Inspection·February 28, 2019

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the comprehensive care plans for activities for two of three sampled residents (Resident 30 and Resident 39) after changes in physical conditions. These failures had the potential for Resident 30 and Resident 39 to receive inappropriate activities, or have unmet psychological and/or emotional needs from lack of appropriate activities. Findings: 1. A review of Resident 30's face sheet dated 1/24/19 indicated she originally admitted to the facility in 2015, and readmitted on [DATE]. The Significant Change in Status Minimum Data Set (MDS, an assessment tool used to guide care) dated 6/27/18, indicated her diagnoses included dementia (a brain disorder affecting the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality), and generalized muscle weakness. The MDS reflected Resident 30 rarely/never understood others, or was understood; had severely impaired hearing; had no speech; and had severely impaired thinking and reasoning skills for daily decision making. A review of the activities care plan revised 12/19/18 reflected Resident 30's responsible party wanted Resident 30 to have the opportunity to engage in the activities of hearing religious services, and listening to music, especially religious music. The MDS dated [DATE] reflected the responsible party confirmed it was very important for Resident 30 to participate in religious services or practices. A review of the facility Participation Log, reflected no participation in the categories of religious activity, and listening to music from 1/1/19 through 2/26/19. 2. Review of Resident 39's face sheet dated 7/19/18 indicated she originally admitted to the facility in 2014, and readmitted on [DATE]. The MDS section F0500 indicated listening to music was very important to Resident 39. A review of the activities care plan, revised 1/28/19, included listening to radio and outings under goals. During random observations of Resident 39 from 2/25/19 to 2/28/19, there was no music playing in her room. Review of the facility Participation Log, for January and February 2019, showed Resident 39 listened to music on four days: 1/3/19, 1/5/19, 2/3/19, and 2/9/19. During an interview with the Activities Assistant (AA) on 2/27/19 at 12:10 p.m., AA stated Resident 39 previously listened to music, went out to eat, and went out on the patio, but was not able to do all those activities now. The AA stated Resident 39 is always sleeping now, and that the care plan should be updated. During an interview with the Regional Nursing Consultant (CON) on 2/28/19 at 10:17 a.m., CON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Center 14766 Washington Avenue San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the expectation was for the facility to review and update care plans, even if residents are on hospice and the hospice agency had its own care plans. Review of the facility policy and procedure, Hospice, revised 3/1/18, reflected the facility was responsible for, meeting the patient's personal and nursing care in coordination with the hospice representative, and ensuring that the level of care provided is appropriate based on the individual patient's needs. Event ID: Facility ID: 056121 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Center 14766 Washington Avenue San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate grooming services for one of one sampled resident (Resident 39) to prevent or treat dandruff (a skin condition usually confined to the scalp, and resulting in accumulation of dry, itchy, flaky scales). Residents Affected - Few This deficient practice resulted in physical discomfort for Resident 39, and had the potential to result in emotional distress from poor grooming negatively impacting her physical appearance. Findings: A review of Resident 39's face sheet dated 7/19/18 indicated she was originally admitted to the facility in 2014, and readmitted on [DATE]. According to the Significant Change in Status Minimum Data Set (MDS, an assessment tool used to guide patient care) dated 1/11/19, had generalized muscle weakness. Review of Resident 39's care plan titled, .it is important that she has the opportunity to engage in daily routines that are meaningful ., revised 1/28/19, reflected as an intervention, It is important for me to keep clean. During an observation with Certified Nursing Assistant (CNA) 1 on 2/27/19 at 12:38 p.m., Resident 39 had white flakes at the front of her scalp. Resident 39 scratched her scalp and stated her scalp itched, and she needed a good shampoo. In a concurrent interview, CNA 1 stated Resident 39 does not take showers. Review of Resident 39's Weekly Bath and Skin Report for February 2019 contained no documentation except the date of February 2019, and that Resident 39's weekly shower days were Wednesdays and Saturdays. There were no signatures under the columns for CNA signature or Charge Nurse Signature; there were no documented abnormal conditions. Review of the facility, ADL [Activities of Daily Living] Record, for February 2019 reflected Resident 39 was completely dependent on staff for bathing, and received bed baths only. The Record specifically excluded hair washing in the bathing record; there was no documented hair washing. During an interview with the interim Director of Nursing (DON) on 2/27/19 at 12:51 p.m., the DON was unable to find any documentation about Resident 39 refusing showers. The DON observed Resident 39's scalp and agreed that she had dandruff. Review of the facility policy and procedure, Activities of Daily Living, revised 11/28/16, reflected, A patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Center 14766 Washington Avenue San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide pressure ulcer treatment and services (pressure ulcer, a wound from prolonged pressure, also known as a bed sore) for one of five sampled residents (Resident 47). Residents Affected - Few For Resident 47 the development of a pressure sore on 2/19/19, and the facility failure to provide treatment and services for eight days, resulted in increased size and depth of the ulcer, and had the potential to result in severe tissue damage at the site. Findings: A review of Resident 47's comprehensive admission Minimum Data Set (MDS, an assessment tool used to guide care) dated 1/18/19 showed Resident 47 was always incontinent of bladder and bowel, and required physical assistance from two people for turning and repositioning in bed. The MDS showed Resident 47 had clear speech, and was usually able to understand and be understood by others. The MDS indicated Resident 47 was at risk for pressure ulcers, but had no healed, or unhealed, pressure ulcers. A review of Resident 47's care plan, At Risk for Skin Breakdown, initiated on 11/5/14, indicated, Monitor skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decreased sensation, and skin that does not blanche easily. Weekly skin assessment by licensed nurse. The care plan's last revision was dated 2/2/19. A review of Resident 47's record showed a form titled, SBAR [Situation, Background, Appearance, Review] Communication Form and Progress Note, dated 2/19/19, by Licensed Vocational Nurse 2 (LVN 2). The SBAR indicated Resident 47 had a newly identified superficial open area on her left buttock, which measured one centimeter (0.37 inches) by one-half centimeter. The SBAR indicated LVN 2 notified the physician about the open area on 2/19/19 at 2 p.m. During an interview with LVN 2 on 2/27/19 at 12:18 p.m., LVN 2 stated she had not completed a skin integrity report, or initiated treatment for Resident 47's pressure ulcer. During an observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 2/27/19 at 9:05 a.m., LVN 1 confirmed Resident 47's left buttock had an open area with minimum bleeding and a red wound bed. LVN 1 stated she had not known Resident 47 had an open area on her buttock. During an observation and interview with LVN 1 on 2/27/19 at 11:29 a.m., LVN 1 measured Resident 47's left buttock pressure ulcer at five centimeters (two inches) in length, one-half centimeter in width, and 0.2 centimeter in depth, with minimum bloody drainage. Calculation of the differences in measurements from 2/19/19 to 2/27/19 showed length increased four centimeters (1.6 inches), and depth increased by 0.2 centimeters. During an observation, and interview with Regional Nursing Consultant (CON), of Resident 47's left buttock on 2/27/19 at 11:03 a.m., CON confirmed Resident 47's pressure ulcer was a Stage II ulcer. In a concurrent record review, CON stated she was unable to find documentation of a skin integrity report, a physician ordered treatment plan, or a nursing care plan with interventions for the ulcer. CON stated Resident 47's pressure ulcer treatment should have been initiated when the nurse first identified the presence of the ulcer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Center 14766 Washington Avenue San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and concurrent record review with the interim Director of Nursing (DON) on 2/27/19 at 10:03 a.m., DON stated the facility procedure for newly identified pressure ulcers was for licensed nurses to complete a SBAR, notify the doctor, notify the responsible party, initiate a skin integrity report, create a care plan, and report the wound to the next shift. During an interview with LVN 1 on 2/27/19 at 11:29 a.m., LVN 1 said she had notified the physician about Resident 47's pressure ulcer, and had received treatment orders this morning. A review of the physician orders showed the physician first ordered treatment of Resident 47's pressure ulcer on 2/27/19. Review of the facility's policy and procedure titled, Skin Integrity Management, revised 11/28/16, indicated nursing staff were to document newly identified skin impairments on the facility 24-hour Summary Report, complete observations and measurements on a Skin Integrity Report, and document daily monitoring of the wound. The policy further reflected nursing was required to, 4. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Center 14766 Washington Avenue San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to serve and store food under sanitary conditions by: Residents Affected - Some 1. The tuna salad was held at an unsafe temperature in the refrigerator. 2. Dry food bin lids, utensils, and equipment were dusty. 3. A dented canned good was stored in a rack for use. These failures placed residents at risk of developing food-borne illnesses. Findings: 1. During the initial kitchen observation on 2/25/19 at 3:50 p.m., the refrigerator had a sealed container labeled tuna salad, start date 2/24/19. DM confirmed the current measured internal temperature of the tuna salad to be 48 degrees Fahrenheit (°F). DM stated refrigerated food should be stored at or below 41°F. (Tuna is a Time/Temperature Control for Safety Food, requiring control of time and temperature to limit the growth of harmful, disease producing organisms.) 2. The lids of five of five dry food storage bin lids were dusty. DM stated dietary aides, including herself, checked utensils and equipment for cleanliness and proper storage in clean areas. DM stated dry food bin lids are cleaned every day by dietary aides per facility procedure. 3. During an observation in the dietary department, and concurrent interview with DM on 2/26/19 at 11 a.m., DM confirmed the presence of one dented can of 104 ounces of beets on a shelf in the dry storage area. DM stated cans are inspected for dents upon arrival and should be placed in a dented can storage area per facility procedure. The facility's policy and procedure titled, Food Handling, revised 12/01/15, reflected, All Time/Temperature Control for Safety Food must maintain an internal temperature of 41°F or lower FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Center 14766 Washington Avenue San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure one of 18 sampled residents (Resident 30) had complete, accurate, and readily accessible records. 1. For Resident 30, the facility failed to ensure care plans accurately represented patient care issues by initiating a care plan for anticoagulant medication (medication used to prevent abnormal clotting of the blood) not ordered or administered. This failure had the potential to result in unnecessary care adjustments such as patient education and dietary changes to prevent adverse effects associated with anticoagulant medications. 2. The facility failed to ensure accurate documentation of treatment when Resident 30's treatment record reflected nursing provided wound care to a resolved left upper thigh blister, and failed to accurately reflect treatment of a right thigh wound. This failure had the potential to result in impairment of nursing ability to monitor, evaluate, and plan interventions on an ongoing basis. Please refer to tags F 656 and F 657. Findings: 1. Review of Resident 30's face sheet dated 1/24/19 indicated she was originally admitted to the facility on [DATE], and re-admitted on [DATE]. The Significant Change in Status Minimum Data Set (MDS, an assessment tool used to guide care) dated 6/27/18, indicated her diagnoses included anemia (a decreased level of red blood cells in the blood stream, resulting in less oxygen availability for the body), dementia (a brain disorder affecting the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality), and generalized muscle weakness. The MDS reflected Resident 30 rarely/never understood others, or was understood; had severely impaired hearing; no speech; and had severely impaired thinking and reasoning skills for daily decision making. The Quarterly MDS dated [DATE] indicated Resident 30 had two pressure ulcers (damage to skin or underlying soft tissue from prolonged pressure). Review of Resident 30's medical record showed a care plan related to anticoagulant medication (medication used to prevent blood from forming clots), initiated 12/19/18, and revised 2/15/19. Review of Resident 30's Order Summary Report for February 2019 showed no order for anticoagulant medication. During an interview with the MDS Coordinator (MDSC) on 2/28/19 at 11:15 a.m., MDSC stated the care plan for anticoagulant medication did not accurately reflect Resident 30's condition, as the resident had not received anticoagulant medication. 2. During an observation of Resident 30's pressure ulcer treatment with Licensed Vocational Nurse (LVN) 3 and Certified Nursing Assistant (CNA) 1 on 2/28/19 at 1:45 p.m., Resident 30 had a right posterior thigh wound, and a sacral (the bony structure located at the bottom of the spine and connected to the pelvis) wound. Review of Resident 30's Treatment Administration Record (TAR) for February 2019 showed nursing provided daily treatments to a left upper thigh blister from 2/1/19 through 2/27/19, with only one day of missed treatment (2/10/19). The TAR also reflected nursing provided treatment to a left posterior (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Center 14766 Washington Avenue San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete thigh wound twice daily from 2/1/19 through 2/15/19, 2/26/19, and 2/27/19 (with the exception of only one treatment on 2/10/19). The record indicated LVN 3 provided a combined total of 19 of the documented treatments to the left upper thigh blister and left posterior thigh wound. During an interview with LVN 3 on 2/28/19 at 2:41 p.m., LVN 3 stated there had been no left posterior thigh wound. LVN 3 stated the order should have indicated treatment for the right posterior thigh. LVN 3 stated Resident 30 had a blister on the left upper thigh, but the wound had healed, and LVN 3 no longer provided treatment to the area. Event ID: Facility ID: 056121 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Center 14766 Washington Avenue San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to document proceedings of the quality assessment and assurance committee during scheduled quarterly meetings. This failure had the potential to result in facility inability to monitor the ongoing, comprehensive evaluation of provision of facility care and services. Residents Affected - Some Findings: During an interview and record review with Regional Executive Administrator (REA) on 2/28/19 at 3:02 p.m., REA confirmed the quality assurance and performance improvement meeting log had no documentation for the quarterly meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Center 14766 Washington Avenue San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Potential for minimal harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review facility failed to conduct quarterly meeting on a regular basis and required members were not in attendance. this deficient practice failed to, monitor departmental performance data routinely in order to identify deviations in performance . Findings: During a review of QAPI log book on 2/28/19 at 2:55pm it was noted that there were no quarterly meeting documentation. the one quarterly meeting which was held on 11/18 there were no Medical Director or designee,no DON(Director of Nursing) and no administrator was in attendance. During an interview on 2/28/10 at 3:02pm, with regional executive Administrator stated: I don't see any documentation of quarterly meetings. not having quartely QA meeting FACILITY QAA and QAPI 02/28/19 03:02 PM no required members in the Q A meeting- no medical director, no DON, ( novembr 2018, ) april 2018 no DON, no administrator met with [NAME] ski executive administrator November meeting held in December FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Center 14766 Washington Avenue San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to ensure the quality assessment and assurance committee had regulatory required members in attendance at the November 2018 quarterly meeting. This failure resulted in facility inability to routinely review and evaluate departmental performance data, and initiate necessary corrective actions. Residents Affected - Some Findings: A review of the Quality Assurance Performance Improvement (QAPI) log on 2/28/19 at 2:55 p.m., reflected the 11/14/18 meeting was not attended by either the Medical Director (or a designee), Director of Nursing, or an admistrator/board member/owner/leadership staff member. During an interview with Regional Executive Administrator (REA) on 2/28/19 at 3:02 p.m., REA stated he was unable to find any documentation of the November QAPI meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 12 of 12