Health inspection·November 7, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Resident 12's Medication Administration Record for the timeframe 07/01/2024 to 07/31/2024, indicated the resident displayed hallucinations and behaviors of crying/yelling out. Resident 12's Medication Administration Record for the timeframe 08/01/2024 to 08/31/2024, indicated the resident displayed hallucinations and behaviors of crying/yelling out. Residents Affected - Few During an interview on 11/06/2024 at 8:18 AM, the Social Service Designee stated Resident 12 had episodes of hallucinations and behaviors and they were not accurately reflected on the resident's MDS. 3. An admission Record indicated the facility admitted Resident 28 on 12/04/2021. According to the admission Record, the resident had a medical history to include diagnoses of essential hypertension, dysarthria and anarthria, encounter for palliative care. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/31/2024, revealed Resident 28 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had no behaviors during the 7-day look-back period. Resident 28's Medication Administration Record for the timeframe 08/01/2024 to 08/31/2024, indicated the resident displayed episodes of restlessness and yelling at staff. During an interview on 11/06/2024 at 8:18 AM, the Social Service Designee stated Resident 28 had behaviors and they were not accurately reflected on the resident's MDS. During an interview on 11/06/2024 at 2:01 PM, the Director of Nursing stated her expectations would be that MDS assessments were coded accurately. During an interview on 11/06/2024 at 2:32 PM, the Administrator stated she expected MDS to be coded accurately. A facility policy titled, Resident Assessments, revised 10/2023, indicated, 6. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. The policy specified, 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 2 of 5 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 11/07/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and facility policy review, the facility failed to ensure the nursing staff locked two of four medication carts when it was not in their eyesight view. This failure had the potential for unauthorized users to access medications. Findings included: During a concurrent interview and observation of medication administration on 11/05/2024 at 7:02 AM and 7:09 AM, Registered Nurse (RN) 1 left medication cart labeled Lower 200 unlocked and out of her view in the hallway and entered a resident's room to administer medication. RN 1 stated the medication cart should be locked and that she forgot. The unlocked, unsecured medication cart contained several medications, not limited to Lasix to treat high blood pressure and fluid retention, Eliquis to prevent blood clot formation, and nitroglycerin to treat acute chest pain. During an interview on 11/05/2024 at 11:22 AM, RN 5 stated nurses must lock the medication cart and computer screen when they step away from the medication cart. During an interview on 11/05/2024 at 11:46 AM, Licensed Vocational Nurse (LVN) stated medication carts must be locked when nurses did not have an eye on the cart. LVN 6 said medication carts were kept in the facility hallways and were not safe when left unlocked. During an interview on 11/05/2024 at 11:48 AM, LVN 3 stated it was the nurse's responsibility to keep the medication cart secured to prevent accidents. During a concurrent interview and observation on 11/06/2024 at 8:57 AM, an unattended and unlocked medication cart was observed in the 100 hall in the hallway. At 9:02 AM, LVN 6 came from facility's entrance door and stated she was the nurse assigned to the cart. LVN 6 stated the medication cart should be locked because of the medications it contained. Per LVN 6, the medication cart contained Eliquis to treat atrial fibrillation, Lisinopril and Lasix used to treat hypertension. During a concurrent interview and observation on 11/06/2024 at 11:50 AM, the medication art labeled Lower 200 was observed unlocked in the hallway. When LVN #7 exited a resident's room, she stated the medication cart was not visible and she should not have left the medication cart opened. During an interview on 11/06/2024 at 2:08 PM, the Director of Nursing (DON) stated the medication carts must be locked when left unsupervised. The DON said it was important to keep it locked due to safety and privacy. The DON stated she expected nursing staff to make sure the medication carts were locked from unauthorized access. During an interview on 11/06/2024 at 2:33 PM, the Administrator stated the nurses must lock the medication when it was not in their eyesight. A facility policy titled, Medication Storage in the Facility with an effective date of 04/2028, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendation or those of the supplier. The medication supply is accessible only to licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 3 of 5 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 11/07/2024 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 0761 nursing personnel, pharmacy personnel, or staff members lawfully authorized. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 4 of 5 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 11/07/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for one (Resident 2) of 21 sampled residents. Residents Affected - Few This failure had the potential to result in the spread of infection. Findings included: An admission Record revealed the facility admitted Resident 2 on 02/27/2024. According to the admission Record, the resident had a medical history that included a diagnosis of encephalopathy, sepsis, enterococcus, methicillin resistant staphylococcus aureus infection and gastrostomy status. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/17/2024, revealed Resident 2 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident 2 had a feeding tube. Resident 2's care plan included a focus area, initiated 05/17/2024, that indicated the resident required enhanced barrier precautions (EBP) related to gastrostomy tube (G-tube) placement. Interventions directed staff to use gown and gloves during high contact resident care activities. Resident 2's Order Summary Report, that contained active orders as of 11/06/2024, revealed an order dated 08/07/2024, for EBP due to tube feeding every shift. During a concurrent observation and interview on 11/05/2024 at 9:20 AM, Registered Nurse (RN) 1 entered Resident 2's room to administer medications to the resident by way of a feeding tube. RN 1 wore gloves and no other personal protective equipment. RN 1 stated a gown was necessary because Resident 2 was on EBP precautions. During an interview on 11/06/2024 at 2:08 PM, the Director of Nursing (DON) stated EBP was initiated for residents at high risk and gowns were required. The DON stated RN 1 must use a gown during medication administration by way of a feeding tube for Resident 2. The DON stated she expected for the nurses to follow the protocols adopted by the facility to deliver diligent care and protect the residents. During an interview on 11/06/2024 at 2:33 PM, the Administrator stated staff must wear a gown when required and expected the staff to comply with the instructions and reach out to the charge nurse when in doubt. An undated facility policy titled, Enhanced Standard/Barrier Precautions, indicated, It is the policy of this facility to implement enhanced standard/barrier precautions for the prevention of transmission of multidrug-resistant organisms [MDRO]. Definitions Enhanced Standard/Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medication devices. Per the policy, c. Chacterisitics of Residents at High Risk for MDRO Colonization and Transmission Functional Disability: i. Presence of indwelling devices: urinary catheter, feeding tube, tracheostomy tube, vascular catheters Ventilator-dependence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056121 If continuation sheet Page 5 of 5