 and 94 and their responsible parties. SSDA also stated that the importance of having an advanced directive was so that the residents' wishes regarding their medical care were respected when the residents could not communicate anymore. During an interview on 4/30/25, at 3:28 p.m., with the Director of Nursing (DON), DON stated that she was not aware of the facility's policy regarding advanced directives. During a review of the facility's policy and procedure ( P&P) titled (Advanced Directives),revised 2008, the P&P indicated, Advanced directives will be respected in accordance with state law and facility policy .3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advanced directives 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .7. The interdisciplinary team will review annually with the resident his or her advanced directives to ensure that such directives are still the wishes of the resident . The CMS Interpretive Guidance states that facilities are required to obtain a written record of resident advance directives upon admission and maintained in the medical record. Importantly, residents have a right to refuse to create an advance directive so the advance directive or the refusal to create an advance directive must be documented. 056103 Page 2 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to maintain a safe, clean, comfortable and homelike environment when: 1. The linoleum flooring in Resident 112's bathroom was discolored with areas of black stains that looked like dirt. 2. The toilet seat and toilet cover had multiple gray and black linear scratch marks, and the linoleum flooring was discolored with areas of black stains that looked like dirt in Resident 113's bathroom. This failure placed Residents 112 and 113 at risk for safety and may negatively impact the residents' psychological health when they had to use an unmaintained bathroom that was not homelike. Findings: 1.During an initial tour on 4/28/25 at 11:20 a.m. Resident 112 was lying in bed. Resident 112 expressed concerns regarding the dirty floor in her bathroom. Resident 112 also stated she was not using the bathroom, but she could see the bathroom floor when the door opened while she was lying in bed, and the dirty floor made her feel uncomfortable. During an observation on 4/28/25 at 11:27 a.m., the linoleum flooring in Resident 112's bathroom was discolored with areas of black stains that looked like dirt. The linoleum flooring of the bathroom appeared old and worn, discolored with some areas with black stains. Review of Resident 112's Minimum Data Set (MDS, an assessment tool) dated 3/18/25, indicated she had a Brief Interview for Mental Status or BIMS of 15 (BIMS score of 13-15 suggests intact cognition). 2. During an interview on 4/28/25, at 1:25 p.m., with Resident 113, the resident was lying in bed with a bedside commode by her bedside. Resident 113 stated she did not want to use the bathroom because the bathroom was dirty and gross. During an observation on 4/28/25 at 1:30 p.m., in Resident 113's bathroom, the linoleum flooring of the bathroom appeared old and worn, discolored with some areas with black stains. The toilet seat and cover had multiple gray and black linear scratch marks. Review of Resident 113's MDS dated [DATE], indicated she had a BIMS of 15 (intact cognition). During an interview on 4/29/25 at 12:12 p.m. with the Housekeeping Supervisor (HKS) , HKS acknowledged that Resident 112 and 113's bathroom did not appear homelike. HKS agreed that the linoleum flooring in Resident 112 and 113's bathrooms were old and worn and further stated that the housekeepers tried to scrub the scattered black discoloration in the floor with disinfectants but was unsuccessful in removing them. Also stated she knew of the gray and black scratch marks in Resident 113's bathroom toilet seat and cover but was not reported yet to the Maintenance Supervisor (MS). 056103 Page 3 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/30/25 at 10:17 a.m. with the MS, MS stated he was not aware of the multiple gray and black scratch marks in Resident 113's bathroom toilet bowl seat and cover. Acknowledged that Resident 113's bathroom did not provide a homelike environment. Further stated that housekeeping department was assigned to the facility bathrooms' linoleum floorings. During an interview on 4/30/25 at 10:53 a.m. with the Administrator (Adm), Adm stated resident 113's bathroom toilet bowl will be replaced and the linoleum flooring in Resident 112 and 113's bathroom will be replaced. During a review of the facility's undated policy and procedure (P&P) titled, Homelike Environment, the P&P indicated, Residents are provided with a safe, clean, comfortable and home like environment .1. Staff shall provide person-centered care that emphasizes the residents comfort, independence and personal needs and preferences. 2. The facility and management maximizes, to the extent possible , the characteristics of the facility that reflect a personalized homelike setting. These characteristics include a. clean sanitary and orderly environment .c. inviting colors and décor . 056103 Page 4 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure two of 25 sampled residents were free from physical restraints when the facility staff installed bed foam bolsters to Residents 63 and 77's bilateral bedrails, which inhibited the residents' freedom to get in and out of their beds (Bed foam bolsters are elongated foam that are designed to prevent residents from falling off the bed). Residents Affected - Some This deficient practice had the potential to cause injury and decline in the residents' quality of life. Findings: a. During an observation on 5/1/2025 at 12:08 p.m., with Registered Nurse (WCN), Resident 63 was awake, lying in bed, appeared agitated and did not want to be bothered. Resident 63's bed had foam bolsters to bilateral side rails, strapped to the bed frame on bilateral sides. There were two straps across the mattress connecting both bolster pads, one strapped on the upper part of the mattress and the other below the mattress. Resident 63 was lying on top of these two straps, with no flat sheet on the mattress. The mattress only had a draw sheet on it. Resident 63 was non interviewable, not responding to questions. The WCN attempted to take Resident 63's blanket off his feet and Resident 63 was yelling and agitated. The WCN stated the foam pads are used for fall risk and that Resident 63 cannot get out of bed when bolster pads are in place. During an interview and observation on 4/30/2025 at 12:14 p.m., with the primary License Vocational Nurse (LVN 3), for Resident 63, LVN 3 stated the foam pads, placed on bilateral sides rails of resident 63's bed are called bolster pads, and they are used for fall risk residents. Resident 63's roommate in the B bed or middle bed had a floor pad in place, instead of foam pads (bolster pad) on his bedside rails. LVN 3 stated the facility did not use bolster pad for the roommate, they instead used a floor pad was the roommate would not attempt to exit his of bed, but for Resident 68, he would try to exit his bed. During an interview on 5/1/2025 at 12:57 a.m., with Registered Nurse (LN 3), LN 3 stated the bolster pads are for fall risk and the facility uses these pads on most residents who are assessed to be a fall risk. LN 3 stated when Residents are not able to remove the bolster pads or exit their bed when bolster pads are in place. LN 3 also stated the bolster pads can only be removed by staff. b. During an observation on 4/29/25, at 8:45 a.m., in Resident 77's room, resident was observed to be lying in bed awake, with bed foam bolsters installed in the bilateral bedrails of her bed . the foam bolsters were tied to the sides of the bed frame of Resident 77's bed. Review of Resident 77's Facesheet (information containing contact details, brief medical history at-a-glance) indicated she was admitted to the facility on [DATE] with diagnoses that included hemiplegia of left dominant side (severe weakness affecting the left side of the body, resulting from damage to the right side of the brain), need for assistance with personal care and adult failure to thrive (a syndrome where an adult experiences a decline in overall health, often marked by weight loss, decreased appetite, reduced energy, and a progressive decline in their ability to perform daily activities). 056103 Page 5 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0604 Level of Harm - Minimal harm or potential for actual harm Review of Resident 77's Minimum Data Set (MDS, an assessment tool) dated 3/13/25, indicated she had a Brief Interview for Mental Status or BIMS of 11 (BIMS score of 8-12 suggests mildly impaired cognition). The MDS Section GG titled, Functional Abilities indicated, Resident 77 was not steady, and was only able to stabilize with staff assistance when moving from seated to standing position and during surface-to-surface transfer (such as when transferring between bed and chair or wheelchair). Residents Affected - Some Review of Resident 77's Physician Orders (PO), dated 12/25/22, the PO indicated, an order of Bolstered mattress to enable and support turning and repositioning when in bed related to diagnosis of cerebrovascular accident with left hemiplegia (cerebrovascular accident with left hemiplegia is brain injury, causing weakness on the left side of the body). During a concurrent observation and interview on 4/30/25, at 12:45 p.m., with the Director of Staff Development (DSD) , in the Resident 77's room, DSD stated the bolster siderail pads were used to keep the resident from falling from her bed. During an interview on 5/1/25, at 10:00 a.m., with Certified Nursing Assistant (CNA) 4, stated Resident 77 was a fall risk and was trying to get out of bed. Stated the bolster side rail pads were used to prevent the resident from getting out of bed and falling. Further stated, because the resident had left side body weakness, the bolster pads only helped the resident to reposition when she was using the right side of her body. During an interview on 5/1/25 at 2:32 p.m., with Assistant Director of Nursing (ADON), ADON acknowledged that the bolster pads were preventing the resident from getting in and out of her bed. During a review of the undated facility's policy and procedure (P&P) titled, Restraints, the P&P indicated, .Definitions .2. Convenience-any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest .6. Physical restraints-any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body .Restraints: .may not be used for purposes of discipline or convenience . 056103 Page 6 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident 45), Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate when Resident 45 MDS section E was not coded accurately to reflect Resident 45's wandering behavior. Residents Affected - Few This failure had the potential for residents to not received appropriate care. Findings: During an observation on 4/28/25 at 10:52 a.m. Resident 45 wandered in hallways with a front wheeled walker looking into other residents rooms. During an interview on 4/30/25 at 8:33 a.m. with Certified Nursing Assistant (CNA1), CNA1 stated Resident 45 wandered around the facility goes into other residents rooms . CNA1 stated Resident 45 was very confused, wanders into other residents rooms, switch off the light in the room and get agitated when redirected. During a review of Resident 45's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 3/17/25, indicated MDS section E wandering presence and frequency was coded zero meaning wandering behavior was not exhibited. During a concurrent interview and record review on 4/30/25 at 12:53 p.m. with Social Services Director (SSD), Residents 45's MDS section E behavior, dated 3/17/25 was reviewed. The MDS indicated, Wandering presence and frequency, has the resident wandered coded zero, behavior not exhibited. SSD stated she was responsible for completion of Resident 45's MDS section E. SSD stated Resident 45's MDS section E for wandering was not coded accurately. 056103 Page 7 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of 25 sampled residents (Residents 47 and 370), received the necessary services of bathing when the residents were not offered a shower as scheduled. Residents Affected - Some This failure had the potential to affect the residents' dignity and their quality of life. Findings: a. During a concurrent observation and interview on 4/28/25, at 10:56 a.m., Resident 47 was observed to be lying in bed. Resident 47's family member who was at the resident's bedside stated resident did not get showers as scheduled. Review of Resident 47's Facesheet (information containing contact details, brief medical history at-a-glance) indicated he was admitted to the facility on [DATE] with diagnoses that included muscle weakness, need for assistance for personal care and depression (a persistent feeling of sadness). Review of Resident 47's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/24/25 under Section C, indicated a score of 7, meaning Resident 47 had severe cognitive impairment. The MDS Section GG titled, Functional Abilities indicated Resident 47 needed partial to moderate physical assistance from one person in taking showers or bathing. Review of Resident 47's Activities of Daily Living (ADL) care plan dated 1/24/25 indicated a goal for the resident to be clean and be free from skin breakdown with the intervention for the staff to assist the resident with showers per schedule and as needed. During a joint concurrent interview and record review on 4/30/25 at 10:23 a.m., with Certified Nursing Aid (CNA) 5 and Assistant Director of Nursing (ADON) , Resident 47's shower schedule was reviewed and the ADON confirmed that the resident's shower days were supposed to be on Mondays, Wednesdays and Fridays in the morning shift (7 a.m. to 3 p.m.). Resident 47's Shower Day Body Check Sheets (or called shower sheets were the forms used by the CNAs to document the residents' showers),for April 2025 were reviewed with CNA 5 and the ADON. The shower sheets indicated Resident 47 only had showers on 4/7/25, 4/10/25, 4/13/25, 4/19/25 and 4/15/25. Resident 47 had no shower sheets on his scheduled shower days on Mondays, Wednesday and Fridays on the following dates: 4/2, 4/4, 4/9, 4/11, 4/14, 4/16, 4/18, 4/21, 4/23, 4/25 and 4/28 of 2025. CNA 5 stated she gave the resident showers on some of the mentioned dates and the resident refused showers on some of the other mentioned dates, but CNA 5 was unable to provide documentation. The ADON stated the risks for Resident 47 in not getting showers as scheduled were body odor and infection. b. During an interview on 4/28/25 at 10:51 a.m., Resident 370 was observed awake in his room lying in his bed. When asked about his showers, the resident stated he was not getting showers and that he never refused a shower. Review of Resident 370's Facesheet indicated he was admitted to the facility on [DATE] with 056103 Page 8 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0676 diagnoses that included weakness and need assistance with personal care. Level of Harm - Minimal harm or potential for actual harm Review of Resident 370's MDS dated [DATE] under Section C, indicated a score of 15, meaning Resident 370 was cognitively intact. The MDS Section GG titled, Functional Abilities indicated Resident 370 needed partial to moderate physical assistance from one person in taking showers or bathing. Residents Affected - Some Review of resident's ADL care plan dated 4/21/25 indicated a goal for the resident to be clean and be free from skin breakdown with the intervention for the staff to assist the resident with showers per schedule and as needed. During a concurrent interview and record review on 4/30/25 at 4:13 p.m., with the Director of Staff Development (DSD), Resident 370's shower schedule was reviewed and the DSD confirmed that the resident's shower days were Tuesdays, Thursdays and Saturdays in the evening shift (3:00 p.m. to 11:00 p.m.). Resident 370's shower sheets for April 2025 were also reviewed with the DSD. The shower sheets indicated Resident 370 only had showers on the following dates: 4/15, 4/19, 4/22, 4/24 and 4/26 of 2025. Resident 370 had no shower sheets on 4/17/25 and 4/29/25. There was no documentation that the resident refused. DSD stated the resident should have had a shower on 4/17/25 and 4/29/25. Stated the risks for Resident 370 in not getting showers as scheduled were bedbugs, scabies and loss of dignity. During a review of the facility's policy and procedure (P&P) titled, shower bath, revised October 2010, the P&P indicated, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1.The date and time the shower/tub bath was performed .5. if the resident refused the shower/tub bath, the reason(s) why and the intervention taken . Notify the supervisor if the resident refuses the shower/ tub bath . 056103 Page 9 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review , the facility failed to provide an ongoing program of activities to meet the interests and psychosocial well-being for two of 25 sampled residents (Residents 112 and 115). Residents Affected - Some These deficient practices had the potential to affect the quality of life of the residents by placing the residents at risk of sensory deprivation and social isolation. Findings: a. During an interview on 4/28/25, at 12:44 p.m., with Resident 112, the resident stated she was not being offered activities. On observation, the resident only had a TV and her cellphone. Review of Resident 112's Facesheet (information containing contact details, brief medical history at-a-glance) indicated she was admitted to the facility on [DATE]. Review of Resident 112's Minimum Data Set (MDS, an assessment tool) dated 3/18/25, indicated she had a Brief Interview for Mental Status or BIMS of 15 (BIMS score of 13-15 suggests intact cognition). Review of Resident 112's Activities care plan dated 3/12/25 indicated that one of the resident's interests included listening to radio, and the care plan also indicated to offer Resident 112 various activity supplies such as books, puzzles, reading materials and magazines. During a concurrent observation and interview on 5/1/25, at 10:45 a.m., with the Activity Director (AD), in Resident 112's room, Resident had no books, no radio or magazines at bedside. AD acknowledged the radio, books and magazines should have been offered to the resident. During a concurrent interview and record review on 5/1/25 at 11:00 a.m., AD stated Resident 112 refused to attend the activities offered but AD was unable to provide documentation of the resident's refusals or any activity progress notes for Resident 112. There was also no plan of care found on Resident 112's refusal of activities. b. During an interview on 4/28/25 at 9:31a.m., with Resident 115, the resident stated she was not being offered any activities to do. On observation, the resident only had a TV in her room. Review of Resident 115's Facesheet indicated she was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a persistent feeling of sadness). Review of Resident 115's MDS dated [DATE] indicated she had a BIMS of 13 (BIMS score of 13-15 suggests intact cognition). During a concurrent observation and interview on 5/1/25, at 11:05 a.m., with Activity Director (AD), in Resident 115's room, Resident had no books, no radio or magazines at bedside. AD acknowledged the radio, books and magazines should have been offered to the resident. During a concurrent interview and record review 5/1/25 at 11:10 a.m., with the AD, AD was unable to provide documentation of Resident 115's activities. Review of Resident 115's Activities care plan dated 3/24/25 indicated that Resident 115 had a 056103 Page 10 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some depressive disorder and needed encouragement from the staff for participation in activity program. One of the interventions was to encourage attendance and participation with activities of choice as tolerated. During a concurrent interview and record review on 4/30/25 at 2:32 p.m., with the Assistant Director of Nursing (ADON), there were no activity progress notes found in Resident 112 and 115's medical records. ADON stated that the risks for the residents in not having activities were decreased quality of life and depression. During a review of the facility's policy and procedure (P&P) titled, Activity Evaluation, revised April 2013, the P&P indicated, .In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident 056103 Page 11 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to provide care and services to six of 25 sampled residents who were dependent on the staff for their care when their call lights were not answered by the facility staff on a timely manner (Residents 4,8, 48,88,113 and 370). Residents Affected - Some This deficient practice had the potential to negatively affect the residents' physical comfort and psychosocial well-being Findings: a. During a concurrent observation and interview on 4/28/25 at 12:30 p.m., Resident 4 was lying in bed and resident stated his call lights took an hour or more to be answered. Stated his needs were sometimes not met. Review of Resident 4's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (muscle wasting, also known as muscle atrophy, refers to the loss of muscle mass and strength). During a review of Resident 4's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/25/25 under Section C, indicated a score of 15, meaning Resident 4 was cognitively intact . b. During a concurrent observation and interview on 4/28/25 at 1024a.m., Resident 8 was lying in bed, and the resident stated her call lights were always not answered on time. Stated it took a while before her soiled diaper was changed. Review of Resident 8's Facesheet indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included legal blindness, anxiety disorder and major depressive disorder (a persistent feeling of sadness). Review of Resident 8's MDS dated [DATE] under Section C, indicated a score of 14, meaning Resident 8 was cognitively intact. The MDS Section GG titled, Functional Abilities, indicated that Resident 8 was dependent on toileting and needed the assistance of 2 or more helpers in performance of her toileting needs. MDS section H indicated Resident 8 was always incontinent in urination and was frequently incontinent in her bowel movements. c. During a concurrent observation and interview on 4/30/25, at 2:00 p.m., Resident 48 was lying in bed and stated he was very upset, resident stated he had been waiting for an hour to have his diaper changed because he had a bowel movement, and stated it was not acceptable that the average wait for the staff to attend to his needs were an average of 40 to 50 minutes. Stated the staff would answer, you are not my patient' and then turn off the call light. Also stated there were times the staff said they would come back to attend to his needs but would never come back. Review of Resident 48's Facesheet indicated, Resident 48 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a persistent feeling of sadness). 056103 Page 12 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 48's MDS dated [DATE] under Section C, it indicated a score of 14, meaning Resident 48 was cognitively intact. The MDS Section GG titled, Functional Abilities indicated a need for ADL (activities for daily living) support with at least one person providing physical assistance. The MDS also indicated that Resident 48 was occasionally incontinent with urine and bowel movement. d. During an initial tour on 4/28/25 at 9:55 a.m. Resident 88 was sitting in bed. Resident 88 expressed concerns regarding the call light. Resident 88 stated his call lights were not answered on time and some of his needs were not met on a timely basis. Review of Resident 88's Facesheet indicated, Resident 88 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (kidneys can no longer function on their own) and dependence on dialysis (kidneys have failed to filter waste from the blood, and dialysis is required to perform these functions). During a review of Resident 88's MDS dated [DATE] under Section C, it indicated a score of 15, meaning Resident 88 was cognitively intact. The MDS Section GG titled, Functional Abilities, indicated that Resident 88 needed moderate to maximal physical assistance from a helper in performance of his ADLs. e. During a concurrent observation and interview on 4/28/25 at 1:25 p.m., Resident 113 was lying in bed with a bedside commode by her bedside, the resident stated her call lights were not always answered on time. Stated the staff did not place her in the bedside commode in time and she would have accidents in her diaper. Review of Resident 113's Facesheet indicated Resident 113 was admitted to the facility on [DATE] with diagnoses that included weakness and fall. During a review of Resident113's MDS, dated [DATE] under Section C, indicated a score of 15, meaning Resident 113 was cognitively intact. The MDS Section GG titled, Functional Abilities indicated, Resident 113 needed substantial to maximal assistance from a helper in toileting/hygiene. f. During a concurrent observation and interview on 4/28/25 at 1051a.m., Resident 370 was lying in bed, and the resident stated his call lights were always not answered on time. Stated his needs were sometimes not met. Review of Resident 370's Facesheet indicated Resident 370 was admitted to the facility on [DATE] with diagnoses that included weakness and need assistance with personal care. Review of Resident 370's MDS dated [DATE] under Section C, indicated a score of 15, meaning Resident 370 was cognitively intact. The MDS Section GG titled, Functional Abilities indicated that Resident 370 needed the partial to moderate physical assistance of a helper in performance of his ADLs. During an interview on 4/30/25 at 9:21a.m., with the Director of Staff Development (DSD), DSD stated, residents call lights should be answered within 2 to 3 minutes. Also stated she conducted an in-service to the staff regarding answering the residents' call lights, but stated she did not have documentation of staff compliance in answering call lights after her staff in-service (an in-service training is education given to the staff to improve performance by equipping them with new knowledge, skills, and abilities to better perform their jobs). 056103 Page 13 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/30/25 at 2:32 p.m., with the Assistant Director of Nursing (ADON), ADON stated the residents' call lights should be answered promptly and the risks of not answering the call lights promptly were the possibility of the residents' falling and skin problems due to incontinence. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised March 2021, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs . If the resident's request is something you can fulfill, complete the task within 5 minutes if possible . 056103 Page 14 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide wound care treatment and services for one of 25 sampled residents, Resident 80's left heel deep tissue injury (DTI, serious type of pressure ulcer where the underlying tissue is damaged), not following the Physician orders and not consistent with the facility's policy and professional standards of practice. Residents Affected - Few This failure has the potential for Resident 80 to develop worsening of his wound, increase deep pressure ulcer, slow wound healing process, pain, infection and possibly hospitalization. During a review of Resident 80's Face sheet (FC), the FC indicated Resident 80 is [AGE] years old newly admitted to the facility, less than 30 days. The FC indicated Resident 80 has a diagnosis of Type 2 Diabetes (adult onset diabetes, characterized by high blood sugar and insulin resistance) with foot ulcer (open sores or wound), Essential Primary Hypertension (high blood pressure), End Stage Renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), Dependency on Renal Dialysis (to rely on machine to filter their blood and remove waste and excess fluid), and Acquired Absence of other right toe (toes lost after birth, through amputation or other medical intervention). During an observation 4/28/25 at 09:33 a.m., Resident 80 was lying in bed resting, and had dressing to his left foot/heel dated 4/26/25. During an observation and an interview on 4/29/25 at 12:10 p.m., with the Registered Nurse (WCN), Resident 80 still had dressing to his left foot/heel dated 4/26/25. Resident 80 was restless and stated he was not feeling good. WCN stated Resident 80's wound treatment had not been performed since 4/26/25. WCN stated Resident 80 is currently being treated for a deep tissue injury. WCN stated he is the only wound care nurse for the facility. WCN further stated the orders for Resident 80's wound care treatment are to perform daily wound care treatment to Resident 80's left foot. WCN further stated he has to perform Resident 80's wound care daily as per the physician orders because it's the physician ordered and to prevent the potential for worsening of the wound. During a review of Resident 80's Treatment Administration Record (TAR), the TAR indicated, clean with normal saline (NaCL), one time daily starting 3/18/2025, left heel DTI clean with NSS, pat dry, apply gauze soaked with Betadine solution, then wrap with kerlix, change dressing daily, schedule day treatment. During a review of Resident 80's physician orders, dated 3/7/2025, the physician orders indicated, apply A & D ointment apply to both heels daily as preventative measure, instructions: one time daily, scheduled day treatment. Order date 3/18/2025, Clean with normal saline (NaCL) left heel DTI clean with NSS, pat dry, apply gauze soaked with betadine solution, then wrap with kerlix. Change dressing daily, schedule day treatment. During an interview on 4/30/2025 at 12:03 p.m., with the WCN, WCN stated Resident 80 had been transferred out to the hospital during evening shift on 4/29/2025. During a review of Resident 80's physician orders, dated 4/29/2025 at 4:30 p.m., the physician orders indicated, send patient out via 911 per MD verbal order. 056103 Page 15 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 80's Treatment Administration Record (TAR), the TAR indicated, on 4/27/2025 and 4/28/2025, nursing staff initials TD, signed the TAR that treatment was provided for resident when dressing to Resident 80's left foot/heel was still dated as 4/26/25. During an interview with Director of Nursing (DON), the DON stated the facility nursing staff must follow the physician's orders, if the orders states daily, facility should do wound care for the Resident daily. DON stated the facility's goal is to make sure the wound is healed and to prevent infection. The DON further stated if wound care was not performed, facility nursing staff should inform the physician that the treatment was not done, and the facility should document it in the TAR. During a review of facility's policy and procedures (P&P), titled Wound Care, dated 2001, the P&P indicated, the purpose of this procedure is to provide guidelines for the care of wounds to promote healing . 1. Verify that there is a physician's order for this procedure . 1. Notify the supervisor if the resident refuses the wound care. 056103 Page 16 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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, for one of three sampled residents (Resident 45), the facility failed to developed and implement adequate person-centered interventions to prevent Resident 45 with dementia from wandering into the rooms of other residents. Residents Affected - Some Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptom and rates of progression. (Adapted from: About Dementia. Alzheimer's Foundation of America. 30). This failure cause Resident 45 falls, injuries, and had the potential to cause residents increased confusion and emotional distress. Findings: During a review of Resident 45's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 3/17/25, indicated Resident 45's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 45's score was 05 meaning poor cognition. MDS indicated Resident 45 is Chinese and preferred language is Mandarin. MDS indicated Resident 45 had no potential indicators of psychosis, no hallucination, no delusions. MDS indicated Resident 45 had fall with injury with admission to facility. Resident 45's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 45's care plan, titled, Behavioral Symptoms, initiated 4/14/23, care plan indicated Resident 45 had physical and verbal behavioral symptoms manifested by wandering episodes, Resident 45 tends to wander around facility. Further review of care plan, titled, Going into other residents rooms initiated 5/21/24 indicated problem included Resident 45 going into other resident's room, verbally aggressive when asked to leave. Care plan goal indicated Resident 45 will be free of avoidable complication, interventions included monitor closely, provide redirection as needed. During an observation on 4/28/25 at 10:52 a.m. Resident 45 wandered in hallways with a front wheeled walker looking into other residents rooms. During a review of Resident 45's clinical notes, dated 1/18/25, the clinical notes indicated, at 6:20 a.m. Resident 45 was seen on the floor in the hallway. Last seen ambulating from station 1 to station 2 and going from room to room. Upon assessment Resident 45 sustained a bump on the right side of forehead. Resident 45 was transferred to hospital. Further review of Resident 45's clinical notes, dated 1/2/25, the clinical notes indicated Resident 45 had an unwitnessed fall. 056103 Page 17 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/29/25 at 11:43 a.m. with Director of Nursing (DON), DON stated Resident 45 wander in hallways. DON stated that on 1/18/25, Resident 45 had a fall in the hallway was found sitting on the floor with bump on the right side of her forehead. DON stated Resident 45 was sent to the hospital for evaluation and came back with closed fracture of the temporal bone (skull fracture). During an interview on 4/30/25 at 8:33 a.m. with Certified Nursing Assistant (CNA1), CNA1 stated Resident 45 wandered around the facility goes into other residents rooms . CNA1 stated Resident 45 was very confused, wanders into other residents rooms, switch off the light in the room and get agitated when redirected. During an interview on 4/30/25 at 8:37 a.m. with CNA 2 , CNA 2 stated Resident 45 roams around the facility. CNA 2 stated CNA2 checked on Resident 45 as she was at risk for falls and sometimes found her in another resident's room. CNA 2 stated Resident 45 liked to check light and switch it off. During a concurrent observation and interview on 4/30/25 at 8:55 a.m. with staff Interpreter (IT), Resident 45 sat up in bed in her room, walker by bedside. Resident 45 with hand gesture instructed both surveyor and IT to leave her room. During an interview on 4/30/25 at 12:07 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 45 wanders around the facility, into other residents rooms and turn off the light. LVN 1 stated Resident 45 continued to wanders into other resident rooms despite redirection. During an interview on 4/30/25 at 12:11 p.m. with Resident 25, Resident 25 stated Resident 45 wanders into his room, switch off light in the room and take ensure supplement that did not belong to her. Resident 25 stated he was not comfortable with Resident 45 coming into his room. During a review of Resident 25's MDS, dated [DATE], indicated Resident 25's BIMS score was 15 meaning intact cognition. During an interview on 5/1/25 at 8:20 a.m. with Resident 66, Resident 66 stated Resident 45 wanders into her room, cuts all our lights off. Resident 66 stated Resident 45 had an habit of taking things, she has taken my roommates clothes, she has taken my clementines before but staff was able to take it from her, feels like invasion of privacy. Resident 66 said she pressed the call light when Resident 45 wandered inside her room. During a review of Resident 66's MDS, dated [DATE], indicated Resident 66's BIMS score was 15 meaning intact cognition. During an interview on 5/1/25 at 8:45 a.m. with CNA 3, CNA 3 stated Resident 45 get agitated when redirected from other residents room. CNA 3 stated Resident 45 was redirected from male residents room to prevent her from getting hurt. During a review of Resident 1's physician order sheet, dated 2/28/24, physician order indicated to monitor Resident 45's behavior of going into other residents room, taking other patient's food/clothes, pulling curtains in other patients room, closing doors , turning off lights, removing other patient's food tray, taking belongings from other residents and monitor Resident 45 every hour episodes of going into other residents rooms for safety. During an interview on 5/1/25 at 12:16 p.m. with Social Services Director (SSD) , SSD stated 056103 Page 18 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 45 wandered around the facility. SSD stated facility had discussed Resident 45's transfer to appropriate facility because of Resident 45 dementia status. SSD stated Resident 45's responsible party did not want Resident 45 transferred from facility. During an interview on 5/1/25 at 12:26 p.m. with Director of Nursing (DON), DON stated Resident 45 needed one-on-one monitoring or memory care placement. DON stated facility had discussed with Resident 45' daughter need for placement in a small building. DON stated Resident 45 continued to wander in the hallways and into other residents rooms despite interventions. During a review of Resident 45's Interdisciplinary team noted (IDT), dated 2/26/24, the IDT indicated, Plan of action would be to move Resident 45 to a facility that can better manage her behaviors. SSD will make list of closeby places that accept memory care residents. Discussed how Resident 45 requires a higher level of care due to her constant behaviors towards other residents and staff like hitting, spitting, rummaging in personal items. (An interdisciplinary team is a group of professional from different fields who collaborate to achive a common goal often focusing on patient care). 056103 Page 19 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to manage, label and store medications for one of one sampled resident, Resident 90, in an accurate, secure, and safe manner according to their facility's policy and procedures and standards of practice, when: 1. facility staff administered Amlodipine Besylate (drug used to treat high blood pressure) to Resident 90 from a medication package that was inaccurately labeled as Amlodipine Besylate 2.5 M instead of administering Amlodipine Besylate 2.5 mg as per physician orders. 2. Facility staff left one loose pill exposed in one of the drawers in medication storage room [ROOM NUMBER]. Findings 1: During a review of Resident 90's face sheet (FC), the FC indicated Resident 90 is [AGE] years old, admitted to the facility in 2023. The FC further indicated Resident 90 has diagnosis of Essential Hypertension (high blood pressure), Calculus (presence of kidney stones, which are hard mineral deposits that form inside the kidneys) of the kidney, and Acute Kidney Failure (a condition in which the kidneys suddenly can't filter waste from the blood. During an observation on 5/1/2025 at 08:58 a.m., with Licensed Vocational Nurse (LVN 2), LVN 2 prepared Amlodipine Besylate from a medication package labeled Amlodipine Besylate 2.5 M and administered the drug to Resident 90. During an observation and an interview on 5/1/2025 at 10:04 a.m., with LVN 2, there were two medication packages labeled Amlodipine Besylate 2.5 M, stored in the medication cart for Resident 90. LVN 2 stated she should have first called pharmacy to verify the correct dosage of the medication ordered. LVN 2 stated night shift nurses are responsible for checking and reviewing the medications after they are delivered by pharmacy and they must sign for it, for accuracy. During a review of Resident 90's Physician orders, the physician orders indicated, ordered date 6/1/2023 . amlodipine 2.5 mg tablet (2.5 mg) tablet oral, one time daily, a.m., med pass, start date 6/2/2023. During a review of Resident 90's Medication Administration Record (MAR), the MAR indicated, orders, amlodipine 2.5 mg tablet (2.5 mg) tablet oral one time daily starting 06/2/2023 . ordered date 6/1/2023. During an interview on 5/1/2025 at 10:10 a.m., with Assistant Director of Nursing (ADON), ADON stated Charge nurses are responsible for checking the medication dosage and expiration date prior to storing them in the medication cart to prevent medication errors. Findings 2: During a review an observation on 4/30/2025 at 12:24 p.m., in the medication storage room [ROOM 056103 Page 20 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few NUMBER], with Registered Nurse (LN 3), one loose pill found in the lower drawer below the narcotic locked drawer. During an interview on 4/30/2025 at 12:25 p.m., with LN 3, LN 3 stated when over the counter medications are delivered to the facility by pharmacy, nursing staff counts and distributes them to the medication carts and then store remaining medications immediately in the central supply storage. LN 3 stated the facility staff does not prepare meds in med storage room [ROOM NUMBER], and the medication was not supposed to have been found in the med drawer. LN 3 stated she does not know where the medication came from, or what type of drug it was. LN 3 stated supervisors are responsible for checking locked cabinets for non-narcotics and dispose of appropriately. LVN 3 stated Facility staff do this to prevent the risk of giving expired medications to residents. During a review of facility's policy and procedure (P&P), titled Administering Medication, dated 2001, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed . 3. Medication must be administered in accordance with the orders, including any required time frame . 5. If a dosage to be inappropriate or excessive for the resident ., the person preparing or administering the medication shall contact the resident's Physician or facility's Medical Director to discuss concerns . 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medications, right dosage, right time, and right method (route) of administering before giving the medication. During a review of facility's policy and procedures (P&P), titled, Storage of Medications, dated March 2020, the P & P indicated, The facility stores all drugs and biologics in a safe, secure, and orderly manner . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During a review of facility's policy and procedures (P&P), titled, Medication Storage in the Facility, dated March 2018, the P & P indicated, medications and biologics are stored safely, securely, and properly, following manufacturer recommendations or those of the supplier. 056103 Page 21 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the Registered Dietitian (RD) and Dietary Services Manager (DSM) carried out the functions of the dietetic services in the food & nutrition services department when multiple issues in food safety, sanitation, and clinical nutrition care for residents with weight loss or weight gain were identified, according to facility policy and standards of practice. This failure had the potential to expose residents to unsafe contaminated food and unsanitary equipment and utensils, leading to foodborne illness and altered nutrition status among 114 residents who consume food from the kitchen. Cross reference F802, F803, F804, and F812 Findings: According to the 2019 California Retail Food Code, CHAPTER 3. Management and Personnel, Article 2 Employee Knowledge, Section 113947, (a) The person in charge and all food employees shall have adequate knowledge of, and shall be properly trained in, food safety as it relates to their assigned duties. (b) The person in charge shall comply with both of the following: . (2) Educate the employees at the food facility .(c) For purposes of this section, person in charge means a designated person who has knowledge of safe food handling practices and the major food allergens as they relate to the specific food preparation activities that occur at the food facility . During an interview in the kitchen with the RD at 4/28/25 11:24 AM, the RD stated she does not do any kitchen sanitation checks because the DSM does them monthly. The RD further stated the DSM reports the findings of deficient practices to the Quality Assurance (QA) Committee. The RD stated she does not discuss the findings from the kitchen sanitation checks with the DSM. The RD and DSM stated they do not regularly meet to discuss the food service and safety operations in the kitchen when the RD is at the facility. During a concurrent record review and interview with the DSM of the facility's Dietary Manager's Reports from 1/7/25 through 3/25/25, the DSM stated these reports were used as kitchen sanitation checks. The report dated 2/20/25 identified improper cool down procedures with tuna salad by kitchen staff and ongoing reeducation was needed. The DSM acknowledged the kitchen checklist reports did not include food sanitation and food safety topics regarding the red bucket sanitizer testing, ice machine cleaning, the cool down process for cooked foods, and three compartment sink creation for emergency use. During an interview in the kitchen with the RD on 4/29/25 at 1:21 PM, stated she was not at the facility all the time, and only worked part-time, twice a week, up to sixteen hours a week. The RD stated she started working at the facility in January 2025 and the previous RD was virtual and never worked onsite. The RD stated she may need to spend more time in the kitchen and doing the kitchen sanitation checks with the DSM. During an interview in the kitchen with the RD and DSM on 4/30/25 at 12:57 PM, the RD and DSM stated they do not do regular test trays evaluations at the facility. After the test tray evaluation of the regular diet and pureed diet lunch meals with the Surveyor, RD and DSM stated the pot roast, and 056103 Page 22 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many spinach could have used more seasoning. The RD further stated she expected the Cooks to follow the recipes because they've already been tested. During a record review of the facility created weights reports dated 4/30/25, the weight report indicated Resident 66 experienced a 10-pound weight gain in 1 month from 331 pounds in March 2025 to 344 pounds in April 2025. During an interview on 4/30/25 at 10:03 AM with Resident 66, the resident was sitting up in her bed watching T.V. The resident stated she wanted Asian foods, and sometimes they don't follow the menu. During a concurrent interview with the RD on 5/01/25 at 12:15 PM and record review of Resident 66's Nutrition assessment dated [DATE] completed by the RD, the assessment indicated the resident was not on a Physician Ordered Diet for weight gain or weight loss, and the Nutrition Goal was to maintain while meeting metabolic needs with adequate fluid for hydration. The RD acknowledged she did not discuss weight gain with the resident during her interview and nutrition assessment because she wanted to know how she liked the food. The RD further stated she should have included a goal weight for the resident in the assessment because continuous weight gain overtime could cause future health problems. During an interview with the RD on 5/1/25 at 12:18 PM, the RD stated she does not attend the weekly weight Interdisciplinary team (IDT) meetings with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The RD stated she writes a daily report of the residents she does nutrition assessments and follow-ups evaluations on, then she sends it to the Administrator (ADM), DSM, and DON. The RD also stated she runs weekly and monthly weight reports from the medical record system, then calculates residents' weight gains or losses. The RD stated she sends the weight report calculations to the DON, the ADON, and waits for feedback, but the RD acknowledged she does not reach out to the DON and ADON and the DON and ADON don't consistently reach out to her to discuss the weights. The RD stated she should be more involved in weight monitoring IDT meetings to have a greater impact on the resident's weight condition and nutrition status. The RD further acknowledged there were at least five residents with significant weight loss or gain, and she did not discuss topics like food substitutions and appropriate options with these residents during her nutrition assessments and evaluations. During an interview on 5/1/25 at 1:49 PM with the ADM, the ADM stated she expected the RD to work with the DON and DSM to ensure the residents receive the appropriate nutrition to prevent weight loss issues and receive healthy foods. During a record review of the facility's undated Job description titled Clinical Registered Dietitian, the job description indicated, .the Clinical Dietitian provides medical nutrition therapy and works with the Dietary Manager to ensure that quality food, service and nutritional care are being provided to residents .a. Is responsible for identifying the nutritional needs of the facility patient, providing support to the Dietary Manager in food and nutrition . d. Participates in interdisciplinary care conference meetings, weight meetings . e. Review and approve menus to meet all guidelines and nutritional therapy to patients . 2) Conducts meal rounds and interviews staff and residents to ensure residents are receiving foods in the amount, type, consistency, and frequency required to maintain or improve nutritional status. 3) Routinely inspects the food service areas and practices for compliance with company policies, procedures, standards, and applicable federal, state, and local regulations .5) Conducts nutrition in-services training for dietary .staff related to nutrition . 056103 Page 23 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a record review of the facility's Job description titled FNS Director, dated 2018, the job description indicated, .DUTIES AND RESPONSIBILITIES: .2. Schedule and supervise the Food & Nutrition Service Staff providing in-service training . 3. Is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed.5. Test cooked food by taste to determine if properly cooked and seasoned. 6. Is responsible for maintaining cleanliness of kitchen equipment and follows all department of health regulations.8. Make menu adjustments as needed .with final approval of the Dietitian. During a record review of the facility's P&P titled Staff Development, dated 2018, the P&P indicated Food and Nutrition Services staff will be in-serviced .by the FNS Director and Consultant Dietitian.In-services will be scheduled monthly, on a variety of subjects, including .infection control, safety .food safety .and therapeutic diets.FNS Director and the Consultant Dietitian will periodically ask .staff questions .to demonstrate knowledge and techniques from recommended in-services to ensure staff has continued understanding of kitchen procedures. During a record review of the facility's P&P titled Nutritional Screening/ Assessments/Resident Care Planning, dated 2018, indicated .The resident's nutritional needs will be assessed. A nutrition program specific to his needs will be planned and implemented and then reassessed periodically for progress.the information .will come from a variety of sources .1. Direct resident interview .3. The medical record .5. Resident care conference .All residents will be reviewed quarterly and annually .Change in eating habits .weight and other problems will be recorded in the dietary progress notes and resident care plan . 056103 Page 24 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

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 record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. Two Cooks (CK 1 and CK 2) did not properly verbalize or demonstrate the correct two-step cool down process used to prevent contamination in a cooked beef pot roast. 2. A Diet Aide (DA 1) did not know how to correctly calibrate a food thermometer. 3. A Diet Aide (DA 3) did not know how to test the sanitizer concentration in a red bucket. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The census was 114. Cross reference F801 and F812 Findings: 1. During an interview on 4/29/25 at 9:10 AM in the kitchen with the morning [NAME] (CK 1), CK 1 stated sometimes they have leftover foods they serve at a later date. CK 1 stated the leftover foods and large meats like a beef roast and turkey cooked from scratch, are cooled down using a cool down process. CK 1 stated the cool down process included lowering the food to a temperature of 100 degrees by using an ice bath method, and checking the food every four (4) hours to make sure it reached 100 degrees or near it, before it is placed in the refrigerator overnight. CK 1 stated he was trained years ago on the cool down process by a previous [NAME] who worked at the facility. During a kitchen observation on 4/29/25 at 2:45 PM, a large metal pan with a cooked beef roast was labeled roast beef 4-29-25 use by 5-1-25 and stored on a rack in the walk-in refrigerator. The surveyor's digital thermometer was placed in the roast and it read 141.8 degrees F. During an interview on 4/29/25 at 2:50 PM with the evening [NAME] (CK 2) and Dietary Services Manager (DSM), CK 2 was asked to describe the cool down foods process. CK 2 stated the cool down process for cooked meats like roast beef, pork, and turkey was to cool the meat down to 40 degrees in 4 hours. CK 2 stated the total cool down process time should be 4 hours. The surveyor asked CK 2 if she cooked the beef roast in the refrigerator, and she stated No, the morning [NAME] cooked it about an hour ago. CK 2 further stated CK 1 asked her to monitor the cool down process for the pot roast because it's for tomorrow's lunch. The DSM acknowledged CK 2 and CK 1 did not correctly the cool down process for cooked meats, and stated they should know it is a two-step method that takes six hours. The DSM stated the final step is for the temperature to reach 41 degrees F or below within four hours. The DSM stated they would restart the cooking process for the beef roast to ensure it was cooked and cooled down safely. A review of the facility's menu titled Daily Spreadsheet Wednesday - Day 25 Week 4- Day 4 .Spring/Summer 2025 indicated .Lunch .Regular diet .3-ounces of Tomato Braised Pot Roast, 1/2 cup of Lyonnaise potatoes, 1/2 cup steamed spinach, 1 Bread or Roll & butter packet, 1 cup of choice of beverage, and a slice of yellow 7-up cake. 056103 Page 25 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's Job Description for the [NAME] position, dated 2018, the job description indicated .1. Responsible for the preparation of food for breakfast and noon meals to be served .4. Knowledge of basic principles of quantity food cooking . According to the 2022 Food & Drug Administration (FDA) Federal Food Code, section 3-501.15, titled Cooling Methods, .Cooling shall be accomplished in accordance with the time and temperature criteria specified under 3-501.14 by using one or more of the following methods .:(1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods . During a review of the facility policy titled Cooling Monitor for Hazardous Foods dated 5/20/2020 indicated Procedure. 1. Transfer cooked products to a container(s) with a depth no greater than two inches. 2. Label and date the container(s). 3. Leave container uncovered or loosely covered during the cooling process. 4. Place container(s) in the refrigerator for cooling. 5. Using the Cooling Monitoring Form (FORM 406) or other designated form record temperature of food every hour. The food should be cooled from 140* to 70* within 2 hours and cooled from 70* to 41* in an additional 4 hours. If a prepared product is initially at (less than or equal to) 41*F there is no need to record this on the Cooling Monitoring form but cover tightly and store in the refrigerator. 6. If the temperature is not dropping adequately consider using an ice bath, if it is roast, cut into smaller pieces, make sure you are using shallow (2 inches or less in depth) pans, etc. Record action taken to achieve proper temperature on the Cooling Monitoring form. 7. When the temperature reaches 41*F, cover tightly and store in the refrigerator or freezer. 8. If temperature does not reach 70*F in 2 hours, reheat to 165*F and try cooling process again. 2. During a concurrent observation and interview on 4/29/25 at 11:57 AM with Diet Aide (DA 2, DA 2 stated he did not know how to calibrate the bi-metal food thermometer, but he used the thermometer to take food temperatures during trayline. The DSM acknowledged DA 2 did not know how to calibrate a thermometer, and then she began to instruct him on how to do it by preparing a cup of ice water. The Diet Aide then asked, Should the thermometer read 20 degrees for calibration? The DSM told him No, it should be 32 degrees Fahrenheit (F) and stated he needs more training on thermometer calibration. The DSM further stated it was important to have accurate temperatures to confirm the food is safe. According to 2022 Federal Food Code, section 4-204.112 titled Temperature Measuring Devices, .The importance of maintaining time/temperature control for safety foods at the specified temperatures requires that temperature measuring devices be easily readable. The inability to accurately read a thermometer could result in food being held at unsafe temperatures. Temperature measuring devices must be appropriately scaled per Code requirements to ensure accurate readings. During a review of the facility's policy and procedures (P&P) titled Thermometer Use and Calibration, dated 2018, indicated .Food thermometers are to be used properly and calibrated to ensure accurate temperature reading .Checking the Accuracy and Calibrating .1. Fill a large glass with crushed ice and add clean tap water until slush is formed .2. Put thermometer's stem into the ice water so that the sensing area is completely submerged .do not let the stem touch the bottom or sides of the glass .3. If the thermometer does not read 32 degrees F, then the thermometer must be calibrated .follow manufacturer's instructions . 3. During a concurrent observation and interview on 4/30/25 at 8:33 AM with Diet Aide (DA 3) and the DSM, DA 3 tested the sanitizer concentration in the red buckets by taking a test strip from a 056103 Page 26 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many container and dipping it in a red bucket full of sanitizer solution, then comparing it to the color grid on the container after dipping it for 1 second. The test strip was a faint yellow color and DA 3 said it needed to be 100-200 PPM (parts per million). DA 3 tested it again and dipped the test strip for 3 seconds then tested it against the strip container, and it was light green color. The DA stated it was still not the correct color. The DSM stated DA 3 did not hold the test strip in the sanitizer for 10 seconds, which would then indicate the correct color and solution concentration. The DSM acknowledged the DA did not know to immerse the test strip for 10 seconds in the solution and further stated she needed to be trained on how to test the sanitizer. During a review of the test strip container, the instructions indicated .Remove one strip .Allow 5-10 seconds to develop, then compare to color chart below . During a review of the facility's Job Description for the Diet Aide position, dated 2018, the job description indicated .b. Prepare juices, milk, water, and other beverages e. Cleaning as assigned on cleaning schedule.g. Assist with trayline .3. Keep work area clean . During a review of the facility's Dietary Services department kitchen staff In-services from May 2024-April 2025, the in-services indicated the topics covered did not include the cool down process, thermometer calibration, or red bucket sanitizer testing. During a review of the facility's policy and procedure (P&P) titled Sanitation, dated 2018, the P&P indicated .21. The FNS Director is responsible for instructing employees in the fundamentals of sanitation in food service for training employees to use appropriate techniques .23. Do not use .sanitizer in the food preparation .areas in any way that could result in contamination of exposed food . During a review of the facility's P&P titled Staff Development, dated 2018, the P&P indicated Food and Nutrition Services staff will be in-serviced .by the FNS Director and Consultant Dietitian.In-services will be scheduled monthly, on a variety of subjects, including .infection control, safety .food safety .and therapeutic diets.FNS Director and the Consultant Dietitan will periodically ask .staff questions .to demonstrate knowledge and techniques from recommended in-services to ensure staff has continued understanding of kitchen procedures. 056103 Page 27 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

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. Based on observation, interview, and record review, the facility failed to ensure the vegetarian menu was followed in accordance with the menu guidance and facility policy. Residents Affected - Few This failure had the potential to decrease the food intake of three unsampled residents (50, 38, and 26) on vegetarian diets, which could further compromise their nutritional status. Cross reference F801, F804 Findings: During a review of the facility's Lunch Menu titled Daily Spreadsheet- Monday Day 23, Week 4 Day 2, the menu indicated .Regular Diet: 1-1/2 cup Penne with Mushroom sauce, 1/2 cup seasoned fresh broccoli florets, 1 slice Garlic bread, 1 cup of choice of beverage, 1 slice of key lime pie.Vegetarian: Select vegetarian item to serve . During a review of the facility's Lunch Menu titled Daily Spreadsheet- Tuesday Day 24, Week 4 Day 3, the menu indicated .Regular Diet: 4 oz. Honey baked ham, 1/2 cup Roasted sweet potatoes, 1/2 Parslied Fresh Cauliflower, 1 Bread or roll, 1 cup of choice of beverage, 1- 3x2 slice of turtle brownie.Vegetarian: Select vegetarian item to serve . During a concurrent observation and interview in the kitchen on 4/28/25 at 11:24 AM of the lunch trayline meal service, [NAME] (CK) 1 was placing the pureed and vegetarian foods on the trayline. CK 1 stated he made multicolored yellow and orange pasta with mushroom sauce as the entrée for the vegetarian diet. CK 1 stated the pasta was minus the bacon. During a concurrent kitchen observation and interview on 4/29/25 at 11:53 AM of the lunch trayline, CK 1 stated there were three residents on a vegetarian diet. CK 1 further stated the residents on vegetarian diets would receive regular pasta with a gravy sauce as the vegetarian entrée for lunch. CK 1 stated the kitchen did not have a vegetarian menu for residents on vegetarian diets. CK 1 further stated he decides what to serve the residents on vegetarian diets and does not get approval from the Registered Dietitian (RD) or the Dietary Services Manager (DSM) for menu options. During a concurrent observation and interview on 4/29/25 at 1:00 PM in Resident 50's room, the resident received multicolored green and orange pasta, sweet potatoes, cauliflower and a peanut butter and jelly sandwich for lunch. Resident 50 stated he requested to be on a vegetarian diet a while ago and he usually receives a lot of pasta and potatoes for lunch. Resident 50 stated he does not receive much protein. Resident 50 stated he likes grilled cheese toast sandwiches and didn't know they were available on the vegetarian menu. Review of Resident 50's breakfast, lunch and dinner meal tray tickets indicated .Vegetarian Mech Soft Chopped CCHO - Regular portion .Prefers Cheese .Beans .Tofu . Review of Resident 38's breakfast, lunch and dinner meal tray tickets indicated .CCHO-NAS Vegetarian Double Portion .Prefers Egg salad sandwich .TOFU . During an interview with the RD on 4/29/25 at 1:21 PM, the RD stated the menu substitutions were 056103 Page 28 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0803 Level of Harm - Minimal harm or potential for actual harm completed by the DSM because she was not there full-time, only part-time, twice a week. The RD stated she approves all the menus and there should be appropriate foods in the kitchen available to serve residents on a vegetarian diet. The RD further stated the kitchen staff should use appropriate foods as equivalent substitutions for the vegetarian options. The RD further stated the kitchen could contact her if they have questions. Residents Affected - Few During an interview with the DSM on 4/29/25 at 2:38 PM, the DSM acknowledged the kitchen did not have a vegetarian menu or diets. The DSM further stated the kitchen should provide the three residents on vegetarian diets with appropriate foods for their vegetarian diets. During a review of the facility's Diet Manual document titled Vegetarian Preferences, dated 2015, the document indicated .The decision to follow a vegetarian preference is an individual choice based on personal beliefs and desires. Research indicates that people who follow vegetarian-style eating patterns tend to have improved health outcomes.vegetarian meal plans can be well balanced .but may pose a challenge in providing all essential nutrients . Realistically, nutrients consumed will vary from day to day and will average weekly within the DRI targets. Protein and Dairy substitutions .eggs, cheese, cooked dry beans, peas, lentils .tofu, vegetarian soy or meat product . During a review of the facility document titled Menu Compliance dated 2022, the document indicated .Menus and recipes meet regulatory requirements and .dated with RD signature or approval.Menu followed with less than 2 temporary changes per week. Changes approved and noted on Substitution form . 056103 Page 29 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

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 observations, interviews, and record reviews, the facility did not ensure the standardized recipes for the regular diet were followed as printed, in accordance with menu guidance and facility policy. Residents Affected - Some This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the nutritional status of the facility residents. The facility census was 114. Cross reference F801 and F803 Findings: During a review of the facility's Lunch Menu titled Daily Spreadsheet- Wednesday Day 25, Week 4 Day 4, indicated Main Regular Diet NAS (4-5 grams): 3 oz. Tomato Braised Pot Roast, 1/2 cup Lyonnaise potatoes, 1/2 Steamed spinach, 1 Bread or roll, 1 cup of choice of beverage, 1 slice of 7-up Cake . During a concurrent kitchen observation, interview and record review on 4/29/25 at 2:38 PM with the evening [NAME] (CK) 2 and Dietary Services Manager (DSM), a large metal pot was found in the walk-in refrigerator with foil on it labeled Pot roast 4-29-25 Use by 5-1-25. CK 2 stated the morning [NAME] made the pot roast and placed it in the refrigerator an hour ago. A review of the Cool Down Log sheet dated April 2025 indicated that the morning [NAME] did not log the cool down start time for when it was placed in the refrigerator. The surveyor's thermometer was placed in the roast meat and it read 141.6 degrees Fahrenheit (F). The DSM and evening [NAME] acknowledged the initial temperature was missing from the log sheet and the temperature on the Surveyor's thermometer. The DSM stated the pot roast needed to be recooked in the oven to ensure it reached the final cooking temperature and to restart the cool down process. The evening [NAME] confirmed there weren't any vegetables like carrots and celery in the pot roast juice for the pot roast in the metal pan. The DSM stated the recipe should have been followed. During a review of the facility's recipe titled Tomato braised Pot Roast- 3 oz., dated 3/14/25, the recipe indicated .1. Season meat with salt .and pepper.Brown at 450 degrees Fahrenheit (F) for about 30 minutes. 2. Add water . tomato puree and bay leaf to browned meat; cover and cook slowly until tender (3-4 hours) . 3. Add carrots, celery, and onion during the last hour of cooking. CCP: At completion of cooking internal temperature should register 145 degrees F for 4 minutes.4. Serve 3 oz. meat with 2 oz. sauce per portion . The Steamed Spinach recipe was requested but not provided. During a concurrent observation and interview on 4/30/25 at 12:57 PM with the Registered Dietitian (RD) and Dietary Services Manager (DSM) of a test tray of the regular diet and pureed diet lunch meals, the RD and DSM each stated they typically do not do test tray evaluations at the facility. After the RD and DSM tasted the Regular diet lunch entrée roast beef and vegetable side, spinach, they both acknowledged the food items tasted bland, and had no flavor. The RD also stated the Regular diet roast beef entrée was also dried out and tasted overcooked. The RD and the DSM stated the brown gravy parts of the roast beef helped improve the flavor. After the RD, DSM, and Surveyor tasted the spinach from the Regular diet, the RD stated, It's like the spinach had no seasoning at all. The DSM stated the regular spinach could have used more seasoning. The RD then stated she 056103 Page 30 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0804 expected the Cooks to follow the recipes because they've already been tested and approved. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled Section 5 Meal Service, dated 2018, the P&P indicated .Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner . Residents Affected - Some During a review of the facility's P&P titled Food Preparation, dated 2018, the P&P indicated .Food shall be prepared by methods that conserve nutritive value, flavor, and appearance.1. The facility will use approved recipes, standardized to meet the resident census.2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. 056103 Page 31 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food safety and sanitation measures were maintained in the kitchen according to standards of practice and facility policy when: Residents Affected - Many 1. An ice machine had pinkish gray slime debris on the drain panel and ice tray, and brown discoloration stains and debris inside the ice making grid, chute and on the right and left walls of the ice machine. 2. The kitchen did not have a three (3)-compartment sink station to wash, rinse, and sanitize dishes in the event of an emergency, if the dish machine was nonoperational. 3. Fourteen white colored plates on a dish rack had blackish dark gray stains on them. 4. Three cutting boards had deep cuts, and large white patches were used during food preparation in the kitchen. These failures had the potential to place residents at risk to develop foodborne illness by exposing residents to contaminated food and unsanitary practices. The facility census was 114. Cross reference F801 and F802 Findings: 1. During a concurrent kitchen observation and interview on 4/29/25 at 10:34 AM with the ice machine vendor technician, the vendor technician stated he last cleaned the ice machine in May 2024. The ice machine did not have a water filter attached. The technician removed the ice machine water tray and curtain covering ice making grid parts to clean them. The technician wiped pink and gray colored slime debris off with warm water and a clear solution in an unlabeled plastic spray bottle. The technician stated the clear solution was a mixture of Zep brand cleaner and water. The technician also had another clear spray bottle with a clear solution labeled bleach and the technician stated he planned to use it to clean other internal ice machine making parts. The technician further stated he had a gallon of Manitowoc cleaner in his car that he may use at the end. The DSM stated she requested the previous cleaning records from last year in May 2024 from the ice machine vendor who cleaned it, but they have not provided them. The DSM acknowledged the pinkish gray slimy substances and brown stained buildup and debris on all the ice machine internal parts that touch the ice. The DSM stated the ice machine should be cleaned correctly with the appropriate chemicals, according to the manufacturer's instructions, so it could make clean ice. The DSM further stated the ice machine should have a filter attached to clean the water used to make the ice. During a review of the undated ice machine manufacturer's instruction manual, Section 4 titled Maintenance the instructions indicated, Cleaning and Sanitizing .An extremely dirty ice machine must be taken apart for cleaning and sanitizing. Manitowoc Ice Machine Cleaner and Sanitizer are the only products approved for use in Manitowoc ice machines . Wash the sink, drip tray, grill and Drain Basin and Manifold with the sanitizer solution. During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, Section 4-204.17 056103 Page 32 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many titled, Ice Units, Separation of Drains, FDA Food Code indicated, Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines .The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin. All equipment will be operated and maintained according to the manufacturer's specifications for cleaning and sanitizing and safe operating condition. During a review of the facility's policy and procedure (P&P) titled Ice Machine Cleaning Procedures, dated 2018, the P&P indicated .The ice machine (bin and internal components) needs to be cleaned monthly and the recorded when cleaned .3. Clean the inside of ice machine with a sanitizing agent per the manufacturer's instructions . 2. During a concurrent observation and interview on 4/30/25 at 11:43 AM with Diet Aide (DA) 4 and the DSM in the kitchen, DA 4 stated the two-compartment sink at the end of the clean side of the dish machine was used for washing and rinsing dishes if the dish machine didn't work. DA 4 did not know where the dishes would be sanitized. The DSM stated the kitchen should have a third compartment created for sanitizing clean dishes from the 2-compartment sink. During a review of the 2022 Federal Food and Drug Administration Food Code (FDA Food Code), Section 3-601.11 titled, Food Labels, FDA Food Code indicated, .(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . 3. During a concurrent observation and interview on 4/28/25 at 9:38 AM with Diet Aide (DA) 1 in the kitchen dish area, DA 1 stated a rack with fourteen white plates in them, were washed, clean and dry. DA 1 stated the fourteen white plates had blackish gray colored stains on them for a while but they were still clean. The DSM stated the dishes should be clean and of good quality. According to the Food and Drug Administration (FDA) Food Code 2022 Cleaning of Equipment and Utensils, section 4-601.11, titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch . 4. During a concurrent observation and interview in the kitchen on 4/28/25 at 9:58 AM with [NAME] (CK) 1, CK 1 stated the three cutting boards, a red, blue, and green one, stacked in a rack in the food preparation area were used to chop vegetables and meats. Each of the cutting boards had a large white stain with several cuts, grooves and scratches on them and were severely worn. The DSM stated the cutting boards should be of higher quality and not severely scratched. According to the Food and Drug Administration (FDA) Food Code 2022, Section 4-501.12, titled Cutting Surfaces, .surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized or discarded if they are not capable of being resurfaced. During a review of the facility's policy and procedure (P&P) titled, Sanitation dated 2018, the P&P indicated, .9. All utensils .and equipment shall be kept .maintained in good repair and shall be free from breaks .cracks and chipped areas .12. Ice which is used in connection with food or drink 056103 Page 33 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0812 Level of Harm - Minimal harm or potential for actual harm shall be from a sanitary source and shall be handled and dispensed in a sanitary manner .17. Separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized 19. Correct temperatures for the storage and handling of foods are used. Thermometers will be used to check the temperatures of refrigerators, freezers and in food storeroom. Thermometers will be used to check the food at mealtimes . Residents Affected - Many 056103 Page 34 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the Arbitration Agreement (a binding agreement by the parties to submit to arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds.) was explained in a manner that one of three sampled residents (Resident 520) understood. Residents Affected - Few This failure resulted in Resident 520 signing the facility's arbitration agreement without full understanding. Findings: During a review of Resident 520's Face Sheet, the Face Sheet printed on 4/30/25 indicated, Resident 520 was admitted in the facility on 4/18/25 with a diagnosis that included multiple fractures of ribs and chronic obstructive pulmonary disease (COPD, a lung disease that makes it difficult to breathe.) During a review of Resident 520's Nursing Evaluation, dated 4/18/25, the Nursing Evaluation indicated, Resident 520 had quick comprehension and was oriented to person, place and time. During a review of Resident 520's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 4/24/25, the MDS indicated, Resident 520 had a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13 out of 15, indicating intact cognitive status. During a concurrent interview and record review on 4/30/25 at 9:13 a.m. with Admissions Representative (AR), Resident 520's Arbitration Agreement dated 4/22/25 was reviewed. The Arbitration Agreement given an option to sign the arbitration agreement electronically or in paper after it was explained. During a follow up interview on 4/30/25 at 9:25 a.m. with the AR, the AR stated, she explained to residents the arbitration agreement was about resident's rights when they are in the facility. The AR stated, she explained to residents they had the right to refuse treatments or showers. The AP stated, she told residents they had the right to request medical records. The AR stated, the Marketing Director (MD) talked to residents who refused to sign the arbitration agreement. During an interview on 4/30/25 at 9:53 a.m. with Resident 520, in Resident 520's room, Resident 520 stated, he recalled signing the arbitration agreement form. Resident 520 stated, the form was not explained and the staff just asked him to sign the form. Resident 520 stated, a copy of the form was not provided. During an interview on 4/30/25 at 10:21 a.m. with the MD, the MD stated, they attempted three times to find out the resident's reason for refusal to sign the arbitration agreement. 056103 Page 35 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/1/25 at 11:08 a.m. with the Administrator (ADM), the ADM stated, staff doesn't need to go back to the resident to ask the resident's reason for refusing to sign the agreement. The ADM stated, residents had the right to refuse to sign the arbitration agreement. The ADM stated, training would be provided to staff on what to explain to the residents about the arbitration agreement. During a review of facility's policy & procedure titled, Arbitration, dated 9/19, indicated, The facility will present the agreement and explain the agreement in a form and manner that is understood by the resident . The facility must inform the resident of their right not to sign the agreement. 056103 Page 36 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff did not follow their infection control prevention policy and standards of practice during med pass for (two of twenty-five residents,) Resident 50 and Resident 86, when: Residents Affected - Some 1. The facility staff did not clean and sanitize the medication cart in between resident's care, (Resident 50 and Resident 86), after placing soiled medication cup used by Resident 50, into the medication cart. 2. An uncapped and exposed lancet (a small needle used to poke the skin, [usually on a finger for Residents with diabetes] to get a small drop of blood) was left in med storage room B with no name or identifier. 3. The facility staff did not keep medication pill crusher (used to crush medications during medication administration), on the medication cart, clean and sanitized. The failure to practice universal precaution and infection control during medication administration had the potential to result in infection or spread of infection for Resident 86 and increased exposure for all facility residents and staff in the facility, possibly hospitalization for Residents. Findings: 1. During a record review of Resident 86's Facesheet (FC), the FC indicated Resident 86 is [AGE] years old, was admitted to the facility in 2022. The FC also indicated Resident 86 has diagnosis of Type 2 Diabetes (adult onset diabetes, characterized by high blood sugar and insulin resistance), Atrial fibrillation (irregular, often rapid heart rate), Urinary Tract Infection (when bacteria enter the urinary tract through and up to the bladder), Hypertension (high blood pressure), Chronic Viral Hepatitis B (a serious liver infection caused by Hepatitis B Virus), and Emphysema (chronic lung disease that progressively damages the alveoli [tiny air sacs] in the lungs). During a review of Resident 50's Facesheet (FC), the FC indicated Resident 50 is [AGE] years old, was admitted to the facility in 2025. The FC also indicated Resident 50 has diagnosis of Pneumonia (infection that causes an inflammation of the lung, which may filled with fluid), Type 2 Diabetes, Malignant Neoplasm of Renal Pelvis (Kidney cancer [healthy cells grow and form a tumor]), Acquired Absence of Kidney (a person is missing one or both kidneys due to injury or surgical procedure), Hypertension (high blood pressure), and Orthostatic Hypotension (low blood pressure that happens when standing up from sitting or lying down. During an observation on 4/29/2025 at 9:41 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 took Resident 50's meds into his room, in a small medication cup, LVN 3 gave all the meds due at 0900 med pass, then Resident 50 refused three of his medications, one Colace, two Senakots tabs and one Midodrine tablet. LVN 3 placed these meds on Resident 50's bedside table and after Resident 50 was done taking his other medications, LVN 3 picked up the medications with her hands and then placed the soiled cup on top of the medication cart designated for Resident med administration. LVN 3 took the soiled med cup and placed it in the top drawer of the med cart. LVN 3 then went to Resident 86's room, prepared Resident 86's medications and administered his medications without sanitizing the med cart. LVN 3 took the med cart back to the storage area and sat down at the nurse's station 2. 056103 Page 37 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/29/2025 at 10:15 a.m., with LVN 3, LVN 3 stated she was supposed to have cleaned the med cart after she had placed the soiled med cup on the med cart for cross contamination purposes. LVN 3 stated she took the cup into Resident 50's room and then placed the cup back on the cart without cleaning the medication cart. 2. During an observation and an interview on 4/30/2025 at 11:12 a.m., with Registered Nurse 1 (LN 3), in medication room B, staff left an old, soft texture zipper black organizer bag with sticky, oily substance, with one small glucometer (machine to check blood sugar), test strips (used to collect blood to measure blood sugar level), and an uncapped sharp pointed lancet in one of the medication cabinet. LN 3 stated the bag with the glucometer, test strips, and uncapped lancet was supposed to have been discarded, destructed. And that Supervisors do destruction (get rid of, damage) every week and then sign they completed the task. LN 3 stated the bag containing the lancet sharp should not be left in the med cabinet for safety, someone does not stick themselves and because it does not have no resident identifier. 3. During an observation and an interview on 4/30/2025 at 10:40 a.m., with LN 3, medication pill crusher on medication cart 1B used to crush residents' medications had residue of dirty, sticky, dark brown particles, and white dusty powder in the inside and outside of it. LN 3 stated the pill crusher looks like it has not been cleaned for a while, and that the med cart should be cleaned once a week to prevent infection and cross contamination. During an interview on 4/30/2025 at10:43 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 stated the pill crusher was used to crush residents' medication on 4/30/2025. During a review of facility's policy and procedures (P&P), titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 2009, the P&P indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendation for disinfection and the OSEA Bloodborne Pathogens Standard . c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1). Non-critical residents care items include bedpans, blood pressure cuffs, crutches and computers . (2). Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location) . d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) . (i). Single resident-use items are cleaned/disinfected between uses by a single-resident and disposed of afterwards . During a review of facility's policy and procedure (P&P), titled Administering Medication, dated 2001, the P&P indicated, 22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 056103 Page 38 of 39 056103 05/02/2025 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain two out of two sampled clothes dryers according to the facility's policy when facility staff documented lint trap (help to reduce the lint and fabric particles that can build up and clog the exhaust hose) was cleaned prior to scheduled time. Residents Affected - Many This failure had the potential for the clothes dryer to be in an unsafe operating condition. Findings: During a concurrent interview and record review on 4/29/25 at 8:52 a.m. with Laundry Personnel (LP) and Housekeeping Supervisor (HKS), in the laundry room, the Lint Trap Cleaning Log, dated 4/29/25 was reviewed. The Lint Trap Cleaning Log indicated, initial after cleaning. The Lint Trap Cleaning Log also indicated, 10:00 a.m., 12:00 p.m. and 2:00 p.m. had written letters LA. The LP stated, the letters LA was her initials. The HKS stated, laundry staff initials the log early because sometimes they forgot to initial. During a review of facility's undated policy and procedure (P&P) titled Interior Maintenance: Laundry, the P&P indicated, 3a. Laundry personnel are cleaning clothes dryer filters every two hours . d. Check exhaust ducts to ensure they are free of lint. 056103 Page 39 of 39