Health inspection·March 28, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observation, interview, and record review, the facility failed to allow two out of 27 Residents (Residents 45 and 70) to exercise their rights to self-determination when they were not provided nutrition in accordance with their preferences. These failures had the potential to result in Residents 45 and 70 feeling upset and disrespected. Findings: During a review of Resident 45's admission Record, printed 3/27/25, the record indicated Resident 45 was admitted to the facility in October 2021 with a diagnosis of constipation. During a review of Resident 45's Brief Interview for 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.), dated 1/22/25, the record indicated Resident 45's BIMS score was 15. During a review of Resident 70's admission Record, printed 3/27/25, the record indicated Resident 2 was admitted to the facility in June 2023 with a diagnosis of constipation. During a review of Resident 70's BIMS, dated 3/12/25, the record indicated Resident 70's BIMS score was 15. During a concurrent observation and interview on 3/24/25, at 1:03 p.m., in the facility dining room, Residents 61 and 70's lunch trays were observed without salad. Residents 61 and 70 stated they were supposed to get salads with their lunch, and they were upset because they did not get them. During a concurrent observation and interview on 3/24/25, at 3:31 p.m., with Resident 45, Resident 45's lunch tray was observed with cut tomatoes in their salad. Resident 45 stated they were not supposed to get tomatoes and did not eat their salad. Resident 45 stated they felt disrespected. During an interview on 3/28/25, at 10:50 a.m., with Registered Dietician (RD), RD stated it was important follow resident food choices so they would have felt comfortable and happy with the food and satisfied. During a review of Resident 70's Lunch Meal Ticket, dated 3/24/25, the Meal Ticket indicated, Resident 70's Likes: Salad with Lunch During a review of Resident 45's Lunch Meal Ticket, dated 3/24/25, the Meal Ticket indicated, Resident 45's Dislikes: .Tomato Products . Page 1 of 43 056280 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0561 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Dietary Profile and Resident Preference Interview, revised April 21, 2022, the P&P indicated, The Dietary Department will provide residents with meals consistent with their preferences and Physician order as indicated on the tray card. Residents Affected - Few 056280 Page 2 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on interview and record review, for one of six sampled residents (Resident 58) who were investigated for advance directives, the facility failed to ensure Resident 58 was afforded the right to formulate an advanced directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated). This failure had the potential to result in Resident 58's wishes for life-sustaining treatment not documented and respected. Findings: During a review of Resident 58's admission Record (AR), the AR indicated, Resident 58 was admitted to the facility in January 2025 with diagnoses that included chronic obstructive pulmonary disease. The AR also indicated Resident 58 was self-responsible, and two significant others, a sister and a friend, as emergency contacts. During a review of Resident 58's Minimum Data Set Assessment (MDS, an assessment tool used to direct resident care) dated 2/5/25 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During a concurrent interview and record review on 3/25/25 at 10:10 a.m. with Registered Nurse (RN) 2, RN 2 stated there is no copy of Resident 58's Physician Order for Life Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration) in the clinical record to show if Resident 58 had an advanced directive. RN 2 stated, should Resident 58 go into cardiac arrest, Resident 58 will be treated as Full Code (indicates that a patient wants their medical team to do everything possible to save their life in the event of a medical emergency, such as cardiac or respiratory arrest.) and all necessary life-saving treatments will be provided since there is no information about Resident 58's choices in the chart. During an interview on 3/27/25 at 11:20 a.m. with Resident 58, Resident 58 stated not having an advance directive but would like to make changes to current code status, if given the opportunity. Resident 58 also stated not wanting to have artificial nutrition and artificial ventilation/respiration and wanted to live a natural life. Resident 58 stated signing the pink paper while in the hospital but has not been offered to formulate an advanced directive since being admitted to the facility. During a joint interview on 3/27/25 at 11:23 a.m. with Resident 58 and Social Services Director (SSD), SSD stated a care conference meeting was held with Resident 58 and Resident 58's son right after Resident 58 was admitted to the facility. SSD stated Resident 58 at the time wanted to be Full Code. Resident 58 stated not recalling such meeting, and added Resident 58's son is not of legal age to make healthcare decisions. Resident 58 stated she wanted to change code status while still cognitively able to make those decisions. 056280 Page 3 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and review of Resident 58's clinical record on 3/27/25 at 11:52 a.m. with SSD, SSD stated there was no documentation in Resident 58's clinical record of a care conference meeting to discuss advance directive and Resident 58's choices of life-sustaining treatment. SSD also added it was not necessary to complete and keep a copy of a signed POLST form in the medical record. During a review of the facility's policy and procedure (P&P) tiled Physician Orders for Life-Sustaining Treatment (POLST) last revised 6/3/2020, the P&P indicated, a resident can change his/her mind about his/her treatment preferences by executing a verbal or written advance directive. 056280 Page 4 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to follow its policy and procedure to immediately report alleged abuse allegations to the California Department of Public Health (CDPH) and the Ombudsman within two hours for one of 27 sampled residents (Resident 92), when Resident 92's sister alleged a Registered Nurse (RN) called Resident 92 stupid. These failures had the potential to cause a delay in investigations and affect physical and psychological well-being of residents. Findings: A review of Resident 92's admission Record printed 3/27/25, indicated Resident 92 was admitted to the facility in September 2023 with a diagnosis of chronic pain. During an interview on 3/26/25, at 1:25 p.m. with RN 1, RN 1 stated, on 2/9/25 Resident 92's sister notified RN 1 that an unknown nurse called Resident 92 stupid. RN 1 stated they did not complete and submit a Report of Suspected Dependent Adult/Elder Abuse (SOC 341), to the ombudsman or CDPH. RN 1 stated they did not notify the ombudsman or CDPH of the alleged abuse. During an interview on 3/26/25, at 3:25 p.m. with Medical Records (MR), MR stated on 2/9/25 Resident 92's sister notified MR an unknown nurse called Resident 92 stupid. MR stated they did not complete and submit a SOC 341, to the ombudsman or CDPH. MR stated they did not notify the ombudsman or CDPH of the alleged abuse. During a concurrent interview and record review on 3/26/25, at 12:03 p.m., with Social Services Director (SSD), Resident 92's SOC 341, dated 2/10/25, was reviewed. SSD stated on 2/10/25, at approximately 5 p.m., Resident 92 notified SSD that RN 1 called Resident 92 stupid. SSD stated they completed the SOC 341, and notified the ombudsman and CDPH of the alleged abuse within 2 hours of the reported abuse. SSD stated their policy was to notify the ombudsman and CDPH within 2 hours of alleged abuse to protect the residents. During a review of the facility's policy and procedure (P&P) titled, Abuse - Reporting & Investigations, revised March 2018, the P&P indicated, Notifications of Outside Agencies of Allegation of Abuse With No Serious Bodily Injury . The Administrator or designated representative will notify within two (2) hours notify, by telephone, CDPH, the ombudsman and Law Enforcement . The Administrator or designated representative will send a written SOC341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within two (2) hours. 056280 Page 5 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.During a record review on 3/25/25 of Resident 37's Facesheet (FC), the FC indicated Resident 37 is [AGE] year old female admitted to the facility in 2021. The FC also indicated Resident 37 has diagnosis of Primary Osteoarthritis (a degenerative joint condition, causing pain, , swelling, stiffness that prevents a person from moving freely) Right Hip, Neuralgia (Nerve pain) and Neuritis (inflammation of the peripheral nerves), low Back Pain, and Arthropathy (disease of the joint). Residents Affected - Few During an observation and an interview on 3/25/25 at 11:20 a.m. in Resident 37's room, Lidocaine 5% patch medication was the packet, left open and unsupervised on Resident 37's bedside table. Resident 37 stated License Vocational Nurse (LVN) 2 had left the medication patch on her bedside table for her assigned Certified Nursing Aide (CNA) to apply the Lidocaine patch on her after assisting her with her morning Activity of Daily Living (ADL) care. Resident 37 stated she is legally blind and cannot see anything, neither the TV. During an interview on 3/25/25 at11:30 a.m. with LVN 2, LVN 2 stated the Lidocaine patch medication placed on Resident 37's bedside table was Resident 37's Lidocaine pain patch medication and that she had placed it on Resident 37's bedside table. LVN 2 further stated she should not have left the medication pain patch unattended on the table as there is a risk of a staff or another Resident picking up the medication and use it for non-intended uses. LVN 2 also stated she had signed for the medication in the Medication Administration Record (MAR) without administering the Lidocaine pain patch to Resident 37. During a record review on 3/25/25 at 11:57 a.m., of Resident 37's MAR, the MAR indicated Lidocaine External Patch 5% administration scheduled time at 8:00 a.m., and the MAR had been signed as given by LVN 2 at 8:00 a.m. During a record review on 3/25/25 at 12:00 p.m., of Resident 37's Physician Order Summary, the Physician Order Summary indicated Lidocaine External Patch 5 % (Lidocaine) to apply to lower back topically one time a day for pain management 12 on, 12 hours off, and remove per schedule, with a start date on 1/03/2025, and no end date. During a record review of facility's Policy and Procedure (P&P), the P&P title Medication-Administration dated 01/01/2021, indicated, Purpose .To ensure the accurate administration of medication for resident in the facility .-I. Medication will be administered directly by a licensed Nurse and upon the ordered a physician or licensed independent practitioner .-II. no medication will be used for any patient other than the patient for whom it was prescribed .1-B. The Licensed Nurse will prepare medications within one hour of administration .I. Medications may be administered one hour before or after the scheduled medication administration time . X. Documentation .A. The time and dose of the drug or treatment administration to the patient will be recorded in the patient's individual medication record y the person who administered the drug or treatment .B. Recording will include the date, the time and the dosage of the medication or type of treatment. Based on observation, interview and record review, the facility failed to provide services to meet professional standards of quality for two of two sampled residents (Resident 12 and 37) when: 1. Licensed Vocational Nurse (LVN) 1 was not knowledgeable of the correct indication, dosage, and administration procedure of Resident 12's rivastigmine (medication used to treat mild, moderate, and 056280 Page 6 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0658 Level of Harm - Minimal harm or potential for actual harm severe dementia (memory loss and mental changes) associated with Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills) transdermal (the application of a medicine or drug through the skin, typically by using an adhesive patch, so that it is absorbed slowly into the body) patch. These failures resulted in Resident 12 to receive inadequate dosage of rivastigmine and not according to manufacturer's specification. Residents Affected - Few 2. Resident 37's lidocaine patch (medication to ease pain by numbing the nerves and making them less sensitive to pain) was not applied per physician orders and left unsupervised at the bedside table. These failures resulted in Resident 37 to not receive lidocaine as ordered by the physician and potential for other residents to have access to unsupervised medication. These failures resulted in Resident 12 not receiving adequate dosage of rivastigmine according to manufacturer's specification and Resident 37 not receiving lidocaine as ordered and other residents to have access to unsupervised medication. Findings: 1. During a review of Resident 12's undated admission Record, the admission Record printed on 3/25/25 indicated, Resident 12 was admitted in the facility in [DATE] with a diagnosis of atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly), essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause) and dementia. During medication administration observation on 3/25/25 at 9:08 a.m. with LVN 1, LVN 1 was observed preparing three medications for Resident 12. These medications included one tablet of Eliquis (a blood thinner medicine that reduces blood clotting), one tablet of Metoprolol (a medication that lowers blood pressure and heart rate) and one Rivastigmine 13.3 milligram (mg)/24 hour (hr) transdermal patch. During a concurrent observation and interview, on 3/25/25 at 9:28 a.m. with LVN 1, in Resident 12's room, LVN 1 administered Resident 12's one tablet of Eliquis and one tablet of Metoprolol. LVN 1 applied one rivastigmine 13.3 mg/24 hr transdermal patch to Resident 12's left rear shoulder without removing the old patch. LVN 1 stated Resident 12's Rivastigmine transdermal patch that was applied the day before was removed by the evening nurse last night. LVN 1 stated the patch was applied to the left shoulder for pain. During a review of Resident 12's Order Summary Report dated 2/26/23, the Order Summary Report indicated, Resident 12 had an order to receive one transdermal patch of rivastigmine 13.3 mg/24 hr one time a day and remove per schedule for dementia. During a follow up concurrent interview and record review, on 3/25/25 at 3:01 p.m. with LVN 1, Resident 12's Medication Administration Record (MAR) dated 3/25/25 was reviewed. The MAR indicated, Resident 12's rivastigmine 13.3 mg/24 hr transdermal patch was to be removed at 08:59 a.m. and applied at 9:00 a.m. one time a day for dementia. LVN 1 stated the evening nurse removed the patch. LVN 1 stated the patch was applied to Resident 12's left rear shoulder because Resident 12 complained of left shoulder pain most of the time. During a review of Resident 12's March 2025 MAR, the MAR indicated, rivastigmine 13.3 mg/24 hr transdermal patch was applied on Resident 12's left rear shoulder on 3/9/25, 3/10/25, 3/12/25, 3/13/25, 056280 Page 7 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3/14/25, 3/15/25, 3/17/25, 3/18/25, 3/19/25, 3/20/25, 3/22/35, 3/23/25, 3/24/25 and 3/25/25. The MAR indicated, the site was not rotated as per manufacturer's guidelines. During a review of rivastigmine manufacturer's specification dated 5/24, the manufacturer's specification indicated, rivastigmine transdermal patch is indicated for the treatment of dementia of the Alzheimer's type . Apply patch on intact skin for a 24-hour period; replace with a new patch every 24 hours . Change the site of patch application daily to minimize potential irritation. (https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/022083s028lbl.pdf) During a review of facility's policy and procedure (P&P) titled, Medication-Administration, dated 1/1/12, indicated, A.ii. Medications will be administered as prescribed to ensure compliance with dose guidelines. 056280 Page 8 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

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, interviews, and record reviews, facility failed to provide assistant for one out of two sampled residents(Resident 193), when Resident 193 who is dependent on staff was not assisted with setting up his meal tray and given required assistant with eating during lunch period. Residents Affected - Few This failure resulted in Resident 193 not being able to eat and enjoy his meals at his own desire time, had his meal cold, challenges eating with his left non-dominant hand, and potential to not maintain good nutritional status and poor quality of care. Findings: During an observation and interview on 3/24/25 at 1:12 p.m.with Resident 193, Resident 193 was sitting up dangling at the bedside awaiting his lunch tray. Resident 193 had a white hard rubber cast to his right arm from his right shoulder down to his mid forearm, and a splint to the right arm down to his fingers. Resident 193 stated he had a gun shot wound to his right shoulder and abdomen which made it very difficult for him to feed himself with his left hand. Resident 193 demonstrated how challenging it was for him when he attempts to lift the spoon up to his mouth to feed himself. Resident 193 stated his hand trembles when he attempts to feed himself and would spill most of the food on himself and on the table or floor. Resident 193 stated he is left-handed only and is not able to open his fruit cup, milk and to chop up his meals. During an observation on 3/24/25 at 1:17 p.m., the Rehabilitation Nursing Assistant (RNA) 1 took Resident 193's lunch tray to his bedside table and left the room. During an observation on 3/24/25 at 1:39 p.m., Resident 193's was still sitting up at his bedside with his lunch tray on his bedside table and the lunch plate still covered. The milk and water were still covered with a ceramic plastic wrap. Resident 193's food not chopped to bite size. Resident 193 stated he cannot remove the plastic wrap use to cover his milk and water from both cups. Resident 193 stated no staff had come into his room to help him with his meals since his tray was served by the RNA. During an interview and observation on 3/24/25 at 1:44 p.m. with Minimum Data Set Coordinator (MDSC), Resident 193's milk and water was still covered with the ceramic plastic wrap, his food not chopped and still covered with the lid. MDSC stated Resident 193 should have been assisted with eating during lunch mealtime as he is one handed, he could only use one hand for now with his present medical condition and getting assistance from staff will make Resident 193 able to eat his food served at lunch. During a review on 3/24/25 of Resident 193's Facesheet (FC), FC indicated Resident 193 is [AGE] years old male newly admitted to the facility, less than 30 days. The FC further indicated Resident 193 has diagnosis of Displaced Comminuted Fracture (bone breaks into three or more fragments) of Shaft of Humerus (long bone of the upper arm from shoulder to the elbow), right arm, need for assistance with his personal care, muscle weakness (generalized), Protein-Calorie Malnutrition (poor nutrition), open wound of right upper arm, open wound of left forearm. During a review on 3/24/25 of Resident 193's Physician Order Summary (POS), the POS indicated, keep 056280 Page 9 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0676 brace on full time. Should remove brace for wound care and clean skin with an ordered date of 3/14/25. Level of Harm - Minimal harm or potential for actual harm During a review on 3/26/25 of Resident 193's Occupational Therapy Treatment Encounter Notes ([NAME]), (OT). Functional skills Assessment- Activities of Daily Living (ADLs) & instrumental ADLs . Eating . =Substantial/maximal assistance . 97535 . Pt noted with tremor with LUE when bringing hand to mouth. Pt provided education on bringing head to stationary utensil held by LUE, able to complete without tremor. Nursing informed and collaborated with nursing regarding pt need for supervision and occasional CGA for self-feeding tasks. Pt need assistance for cutting-up food at this time. Residents Affected - Few During an interview on 3/25/25 at 11:38 a.m. with OT, OT stated Resident 193 has been getting OT for the past one week. OT further stated Resident 193 needs contact guard (assistant to help support his hand),' with his meals. OT stated it is important Resident 193 gets the assistant he requires from staff as it is very challenging for Resident 193 when he tries to self-feed, without any staff supervision or assistant. 056280 Page 10 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

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, for one of four sampled residents (Resident 87) reviewed for anticoagulant use, the facility failed to provide treatment and care in accordance with professional standards of care when licensed nurses did not administer medications, enoxaparin sodium (Lovenox, an anticoagulant for DVT [a condition that occurs when a blood clot forms in a vein deep inside a part of the body that could potentially travel to the lungs and cause pulmonary embolism] prophylaxis) and omeprazole oral capsule (Prilosec, an antacid, treats gastro-esophageal reflux disease) as ordered by the physician. Residents Affected - Some This failure had resulted in Resident 87 experiencing heartburn (a burning sensation in the chest or upper abdomen caused by stomach acid backing up into the esophagus) and discomfort and had the potential to result in DVT from not receiving anticoagulant. Findings: During a review of Resident 87's admission Record and the Minimum Data Assessment (MDS, an assessment tool used to direct resident care) dated 2/20/25, the admission Record indicated Resident 87 was admitted to the facility on [DATE]. The MDS indicated Resident 87 had diagnoses that included gastro-esophageal reflux disease (GERD, is a common digestive disorder where stomach contents, including acid, flow back up into the esophagus, causing symptoms like heartburn and other digestive issues) and unspecified atrial fibrillation (Afib, an irregular heart rhythm that begins in your heart's upper chambers (atria). During a review of Resident 87's MDS dated [DATE], the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During a concurrent observation and interview on 3/24/25 at 10:07 a.m. with Resident 87, Resident 87 stated not being given injectable blood thinner for the past three days. Resident 87 stated staff said they ran out of supply. There was a round pill in a medication cup on Resident 87's nightstand. Resident 87 stated it was one of the two Tums (calcium carbonate, an over-the-counter antacid to treat GERD) that staff had given for heartburn. Resident 87 stated he told staff Tums did not work and asked for Prilosec instead, but staff said Prilosec was not available. During a review of Resident 87's Order Summary Report dated 3/25/25, the Order Summary Report indicated, a physician's order dated 2/13/25 for enoxaparin sodium injection solution prefilled syringe 40 milligram (mg) per 0.4 milliliter (ml) inject 0.4 ml subcutaneously one time a day for DVT prophylaxis (DVT prophylaxis, measures taken to prevent the formation of blood clots (thrombi) in the deep veins, typically in the legs) and omeprazole oral capsule delayed release give 1 tablet by mouth one time a day for GERD. The Order Summary Report did not indicate a physician's order for Tums. During a review of Resident 87's Medication Administration Record (MAR) for March 2025 on 3/25/25 at 10:54 a.m. the MAR indicated, Lovenox was not administered on 3/22/25, 3/23/25, 3/24/25 and 3/25/25. During an interview on 3/25/25 at 12:49 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated 056280 Page 11 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0684 Level of Harm - Minimal harm or potential for actual harm she had ordered Lovenox on 3/21/25, when she administered the last dose, only for her to return today, 3/25/25 to find Lovenox was still not available. LVN 2 stated, she had found out, pharmacy delivered the medication on 3/23/25 but was not brought to the correct station (Station 2), the medication was found in Station 1. LVN 2 stated Resident 87's clinical record did not indicate Resident 87's attending physician was not notified of the missed medications. Residents Affected - Some During a review of the Physician/PA/NP Note (Physician Assistant/Nurse Practitioner) dated 3/24/25, the Physician/PA/NP Note indicated, plan was for Resident 87 to continue to receive Lovenox for DVT prophylaxis and Prilosec for GERD. The note also indicated Resident 87 was at risk for falls, DVT and skin breakdown. During a review of the MARs for February 2025 and March 2025 on 3/25/25 at 1:52 p.m. the MAR for February 2025 indicated, an order for omeprazole oral capsule delayed release give 1 tablet by mouth one time a day dated 2/14/25. The medication was signed off by multiple staff on some days but was marked 9 on 2/18/25, 2/24/25, and 2/27/25. The MAR for March 2025 indicated the medication was marked 9 on the following dates: 3/4/25, 3/5/25, 3/6/25, 3/9/25, and 3/10/25; and was not signed off on the following dates: 3/14/25, 3/15/25, 3/19/25, 3/20/25, 3/21/25, 3/22/25, 3/23/25, 3/24/25 and 3/25/25. During a concurrent observation and interview on 3/25/25 at 3 p.m. with LVN 2, LVN 2 stated there was no omeprazole in the medication cart. LVN 2 stated, a 9 indicated the medication was not available for administration or the resident refused the medication. During a telephone interview on 3/25/25 at 3:30 p.m. with Pharmacy Technician (PhT), PhT stated facility staff need to request refills three days before the actual re-fill date. PhT stated Resident 87's Lovenox was delivered 3/23/25 but the omeprazole needed clarification with the prescribing physician because it did not indicate the strength. PhT stated facility staff were told to clarify the order with the physician, but facility did not follow-up, the medication was never delivered to the facility since Resident 87's admission in February 2025. During an interview on 3/26/25 at 11:50 a.m. with Resident 87, Resident 87 stated not receiving Prilosec since being admitted because staff said they did not have it. Resident 87 stated having heartburn and Tums did not help at all. 056280 Page 12 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview and record review, for two of four sampled residents (Resident 8 and Resident 9) who were reviewed for range of motion/mobility needs, the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion when Restorative Nursing Assistant (RNA) services ( RNA program, focuses on nursing interventions that help residents in long-term care maintain or regain their ability to perform activities of daily living (ADLs) and improve their overall well-being) was not provided as indicated in the comprehensive care plan. This failure had the potential to result in further decline in range of motion. Findings: During a review of Resident 8's admission Record (AR), the AR indicated, Resident 8 was admitted to the facility in July 2023 with diagnoses that included hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction affecting left non-dominant side. During an observation between 3/24/25 at 10:21 a.m. and 3/28/25 at 10:24 a.m., Resident 8 could not move or raise his left arm, contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) from the elbow down to wrist and fingers. During an interview on 3/28/25 at 10:26 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 8's left upper extremity has been contracted since she started working for facility in November 2024. LVN 2 stated she did not know if Resident 8 was on RNA program. During a review of Resident 8's range of motion care plan initiated 5/21/24, last revised 3/27/25, the care plan indicated, bilateral lower extremity active range of motion (the movement of a joint achieved by the patient's own muscle contractions, without external assistance) while seated on edge of bed as tolerated and for Resident 8 to participate in RNA program five times weekly. The care plan also indicated to observe for change in ROM (stiffness, tightness, and/or pain) and report to MD. During an interview on 3/28/25 at 10:32 a.m. with Restorative Nursing Assistant (RNA) 2, RNA 2 stated, Resident 8 used to be on RNA program for upper extremities in the past but not anymore and she did not know why. During a review of Resident 9's AR, the AR indicated Resident 9 was admitted to the facility in February 2024 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. During dining observation on 3/24/25 at 1:07 p.m., Resident 9 was in a reclining wheelchair being fed by a Certified Nursing Assistant (CNA). Resident 9 slumped on the right side of the wheelchair. During a review of Resident 9's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/16/25, the MDS indicated Resident 9 had functional limitation in range of motion on one side of the upper and lower extremity. The MDS also indicated, once seated in a wheelchair, 056280 Page 13 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 9 required substantial/maximal assistance (helper does, more than half the effort, helper lifts or holds trunk or limbs, and provides more than half the effort) to wheel at least 50 feet and make two turns. During a review of Resident 9's range of motion care plan initiated 5/22/24, last revised 2/6/25, the care plan indicated interventions to help Resident 9 maintain current joint range of motion and prevent contractures that included observing for change in range of motion such as stiffness, tightness, and/or pain, and for Resident 9 to participate in the RNA program three times weekly for bilateral lower extremities passive range of motion (the movement of a joint through its range of motion by an external force, like a therapist or a machine, without any effort from the individual, who remains relaxed) three sets of 10 repetitions as tolerated. During a concurrent observation and interview on 3/28/25 at 9:37 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated she did not know if Resident 9 was on RNA program. Resident 9 was transferred from the bed to wheelchair using a Hoyer lift (an assistive device that enables the movement, transfer, and positioning of an immobilized patient), not able to lift right leg to the footrest. Resident 9 slumped to the right side and not able to move right arm when prompted. During an interview on 3/28/25 at 9:48 a.m. with RNA 2, RNA 2 stated, Resident 9 was not on RNA program. During a review of the facility's policy and procedure (P&P) titled Restorative Program Guidelines last revised 9/19/19, the P&P indicated, The RNA carries out the restorative program according [to] the care plan. The RNA documents the frequency of the program, the amount of time the resident spent in the activity and their tolerance to the program .The Care Plan for each resident will be updated with any changes to the Restorative Nursing Program when they occur and reviewed quarterly or as needed . 056280 Page 14 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for two of 27 sampled residents (Resident 58 and Resident 90), the facility failed to ensure an environment that is free of accident hazards as possible, and that each resident receives adequate supervision when: 1.Resident 58's bed wheels did not lock. This failure had the potential to result in preventable falls. 2.Resident 90 was not supervised while out smoking. This failure had resulted in Resident 90 leaving the facility premises undetected. Resident 90's whereabouts remain unknown. Findings: 1. During a review of Resident 58's admission Record (AR), the AR indicated, Resident 58 was admitted to the facility in January 2025 with diagnoses that included epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures), hemiplegia (a condition characterized by paralysis or weakness on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) affecting left side, right foot drop and history of falling. During a review of Resident 58's Minimum Data Set Assessment (MDS, an assessment tool used to direct resident care) dated 2/5/25 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During an interview on 3/24/25 at 11:33 a.m. with Resident 58, Resident 58 stated the facility had exchanged her bed with another that had wheels that did not lock. Resident 58 stated being told by the management to wait for another resident to be discharged from the facility for her bed to be switched. Resident 58 stated being afraid she might fall off the bed as the bed moved whenever Resident 58 repositioned while in bed. During an interview on 3/24/25 at 11:36 a.m. with Environmental Service Director (ESD), ESD stated replacing Resident 58's bed frame two weeks ago and did not know of any current issues with the bed. 2. During a review of Resident 90's AR, the AR indicated Resident 90 was admitted to the facility on [DATE] with diagnoses that included old myocardial infarction (a medical emergency that occurs when blood flow to the heart muscle is blocked, causing damage or death of heart tissue), need for assistance with personal care, depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels) and history of traumatic brain injury (TBI, a brain injury caused by an external force, such as a blow to the head. TBIs can cause physical, cognitive, emotional, and behavioral effects). During a review of Resident 90's Clinical Admission dated 12/29/24, the Clinical Admission indicated Resident 90 was alert oriented x 3 (the patient knows their own identity/name, where they are/place, and the approximate time of day, date, and year). 056280 Page 15 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 3/27/25 at 2:27 p.m. with Regional Quality Management Consultant (RQMC), Resident 90's Elopement Evaluation dated 12/29/24 was reviewed. The Elopement Evaluation indicated an elopement score of 1.0 (score value of 1 or higher indicates risk of elopement). The Elopement Evaluation did not indicate any clinical suggestions or comments as these sections of the evaluation were left blank. RQMC stated the fact that Resident 90 was a new admit and was not accepting of current living condition added more risk for elopement. RQMC stated there should have been a baseline care plan to address elopement risk but there was no care plan in the clinical record. The following were documentation by multiple staff on 12/30/24. -At 13:32, Orders-Administration Note, Resident eloped from facility. -At 13:33, Orders-Administration Note, Resident eloped from facility. -At 14:46, Case Management, late entry, CM (Case Manager) spoke with resident earlier in the day and introduced herself and arranged for an IDT (Interdisciplinary team, a group composed of individuals from different departments of the facility) meeting for this afternoon. Resident agreed to meeting and time. Once CM went to inform resident of meeting Charge Nurse made CM aware that resident had requested to have a cigarette around noon and resident has not been seen since. -At 15:35, Physician/PA (Physician Assistant)/NP (Nurse Practitioner) Note, [Resident 90] was seen and examined .IDT, SS, and nursing notes reviewed . -At 17:21, Health Status Note, Resident alert and verbally responsive, VS (vital signs) within normal limits. All due meds (medications) given and tolerated well. Resident left facility around 12 noon. MD, Administrator, and police notified. -At 19:46, Orders-Administration Note, Resident out for elopement. -At 22:17, Orders-General Note from eRecord, There is no patient to chat. -At 22:53, Orders-Administration Note, Resident elope & didn't come back to the facility. -At 00:21, Orders-General Note from eRecord, Patient is not available. During a concurrent interview and review of Resident 90's clinical record on 3/27/25 at 2:49 p.m. with RQMC, RQMC stated the staff's documentation was incomplete and did not indicate details on how and when Resident 90 left the facility. RQMC also stated the Social Services Director (SSD) at the time should have called the resident or any family member listed on file to know where Resident 90 was. The clinical record did not indicate if there was any investigation done to find Resident 90. RQMC stated, at the time of survey, facility did not know where Resident 90 was. During a review of the facility's policy and procedure (P&P) titled Wandering and Elopement last revised 1/31/23, the P&P indicated, the licensed nurse will assess the resident upon admission to determine their risk of elopement and preventative interventions will be documented in the resident's clinical record. The facility staff member who finds the resident is missing will alert facility staff, the charge nurse will make an announcement in the facility and organize a search including common areas, bathrooms, showers, closets, other residents' rooms, and outside areas. A staff will be 056280 Page 16 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assigned to perform a perimeter search around the exterior of the building to ensure the missing resident is not behind any structures. If the resident cannot be found, the charge nurse will notify the Administrator, Director of Nursing, Attending Physician, Responsible Party, and Local Law Enforcement. The Administrator will continue to work with law enforcement and the responsible party until the resident is located. The licensed nurse most familiar with the incident will document in the resident's clinical record the details of the elopement. 056280 Page 17 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0692 Provide enough food/fluids to maintain a resident's health. 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 eight sampled residents (Resident 87) reviewed for nutrition and hydration concerns, the facility failed to ensure Resident 87 maintained proper hydration status when fluid restriction was not followed as ordered. Residents Affected - Few This failure had the potential to result in fluid retention and fluid overload. Findings: During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility in February 2025 with diagnoses that included congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively). During a review of Resident 87's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/8/25 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During a review of Resident 87's Order Summary Report dated 3/25/25, the Order Summary Report indicated a physician's order dated 2/28/25 for fluid restriction 2000 milliliters (ml) per day and to Monitor intake and output every shift for Fluid Restrictions, if taking less or more than 2000 ml per day, or having congestions, notify MD. During a review of Resident 87's nutritional problem care plan dated 2/14/25, the care plan indicated for staff to monitor intake and output every meal. During a concurrent interview and record review on 3/26/25 at 11:42 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 87's clinical record and Medication Administration Record (MAR) for March 2025 were reviewed. LVN 2 stated Resident 87 was not on fluid restriction. Review of [DATE] indicated an order for intake monitoring every shift that were signed off by multiple licensed nurses that included LVN 2. LVN 2 then stated, Well, I guess [Resident 87] is on fluid restriction. During a concurrent observation and interview on 3/26/25 at 11:50 a.m. with Resident 87, there were two pink water pitchers on the over-the-bed table and two full glasses of dark pink liquid. Resident 87 stated always having water pitcher at the bedside which were routinely re-filled by staff with water and some ice. Resident 87 stated not being told by staff to limit fluid intake. During a concurrent interview and review of clinical record on 3/26/25 at 1:11 p.m. with Regional Quality Management Consultant (RQMC), MAR for March 2025 was reviewed. RQMC stated, if a resident is on fluid restriction, the resident's intake should be monitored and documented in the MAR to be able to see at a single glance how much fluids the resident received in a 24-hour period. RQMC stated there should be no water pitchers at the bedside. During an interview on 3/26/25 at 1:15 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she re-filled the water pitchers for Resident 87 twice in an eight-hour shift. CNA 1 stated Resident 87 usually drank half of the water from the pitchers and CNA 1 would give a new pitcher with water and ice. CNA 1 stated she documented Resident 87's fluid intake from the fluids (juices and coffee) 056280 Page 18 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few served during meals but not from the water pitchers. CNA 1 stated she did not know Resident 87 was on fluid restriction. During a concurrent interview and review of clinical record on 3/28/25 at 11:34 a.m. with Registered Dietician (RD), Resident 87's Nutritional Risk Assessment dated 2/14/25 and Nutrition/Dietary Note dated 3/7/25 were reviewed. Nutritional Risk Assessment indicated nutritional intervention to receive a total of 1280 ml from dietary, from three meals a day, and a total of 720 ml from nursing. RD stated Resident 87 should not have a water pitcher at the bedside to be able to restrict fluid intake. RD stated the Nutrition/Dietary Note indicated Resident 87 gained 11 pounds over 30 days. RD stated the significant weight gain could be associated with Resident 87 drinking more than allowed. During a review of the facility's policy and procedure (P&P) titled Fluid Restrictions last revised 4/21/22, the P&P indicated residents on fluid restriction will be monitored for intake and will receive appropriate interventions to alleviate discomfort from the fluid restriction for the duration of the Attending Physician order. The licensed nurse will: educate resident regarding fluid restriction, initiate strict intake measurement per the Attending Physician order, remove the water pitcher and notify care givers of the fluid restriction, monitor for compliance with the fluid restriction, record any fluids given on the Intake and Output record, total the amount of fluid each 24 hours and compare it with Fluid Restriction Guidelines, review Intake and Output weekly and address the adequacy of fluids and accuracy of documentation, document fluid restriction outcomes, Intake and Output, and compliance, in the resident's medical record. The CNAs will record all fluid Intake and Output in the medical record. 056280 Page 19 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews for one of two residents( Resident 83), facility failed to follow their policy and procedure when nursing staff infused Resident's 83's Jevity tube feed at the correct rate and dose as per the Physician's order, stopped Resident 83's Percutaneous endoscopic gastrostomy (PEG[a tube that is passed into a patient's stomach sugically through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate]) tube feedings without flushing the PEG immediately after, and left the tubing connected to Resident 83 for up to one hour after the infusion was completed. This failure has the potential for Resident 83's PEG tube to clog up, complications with PEG tube, infection, possible tube replacement, and hospitalization. Findings: During a review of resident 83's Facesheet (FC), FC indicated Resident 83 is [AGE] years old admitted to the facility in January 2025. The FC further indicated Resident 83 has a diagnosis Dysphasia (difficulty swallowing) following non-Traumatic Intracerebral Hemorrhage (brain bleed), Aphasia (loss of ability to understand or express speech), Hemiplegia (paralysis on one side of the body), Hemiparesis (weakness on one side of the body), Protein-Calorie Malnutrition, Encounter for Attention to Gatrostomy During an observation on 03/26/25 at 10:09 a.m. Resident 83's Jevity 1.2 Kilocalories (Kcal) tube feed infusing via pump at 75 ml/hr, infusion was almost completed. Jevity bottle had about 10 ml remaining to empty. Resident 83 was awake in bed getting physical therapy (PT) treatment. During an observation on 3/26/25 at 10:18 a.m., Jevity tube feeding was completed, tube feed pump turned off, tube feed still connected to Resident, not flushed, Resident 83 lying in bed resting. During an interview and an observation 3/26/25 at 11:03 a.m., with Director of Nursing (DON), Jevity tube feed was observed. DON stated Jevity tube feed remained connected to Resident 83, pump was turned off with enteral Jevity 1.2 feeding in the tubing line with some air bubbles above the tubing line. During an interview and an observation 3/26/25 at 11:06 a.m. with License Vocational Nurse (LVN) 2, LVN 2 and DON, LVN 2 stated she had turned off the pump few minutes ago. When further interviewed LVN 2 stated she had turned off the pump about 30 minutes ago after it was set on the pump to be completed. LVN 2 stated the orders for Resident 83's tube feeding, is to turn the pump off at 10:00 a.m. LVN 2 stated the facility's process is after tube feeding infusing, the pump should be turned off, tubing disconnected from the resident, and to flush PEG tube immediately after to clear the G tube line and to make sure no build up or clog occurs in the G tube. LVN 2 stated Resident 83's Jevity 1.2 KCal pump was infusing 60ml/hr. LVN 2 turned on the tube feed pump and the previous pump program settings was at 75ml/hr. LVN 2 stated the pump was supposed to have been infusing at 60 ml/hr as per Physician orders. LVN 2 stated there are two different orders for Jevity tube feeding in the Resident chart. During a record review (RR) on 3/26/25 at 11:20 a.m., of Resident 83's Physician Order Summary 056280 Page 20 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (POS), the POS indicated two active orders for Jevity tube feedings. Jevity 1.2 Cal at 60 ml/hr, order date 3/22/25 with no stop date. Jevity 1.5 Cal at 75ml/hr ordered date 1/15/25 with no end date. During a RR on 3/26/25 at 11:26 a.m. with Minimum Data Sheet Coordinator (MDSC) stated the order for Jevity 1.2 Cal at 75ml/hr should have been discontinued prior to entering the 60 ml/hr infusing order to prevent the risk of administering Resident 83's feeding at wrong dose rate. MDSC stated the facility's protocol is to flush tubing line before and after each infusion to prevent the G tube from clogging. During an observation and an interview on 3/26/25 11:30 AM with MDSC, Resident 83's Jevity bag label indicated as Jevity 1.2 Cal, dated on 3/25/25, start time at 5:00p.m., infusion rate at 75ml/hr. During a review and an interview on 3/25/25 at 11:26 a.m., of Resident 83's Order Summary Report (OSR) with MDSC, the OSR indicated, enteral feed order every shift flush tube (type) with 200 ml water, start date 1/15/2025. Enteral feed order every shift observe for signs and symptoms of infection to stoma site and notify MD prn, start date 1/15/2025. Flush tube GT with 30 ml water before and after medication administration. Flush GT with 10 ml of water in-between medication administration every shift, order date 1/15/25, start date 1/15/25. Enteral feed order two times a day, Jevity 1.2 Cal at 75ml/hr via pump x 20 hr = 1500 ml/24 hr 1800 calories 24hr via PEG tube continuously until feeding completed for indications/dx of Dysphagia. On at 2 PM, off at 10 AM. Order date 1/15/25, start date 1/15/25. Jevity 1.5 Cal at 60 ml/hr via pump x 20 hr = 1200 ml/24hr 1800 calories 24hr via PEG tube continuously until feeding completed by indication/dx of Dysphagia. On at 2 p.m., off at 10AM. Order date 3/22/25. MDSC stated the most current order is Jevity 1.5 Cal at 60 ml/hr, and the order for 75ml/hr should have been discontinued prior to entering the new order of Jevity 1.5 Cal at 60ml/hr because Resident cannot have double Jevity orders in the chart. MDSC stated this will prevent errors. During an interview on 3/28/25 at 10:47 a.m. with Registered Dietitian (RD), RD stated Jevity 1.5 Cal at 60 ml/hr has more calories, so it requires lesser flow rate. RD stated Jevity at 60 ml/hr will give lesser flow rate meaning less fluid volume to meet the same calorie need. During a review of facility policy & procedures (P&P), P&P titled, P-NP 135 Enteral Management: Gastrostomy Tube-Jejunostomy Tube, dated 2022, the (P&P) indicated, policy . to maintain patency and safety of enteral tubes feeding before initiating enteral feeding, hydration, and medication administration . 6vi. Note the tube may become obstructed with gastric contents, feeding formula, or crushed medication, making aspiration difficult. 056280 Page 21 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility on [DATE] with diagnoses that included gastro-esophageal reflux disease (GERD, is a common digestive disorder where stomach contents, including acid, flow back up into the esophagus, causing symptoms like heartburn and other digestive issues) and unspecified atrial fibrillation (Afib, an irregular heart rhythm that begins in your heart's upper chambers (atria). During a review of Resident 87's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/8/25 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During a concurrent observation and interview on 3/24/25 at 10:07 a.m. with Resident 87, Resident 87 stated not being given injectable blood thinner for the past three days. Resident 87 stated staff said they ran out of supply. There was a round pill inside a medication cup on Resident 87's nightstand. Resident 87 stated it was one of the two Tums that a nurse had given for heartburn. Resident 87 stated he told staff Tums did not work and asked for Prilosec instead, but staff said Prilosec was not available. During a review of Resident 87's Order Summary Report dated 3/25/25, the Order Summary Report indicated a physician's order dated 2/13/25 for enoxaparin sodium (Lovenox, an injectable anticoagulant, prevents blood from clotting) injection solution pre-filled syringe 40 milligram (mg) per 0.4 milliliter (ml) inject 0.4 ml subcutaneously one time a day for DVT (a condition where a blood clot forms in a deep vein, most commonly in the legs, but can also occur in the arms or other veins) prophylaxis (DVT prophylaxis, measures taken to prevent the formation of blood clots (thrombi) in the deep veins, typically in the legs) and omeprazole oral capsule delayed release give 1 tablet by mouth one time a day for GERD. There was no physician's order for Tums (calcium carbonate, an antacid to treat GERD). During a review of Resident 87's Medication Administration Record (MAR) for March 2025 on 3/25/25 at 10:54 a.m., the MAR indicated Lovenox was not administered on 3/22/25, 3/23/25, 3/24/25 and 3/25/25. During an interview on 3/25/25 at 12:49 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she had ordered Lovenox on 3/21/25, when she administered the last dose, only for her to return today, 3/25/25 to find Lovenox was still not available. LVN 2 stated pharmacy delivered the medication on 3/23/25 but was not brought to the correct Station. LVN 2 stated Resident 87's clinical record did not indicate Resident 87's attending physician was not notified of the missed medications. During a review of the MARs for February 2025 and March 2025 on 3/25/25 at 1:52 p.m., the MAR for February 2025 indicated omeprazole was signed off by multiple staff and was marked 9 on 2/18/25, 2/24/25, and 2/27/25. The MAR for March 2025 indicated the medication was marked 9 on the following dates: 3/4/25, 3/5/25, 3/6/25, 3/9/25, and 3/10/25; and was not signed off on the following dates: 3/14/25, 3/15/25, 3/19/25, 3/20/25, 3/21/25, 3/22/25, 3/23/25, 3/24/25 and 3/25/25. During a concurrent observation and interview on 3/25/25 at 3 p.m. with LVN 2, LVN 2 stated there 056280 Page 22 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was no omeprazole in the medication cart. LVN 2 stated, 9 indicated the medication was not available for administration or the resident refused the medication. During a telephone interview on 3/25/25 at 3:30 p.m. with Pharmacy Technician (PhT), PhT stated facility staff need to request refills three days before the actual re-fill date. PhT stated Resident 87's Lovenox was delivered 3/23/25 but the omeprazole needed clarification with the prescribing physician because it did not indicate the strength. PhT stated facility staff were told to clarify the order with the physician, but facility did not follow-up, the medication was never delivered since Resident 87's admission to the facility in February 2025. During a review of the facility's policy and procedure (P&P) titled Medication Ordering and Receiving From Pharmacy effective April 2008, the P&P indicated: when ordering medications from the pharmacy, medication orders are written on a medication order form written by the physician or authorized personnel and transmitted to the pharmacy that includes; date ordered, resident's name and other identifying information, medication name and strength when indicated, and directions for use. Repeat medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing it on the order form and ordered as follows: reorder medication five days in advance of need to assure as adequate supply is on hand. Based on observation, interview and record review, the facility failed to provide pharmaceutical services which includes procedures that assure the accurate acquiring, receiving, dispensing, and administering of routine and emergency medications to meet the needs of three out of six sampled residents (Resident 12, 16 and 87) and to ensure controlled medication (those with high potential for abuse and addiction) were fully accounted for two out of three sampled residents (Resident 58 and 72) when: 1. Resident 12's Digoxin (medication to treat congestive heart failure [CHF, a condition where the heart muscle is weakened and cannot pump blood effectively]and heart rhythm problems), Furosemide (medication used to treat fluid build-up and swelling caused by CHF, . and treats high blood pressure) and Jardiance (medication used to help lower blood sugar levels in people with type 2 diabetes (a chronic condition where the body does not use insulin [a hormone produced by the pancreas that plays a crucial role in regulating blood sugar levels] effectively or does not produce enough insulin to regulate blood sugar levels) and Resident 16's Gabapentin (medication to treat nerve pain) were not available for administration. 2. Controlled medications for Residents 58 and 72 were not documented accurately in the MAR and accountability record. These failures resulted in inaccurate accountability of controlled medications and potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purpose not intended by the prescriber) of controlled medications. 3. One out of one oral emergency medication kit was open and not re-ordered timely. 4. Resident 87's antacid and anticoagulant medications were not available. These failures resulted in Resident 87 to not receive medications as ordered by the physician These failures resulted in multiple residents not receiving medications as ordered by the physician and also had the potential for facility residents with a census of 91 to not receive emergency medications when needed. 056280 Page 23 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0755 Findings: Level of Harm - Minimal harm or potential for actual harm 1 a. During a review of Resident 12's undated admission Record, the admission Record printed on 3/25/25 indicated, Resident 12 was admitted in the facility in January 2016 with a diagnosis of atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly), essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause), heart failure and dementia. Residents Affected - Some During a concurrent medication administration observation and interview on 3/25/25 at 9:08 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed preparing and administering only three medications out of 6 scheduled medications for Resident 12. LVN 1 stated Resident 12's Digoxin, Furosemide and Jardiance medications were not available for administration. LVN 1 stated she would re-order the medications from the pharmacy. During a review of Resident 12's Order Summary Report dated 1/31/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of Digoxin 125 micrograms (mcg) one time a day for CHF. During a review of Resident 12's Order Summary Report dated 4/27/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of Furosemide 40 milligrams (mg) two times a day for CHF. During a review of Resident 12's Order Summary Report dated 4/27/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of Jardiance 10 mg one time a day for type 2 diabetes. During a concurrent interview and record review, on 3/26/25 at 3:08 p.m. with LVN 1, Resident 12's Medication Administration Record (MAR), dated 3/25/25 was reviewed. The MAR indicated, LVN 1 documented number 9 on Resident 12's Digoxin, Furosemide and Jardiance. LVN 1 stated the number 9 meant the medication was not given and was not available. LVN 1 stated Digoxin prevented decreased or increased heart rate. LVN 1 stated Furosemide reduced fluids from the body. LVN 1 stated Jardiance lowered blood sugar level. 1 b. During a review of Resident 16's undated admission Record, the admission Record printed on 3/27/25 indicated, Resident 16 was admitted in the facility in June 2013 with a diagnosis of polyneuropathy (damage or disease affecting peripheral nerves (nerves that extend from the brain and spinal cord to the rest of the body, such as the arms, legs, and organs) in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain). During a review of Resident 16's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 1/25/25, the MDS indicated, Resident 16 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 15 out of 15, indicating intact cognitive status. During an interview on 3/24/25 at 11:53 a.m. with Resident 16, in Resident 16's room, Resident 16 stated he doesn't get his pain medication on time. Resident 16 stated the nurses would tell him the medication was coming but did not get it. 056280 Page 24 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/24/25 at 12:18 p.m. with LVN 1, LVN 1 stated Resident 16's Gabapentin medication was not available for administration at 2:00 p.m. LVN 1 stated she would re-order the medication from the pharmacy. During a concurrent interview and record review, on 3/26/25 at 3:08 p.m. with LVN 1, Resident 16's MAR, dated 3/24/25 was reviewed. The MAR indicated, LVN 1 documented number 9 on Resident 16's gabapentin scheduled at 2:00 p.m. LVN 1 stated the number 9 meant the medication was not given and was not available. During a review of Resident 16's Order Summary Report dated 2/10/22, the Order Summary Report indicated, Resident 12 had an order to receive one capsule of Gabapentin 400 mg three times a day at 6:00 a.m., 2:00 p.m. and 08:00 p.m. for neuropathy. During a review of facility's policy and procedure (P&P) titled, Medication-Administration, dated 1/1/12, indicated, A.ii. Medications will be administered as prescribed to ensure compliance with dose guidelines. 2 a. During a review of Resident 58's undated admission Record, the admission Record printed on 3/28/25 indicated, Resident 58 was admitted in the facility on 1/29/25 with a diagnosis of anxiolytic (medications used to treat anxiety disorders and reduce anxiety symptoms) dependence. During a concurrent interview and record review, on 3/28/25 at 11:29 a.m. with the MDSC, Resident 58's March 2025 MAR and Individual Narcotic (Controlled Medication) Record (an inventory sheet that keeps record of the usage of controlled medications) dated 2/7/25 and 2/23/25 was reviewed. The MAR and Individual Narcotic Record indicated, one tablet of Lorazepam (medication used to treat anxiety disorders) 0.5 mg was given to Resident 58 when the order was to give two tablets. The MDSC stated the documentation in the MAR and the narcotic record should match. During a review of Resident 58's Order Summary Report dated 2/15/25, the Order Summary Report indicated, Resident 58 had an order to receive two tablets of Lorazepam 0.5 mg every 12 hours as needed for anxiety. 2 b. During a review of Resident 72's undated admission Record, the admission Record printed on 3/28/25 indicated, Resident 72 was admitted in the facility on 1/19/24 with a diagnosis of osteoarthritis (occurs when the flexible, protective tissue at the ends of bones, called cartilage, wears down, resulting in pain) of hip. During a concurrent interview and record review, on 3/28/25 at 11:19 a.m. with the MDSC, Resident 72's March 2025 MAR and Individual Narcotic Record dated 3/2/25 was reviewed. The Individual Narcotic Record indicated, one table to hydrocodone-acetaminophen (controlled medication to treat pain) 10 mg-325 mg was given to Resident 72 at 07:15 a.m. The MAR was blank and was not documented. The MDSC stated the nurses should document the administration of the medication in both the MAR and narcotic record to show the medication was given to the resident. During a review of Resident 72's Order Summary Report dated 1/2/25, the Order Summary Report indicated, Resident 72 had an order to receive one tablet of hydrocodone-acetaminophen every six hours as needed for moderate to severe pain. During a review of facility's P&P titled, Preparation and General Guidelines-Controlled 056280 Page 25 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0755 Level of Harm - Minimal harm or potential for actual harm Medications, dated 8/14, indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substance are subject to special . recordkeeping in the facility, in accordance with federal and state laws and regulations . C. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR). Residents Affected - Some 3. During a concurrent observation and interview, on 3/26/25 at 12:23 p.m. with the MDSC, in the medication room, a gray container with label oral emergency kit had a yellow plastic security seal zip tie. The MDSC stated the yellow plastic security zip tie meant the emergency kit was opened, and a medication was taken out. The MDSC was unable to identify when the emergency kit was opened or what medication was taken out. During a follow up concurrent observation and interview on 3/26/25 at 12:25 p.m., with the MDSC, in the medication room, the MDSC cut the yellow plastic security seal zip tie of the emergency kit. The MDSC removed a paper from the emergency kit with label Emergency Kit Pharmacy Log. The MDSC stated the white paper copy of the log should be kept by the facility and the yellow paper copy should be inside the emergency kit. During a concurrent interview and record review on 3/26/25 at 12:27 p.m. with the MDSC, the Emergency Kit Pharmacy Log, dated 3/23/25 was reviewed. The log indicated, one tablet of sulfamethoxazole/trimethoprim (a combination antibiotic used to treat various bacterial infections) was removed from the emergency kit at 04:00 p.m. The MDSC was unable to identify when the emergency kit was re-ordered. The MDSC stated the emergency kit should be re-ordered as soon as it was opened. The MDSC stated timely re-ordering of emergency kit ensured medications was available when needed. During a review of facility's P&P titled, Medication Ordering and Receiving from Pharmacy, dated 8/14, indicated, I. As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the emergency drug supply. 056280 Page 26 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medication error rate was less than 5% when four medication errors out of 26 opportunities were observed during the medication administration for two out of five sampled residents (Resident 12 and 56). Residents Affected - Some 1.Resident 12 did not receive Digoxin (medication to treat congestive heart failure (CHF, a condition where the heart muscle is weakened and cannot pump blood effectively) and heart rhythm problems), Furosemide (medication used to treat fluid build-up and swelling caused by CHF, . and treats hypertension (high blood pressure)) and Jardiance (medication used to help lower blood sugar levels in people with type 2 diabetes (a chronic condition where the body does not use insulin (a hormone produced by the pancreas that plays a crucial role in regulating blood sugar levels) effectively or does not produce enough insulin to regulate blood sugar levels) as ordered by the physician. 2. Resident 56 did not receive Vitamin D as ordered by the physician. These failures resulted in a medication error rate of 15.38%. Findings: 1. During a review of Resident 12's undated admission Record, the admission Record printed on 3/25/25 indicated, Resident 12 was admitted in the facility in June 2016 with a diagnosis of atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly), essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause), heart failure and dementia. During a concurrent medication administration observation and interview on 3/25/25 at 9:08 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed preparing and administering only three medications out of 6 scheduled medications for Resident 12. LVN 1 stated Resident 12's Digoxin, Furosemide and Jardiance medications were not available for administration. LVN 1 stated she would re-order the medications from the pharmacy. During a review of Resident 12's Order Summary Report dated 1/31/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of digoxin 125 micrograms (mcg) one time a day for CHF. During a review of Resident 12's Order Summary Report dated 4/27/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of furosemide 40 milligrams (mg) two times a day for CHF. During a review of Resident 12's Order Summary Report dated 4/27/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of Jardiance 10 mg one time a day for type 2 diabetes. During a concurrent interview and record review, on 3/26/25 at 3:08 p.m. with LVN 1, Resident 12's Medication Administration Record (MAR), dated 3/25/25 was reviewed. The MAR indicated, LVN 1 documented number 9 on Resident 12's Digoxin, Furosemide and Jardiance. LVN 1 stated the number 9 meant the medication was not given and was not available. LVN 1 stated Digoxin prevented decreased or 056280 Page 27 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some increased heart rate. LVN 1 stated Furosemide reduced fluids from the body. LVN 1 stated Jardiance decreased blood sugar level. 2. During a review of Resident 56's undated admission Record, the admission Record printed on 3/25/25 indicated, Resident 56 was admitted in the facility in [DATE] with a diagnosis of systemic lupus erythematosus (disease where the body's immune system mistakenly attacks its own healthy tissues and organs). During a concurrent medication administration observation and interview, on 3/25/25 at 8:36 a.m., with LVN 1, LVN 1 was observed preparing and administering five medications for Resident 12. These medications included one tablet of folic acid (a B vitamin that helps the body make healthy new cells) 1 mg, one tablet of Vitamin D3 25 mcg and one drop of Timolol, Brimonidine and Dorzolamide (medications to treat increased pressure in the eye) eye drop to left and right eye. During a review of Resident 56's Order Summary Report dated 7/4/23, the Order Summary Report indicated, Resident 56 had an order to receive one tablet of Vitamin D3 50 micrograms (mcg) one time a day for supplement. During a concurrent interview and record review on 3/25/25 at 2:59 p.m. with LVN 1, Resident 56's MAR dated 3/25/25, was reviewed. The MAR indicated; Resident 56 was to receive one tablet of Vitamin D3 50 micrograms (mcg) one time a day for supplement. LVN 1 stated two tablets of Vitamin D3 25 mcg should have been given to Resident 56. LVN 1 stated Resident 56 did not receive the correct dosage of Vitamin D3. LVN 1 stated Vitamin D3 supplement prevents Vitamin D3 deficiency. During a review of facility's policy and procedure (P&P) titled, Medication-Administration, dated 1/1/12, indicated, A.ii. Medications will be administered as prescribed to ensure compliance with dose guidelines. 056280 Page 28 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication error for one of five sampled residents (Resident 12) during medication administration observation when: Residents Affected - Few 1. Resident 12 did not receive Digoxin (medication to treat congestive heart failure (CHF, a condition where the heart muscle is weakened and cannot pump blood effectively) and heart rhythm problems) and Furosemide (medication used to treat fluid build-up and swelling caused by CHF and treats high blood pressure) as ordered by the physician. 2. Resident 12's physician was not informed of the significant medication error. These failures resulted in Resident 12 to experience significant medication error from the omitted (a dose of medication that is ordered but not given) dose of digoxin and furosemide. Findings: 1. During a review of Resident 12's undated admission Record, the admission Record printed on 3/25/25 indicated, Resident 12 was admitted in the facility in January 2016 with a diagnosis of atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly), essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause), heart failure and dementia. During a concurrent medication administration observation and interview, on 3/25/25 at 9:08 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed preparing and administering three medications for Resident 12. These medications included one tablet of Eliquis (a blood thinner medicine that reduces blood clotting), one tablet of Metoprolol (a medication that lowers your blood pressure and heart rate) and one Rivastigmine transdermal patch. LVN 1 stated Resident 12 should also be given Digoxin and Furosemide medications at this time, but they were not available. LVN 1 stated she would re-order the medications from the pharmacy. During a review of Resident 12's Order Summary Report dated 1/31/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of Digoxin 125 micrograms (mcg) one time a day for CHF. During a review of Resident 12's Order Summary Report dated 4/27/24, the Order Summary Report indicated, Resident 12 had an order to receive one tablet of Furosemide 40 milligrams (mg) two times a day for CHF. During a concurrent interview and record review, on 3/26/25 at 3:08 p.m. with LVN 1, Resident 12's Medication Administration Record (MAR), dated 3/25/25 was reviewed. The MAR indicated, LVN 1 documented number 9 on Resident 12's digoxin and furosemide. LVN 1 stated the number 9 meant the medication was not given and was not available. LVN 1 stated digoxin prevented decreased or increased heart rate. LVN 1 stated furosemide reduced fluids from the body. 2. During a review of Resident 12's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 1/16/25, the MDS indicated, Resident 12 had a Brief Interview for Mental Status (BIMS, is a scoring system used 056280 Page 29 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0760 Level of Harm - Minimal harm or potential for actual harm to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 12 out of 15, indicating moderate impaired cognitive status. During an interview on 3/27/25 at 8:50 a.m., with Resident 12, in Resident 12's room, Resident 12 stated she was not informed Digoxin and Furosemide were not available and were not given. Residents Affected - Few During a concurrent interview and record review on 3/27/25 at 2:47 p.m. with LVN 3, Resident 12's Progress Notes dated 3/25/25 was reviewed. The 'Progress Notes indicated, Resident 12 and Resident 12's physician were not informed of Digoxin and Furosemide not administered. LVN 3 stated Resident 12 and Resident 12's physician should have been informed as soon as the medications were found to be unavailable. During a review of facility's policy and procedure (P&P) titled, Medication-Errors, dated 7/18, indicated, I. All errors related to the administration of medications will be reported to the . attending physician . immediately . II. Medication error means the administration of medication . C. At the wrong dose . I.A. The Director of Nursing Services (DNS) will notify the Attending Physician, resident, and responsible party of the medication error. 056280 Page 30 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for one of six sampled residents (Resident 87), the facility failed to provide menus that meet residents' nutritional needs when Resident 87 was not provided double portion as ordered. This failure had the potential to result in weight loss. Findings: During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility on [DATE] with diagnoses that included gastro-esophageal reflux disease (GERD, is a common digestive disorder where stomach contents, including acid, flow back up into the esophagus, causing symptoms like heartburn and other digestive issues) and unspecified protein-calorie malnutrition. During a review of Resident 87's Order Summary Report dated 3/25/25, the Order Summary Report indicated a physician's order dated 2/24/25 for No Added Salt (NAS) diet regular texture, regular consistency double portion with extra gravy/sauce. During a review of Resident 87's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/8/25 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During an interview on 3/24/25 at 10:07 a.m. with Resident 87, Resident 87 stated he had lost almost 70 pounds while in the hospital and wanted to gain the weight back. Resident 87 stated telling Registered Dietician RD) he wanted to get double portions. Resident 87 stated getting a single portion and had to ask for extra food every mealtime. During a concurrent observation and interview on 3/24/25 at 1:20 p.m. with Resident 87, during lunch, Resident 87's lunch tray had one patty served with small amount of gravy and some mixed vegetables and potatoes. The meal ticket that came with the tray indicated regular consistency (extra gravy) double portion. During a review of Resident 87's Nutritional Risk Assessment dated 2/14/25, the Nutritional Risk Assessment indicated Resident 87's current weight was 138.2 pounds (lbs.) with IBW (Ideal Body Weight) of 160 lbs. No data on [Resident 87] intake of meals or snacks or fluid intake. But [Resident 87] reports he is eating well and quantities insufficient for him at this time as his weight is low and wants to gain weight. The goal/intervention was to increase hot food portions to double, Resident 87 would like larger portions as meal served was insufficient. During a review of Nutrition/Dietary Note dated 2/18/25, the Nutrition/Dietary Note indicated Resident 87's weight was 131.2 lbs., with a significant weight loss of 7 lbs. over 4 days. Resident 87 ate 76-100% of meals served. During an interview on 3/27/25 at 11:07 a.m. with Dietary Manager (DM), DM stated double portion 056280 Page 31 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0803 has to be double the regular sized meal, Resident 87 should have two veggie patties on the tray. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056280 Page 32 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of eight residents (Resident 20) reviewed for concerns regarding food, the facility failed to provide nourishing bedtime snacks to Resident 20, a diabetic, consistent with plan of care and resident's request. This failure had the potential to result in hypoglycemia (abnormally low blood sugar level). Findings: During a review of Resident 20's admission Record (AR), the AR indicated Resident 20 was admitted to the facility in October 2024 with diagnoses that included diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar levels). During a review of Resident 20's diabetes care plan dated 10/29/24 last revised 2/20/25, the care plan indicated a goal for Resident 20 to be free from any signs and symptoms of hypo/hyperglycemia (abnormally low/high blood sugar levels). Interventions included for staff to Discuss mealtimes, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan. During an interview on 3/24/25 at 11:15 a.m. with Resident 20, Resident 20 stated she did not get bedtime snacks even when she asked for it. During an interview on 3/26/25 at 3:06 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated all bedtime snacks came labeled with residents' names. LVN 4 stated, if a resident asked for a snack after the kitchen had already closed, and there were no snacks labeled with their name, then staff would not have anything to give them. LVN 4 stated, there would be extra crackers but not everybody could have them, depending on their ordered diet. During an interview on 3/26/25 at 3:22 p.m. with Dietary Aide (DA), DA stated she prepared bedtime snacks before leaving for the day at 7 p.m., after which the kitchen would be closed. DA stated Dietary Manager (DM) would give her label stickers with residents' names and their respective diets to put on the prepared snacks. DA stated there was no label sticker with Resident 20's name and diet. DA also stated she did not prepare extra sandwiches that did not have label stickers because she needed to know what to prepare for a particular resident based on their diets. During an interview on 3/26/25 at 3:41 p.m. with Dietary Manager (DM), DM stated Resident 20 was recently transferred to the hospital and was taken off the list but was not put back on after Resident 20 was re-admitted . DM stated Resident 20 should have 1/2 sandwich for bedtime snacks. During a review of Resident 20's clinical record, Resident 20's Clinical Admission dated 1/2/25 indicated Resident 20 was re-admitted to the facility on [DATE]. 056280 Page 33 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

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, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when: Residents Affected - Some 1.Unlabeled, undated food items were stored in the kitchen refrigerator. 2.A staff drink was stored in the kitchen freezer. 3. Beyond use by date food was stored in the kitchen dry storage. 4.Unlabeled, undated and beyond use by date food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for 90 residents who received food from the kitchen. Findings: During an observation 3/24/25, at 10:00 a.m., the kitchen refrigerator was observed with six unlabeled and undated ready to eat puddings and the kitchen freezer was observed with a staff's energy drink. During and observation on 3/24/25, at 10:07 a.m., the kitchen dry storage was observed with a bulk container of black eye peas with a use by date of 1/3/25. During an observation on 3/24/25, at 10:35 a.m., the nurses' station resident refrigerator and freezer was observed with the following food items that were not labeled with resident identification or date: one strawberry milk, four apple juices, and two turkey sandwiches. The resident refrigerator and freezer had one pack of popsicles with a use by date of 1/2/25. During an interview on 3/28/25, at 10:50 a.m., with Registered Dietician (RD), RD stated all food in the kitchen refrigerator and freezer should have been labeled with open date and use by date. RD stated it was not safe and sanitary for staff to store staff food with resident food in the facility refrigerator or freezer. RD stated food that was beyond their use by date should have been discarded for food quality and resident safety. RD stated food in the resident refrigerator and freezer should have been labeled with resident name, room number and date to make sure residents get their diet that was safe for them and to prevent cross contamination. During a review of the facility's P&P titled, Food Storage and Handling, revised 2/29/24, the P&P indicated, Food items will be stored, thawed and prepared in accordance with standard sanitary practices. All items will be correctly labeled and dated. During a review of the facility's P&P titled, Food Brought in by Visitors, revised June 2018, the P&P indicated, Perishable food requiring refrigeration . if refrigerated it will then be labeled, dated, and discarded after 48 hours. 056280 Page 34 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to operate and provide services in compliance with State regulations when an unusual occurrence of a successful elopement by a resident was not reported to the State Agency. This failure had the potential to result in the lack of oversight for resident safety. Findings: During a review of Resident 90's AR, the AR indicated Resident 90 was admitted to the facility on [DATE] with diagnoses that included old myocardial infarction (a medical emergency that occurs when blood flow to the heart muscle is blocked, causing damage or death of heart tissue), need for assistance with personal care, depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels) and history of traumatic brain injury (TBI, a brain injury caused by an external force, such as a blow to the head. TBIs can cause physical, cognitive, emotional, and behavioral effects). The following were documentation by multiple staff on 12/30/24. -At 13:32, Orders-Administration Note, Resident eloped from facility. -At 13:33, Orders-Administration Note, Resident eloped from facility. -At 14:46, Case Management, late entry, CM (Case Manager) spoke with resident earlier in the day and introduced herself and arranged for an IDT (Interdisciplinary team, a group composed of individuals from different departments of the facility) meeting for this afternoon. Resident agreed to meeting and time. Once CM went to inform resident of meeting Charge Nurse made CM aware that resident had requested to have a cigarette around noon and resident has not been seen since. -At 15:35, Physician/PA (Physician Assistant)/NP (Nurse Practitioner) Note, [Resident 90] was seen and examined .IDT, SS, and nursing notes reviewed . -At 17:21, Health Status Note, Resident alert and verbally responsive, VS (vital signs) within normal limits. All due meds (medications) given and tolerated well. Resident left facility around 12 noon. MD, Administrator, and police notified. -At 19:46, Orders-Administration Note, Resident out for elopement. -At 22:17, Orders-General Note from eRecord, There is no patient to chat. -At 22:53, Orders-Administration Note, Resident elope & didn't come back to the facility. -At 00:21, Orders-General Note from eRecord, Patient is not available. During a concurrent interview and review of Resident 90's clinical record on 3/27/25 2:49 p.m. with 056280 Page 35 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0836 Level of Harm - Minimal harm or potential for actual harm RQMC, RQMC stated the staff's documentation was incomplete and did not indicate details on how and when Resident 90 left the facility. RQMC also stated the Social Services Director (SSD) at the time should have called the resident or any family member on file to know where Resident 90 was. The clinical record did not indicate if there was any investigation done to find Resident 90. RQMC stated, at the time of survey, facility did not know where Resident 90 was. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled Wandering and Elopement last revised 1/31/23, the P&P indicated, if the resident cannot be found, the charge nurse will notify the Administrator, Director of Nursing, Attending Physician, Responsible Party, and Local Law Enforcement. The Administrator will continue to work with law enforcement and the responsible party until the resident is located. The licensed nurse most familiar with the incident will document in the resident's clinical record the details of the elopement. The facility will make necessary reports to the state agencies in compliance with occurrence reporting. During an interview on 3/28/25 at 2:54 p.m. with RQMC, RQMC stated Administrator (ADM) 2 did not report this incident to the State Survey Agency. 056280 Page 36 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

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 observations, interviews, and record reviews, the facility failed to follow proper infection control techniques and did not follow their infection control policies and procedures for two of two sampled residents, Resident 6 and Resident 35, when: Residents Affected - Some 1. Nursing staff did not don gloves when handling Resident 6's soiled bed linens and personal clothing. 2. Resident 35's mattress was worn out and soiled with urine and bodily fluids. 3. Staff in the laundry room did not separate clean linens from soiled linens in the laundry room. 4. Staff in the laundry room did not change gloves after loading soiled laundry and before handling clean linens. 5. Staff in the laundry room did not clean and sanitize washing machine's exterior after loading soiled laundry. These failures resulted in Resident 35 to sleep on an unsanitary and uncomfortable worn-out mattress, not homelike, being at risk for infection, and residents being at risk for infections from cross contamination from staff causing the spread of infection among residents in the facility which could lead to hospitalization and possibly death. Findings: During a record review of Resident 35's Face Sheet, the Face Sheet indicated Resident 35 is a [AGE] year old female admitted to the facility in 2018. The Face Sheet indicated Resident 35 has diagnoses to include asthma (inflammation and narrowing of the airway in the lung), overactive bladder (sudden need to urinate), and hypertension (high blood pressure). During an observation on 3/24/25 at 10:15 a.m. with Restorative Nursing Assistant (RNA) 2, Resident 35 was in the middle bed 21 B, and had two roommates, 21 A (door bed) and 21 C (window bed). A soiled linen cart was placed at the entrance to the room. There was no bedding or sheets on Resident 35's bed, soiled bed linens were rolled up and placed on top of the foot of Resident 35's bed. Resident 35 was seated in her wheelchair, and RNA 2 had just completed grooming Resident 35. RNA 2 picked up Resident 35's rolled up soiled linens (blankets, sheet, pillowcases) without wearing gloves, linens held close against her clothing, walked a few steps to the door where the cart was placed, and placed Resident 35's soiled linens in the soiled linen cart. RNA 2 stated she was not supposed to hold the soiled linens without gloves, and she typically held linens with gloves because they are soiled, have germs, and she needs the required personal protective equipment (PPE) to prevent cross contamination to other Residents not in her room. During an observation on 3/24/25 at 10:20 a.m., with RNA 2, Resident 35 was sitting up in her wheelchair by the sliding door with a mouth full of clear bubbly sputum and spit up on the floor and on her wheelchair. During an interview on 3/26/25 at 12:57 p.m., with Infection Preventionist (IP) and Regional 056280 Page 37 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Infection Preventionist (RIP), IP stated soiled linens should be carried in a plastic bag, with one glove on to carry the plastic bag, the other hand without gloves to open the lid of the linen cart. IP stated, it's not the process, staff should not be handling soiled linens without gloves to prevent the spread of infection, that it was better to wear PPE (personal protective equipment). 2. During a record review of Resident 6's Face Sheet, the Face Sheet indicated Resident 6 is a [AGE] year old female admitted to the facility in 2017. The Face Sheet indicated Resident 6 has diagnoses to include chronic kidney disease Stage 3 (mild to moderate kidney damage), chronic viral hepatitis B (serious viral liver infection), atrial fibrillation (irregular rapid heart rate), and acute ischemic heart disease (sudden blockage or reduction of blood flow to the heart). During an observation on 3/24/25 at 10:25 a.m., Resident 6's bed is in 19A by the door. Resident 6 had two roommates in 19B and 19C, both lying in bed resting. Resident 6 was not in her room and her bed was stripped, no sheets, blankets, or pillows. Resident 6's bed had a deep indentation or body impression in the middle of the mattress, with brown/yellowish discoloration on the middle part of the mattress. During an interview on 3/24/25 at 10:30 a.m. with Director of Staff Development (DSD), DSD stated the mattress was worn out and it needs to be replaced or disinfected several times for infection control prevention. During an interview on 3/24/25 at 11: 29 a.m., with Environmental Service Director (ESD), ESD stated the mattress is worn out and needs to be replaced. ESD stated Resident 6's mattress was on his to do list. 3. During an observation and an interview on 3/27/25 at 09:48 a.m. with IP and Laundry Staff (LS), the laundry room hard a door to the clean side and a door to the soiled side. The washer was placed on the clean side of the laundry room. LS was standing in the clean side of the laundry room with gown and gloves on, sorting out Residents soiled linens (gown, beddings, blankets, wash cloths, towels) into the washing machine. The clean linen cart with clean linens in it and soiled linen cart with soiled linens in it were placed on the same side (dirty side) in the laundry room. IP stated clean linens must be separated from soiled linens, and they should not be on the same side of the laundry room. 4. During an observation on 3/27/25 at 09:48 a.m. with LS and IP, LS did not doff gloves and gown after sorting out soiled linens. LS repeatedly touched the clean linens in the cart with her soiled gloves. LS stated the blankets placed in the soiled area are clean linens. IP stated LS should have removed the soiled gown and gloves before handling the clean linens in the clean laundry cart for infection control purposes. 5. During an observation and an interview on 3/27/25 at 10:01 a.m. with IP and LS, LS removed her gloves and gown, left the laundry room for a break, without sanitizing the exterior of the washing machine. The outside of the two washing machines had white dust particles on them. During an interview on 3/27/25 at 10:04 a.m. with ESD, IP, and Regional Infection Preventionist (RIP), ESD stated the exterior part of the washing machine should be clean and sanitized after every laundry load in the washing machine. so that once the clothes came out of the washer, the clean laundry does not touch the dirty part of the washer and the clean laundry are all clean and sanitized. IP stated it was the policy for staff to sanitize the exterior of the washing machine after loading the 056280 Page 38 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some soiled linens to help with cross contamination. RIP stated staff should sanitize the exterior of the washing machine after loading soiled linens in the washer as it is the facility's process for infection control. During a review of facility's policy and procedure (P&P), titled Infection Control- Policies & Procedures. The P&P indicated, purpose . to provide infection control policies and procedure required for safe and sanitary environment. Policy . The facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections. Procedure . 1. The facility's infection control policies and procedures apply equally to all Facility Staff, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed .or payor source. During a record review of facility's policy and procedures (P&P), titled Infection Control Committee, Composition and Duties. The P&P indicated, II. Risk Exposure categories . i . b. identify all facility staff who perform tasks that may involve blood and/or body fluids as part of their regular employment .ii. Develop and/or supervise processes for tasks involving exposure to blood and body fluids . a. the processes include mandatory work practices and required PPE. During a record review of facility's (P&P), titled Laundry Services. The P&P indicated, purpose . to ensure that the facility provides laundry services that meets the needs of the residents .Policy . 1. The facility works to maintain its own or contract laundry for the residents. To do so, the facility adheres to the following: . Procedure . I. On site laundry services: . A. When the facility operates its own laundry, the laundry: . iii. Has equipment that is of a suitable capacity, kept in good repair and maintained in a sanitary condition . iv. Is maintained in a clean and sanitary condition . v. has written procedures for handling, storage, transportation and processing of linens in the laundry room. 056280 Page 39 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide documentation for pneumococcal and influenza immunization screening (education, offered, and refusal of vaccine) for three of five sampled residents, Resident 14, Resident 67, and Resident 52. Residents Affected - Few This failure has the potential for Resident 14, Resident 67, and Resident 52 to have infection, the spread of infection among other residents, hospitalization, and possibly death. Findings: During an interview on 3/27/25 at 09:35 a.m. with Infection Preventionist (IP), IP stated she had no records of PNA (pneumonia) and Flu (influenza) vaccine screening offered to or refusal of vaccines to Resident 14, Resident 67, and Resident 52. IP stated she or the previous facility IP did provide the consent for the vaccine, but it was not documented in the chart or point click care (PCC, an electronic medical record). IP stated it was important to have documentation of vaccination whether offered, refused, or given to Residents and their Responsible Party (RP), so the facility would know whether Residents received or did not receive vaccination for infection control prevention. During a record review of Resident 14's Face Sheet, the Face Sheet indicated Resident 14 is [AGE] years old admitted to the facility in 2021. The Face Sheet indicated Resident 14 has diagnoses to include pressure ulcer of sacral area, stage 4 (injury to the skin and underlining tissue from constant pressure for long time), paraplegia (paralysis of the legs), colostomy (an operation that creates an opening [stoma] into the colon [large intestine] to the outside of the body), and retention of urine. During a record review of Resident 52's Face Sheet, the Face Sheet indicated Resident 52 is [AGE] years old and a new admit, less than 30 days to the facility in 2025. The Face Sheet indicated Resident 52 has diagnoses to include sepsis (life threatening complication of an infection), urinary tract infections (bacteria infection that enters the tube that carries urine), diffuse large B-cell lymphoma (blood cancer that originates in the B cells that produce antibodies to fight infection), and hypertension (high blood pressure). During a record review of Resident 67's Face Sheet, the Face Sheet indicated Resident 67 is [AGE] years old admitted to the facility in 2024. The Face Sheet indicated Resident 67 has diagnoses to include hypertension (high blood pressure) and epilepsy (disorder in which the nerve cell in the brain causing seizures). During an observation on 3/24/25 at 10:49 a.m., Resident 14 is in a two bed room, window bed, with a roommate in the A bed (door) on Enhanced Barrier Precaution (infection control measures to reduce transmission). During a review of Resident 14's Medication Administration Record (MAR) and Immunization Record (IR), the MAR and IR indicated no documentation of PNA vaccine were offered or refused by Resident 14 or Responsible Party (RP). During an observation on 3/24/25 at 10:23 a.m., Resident 52 is in a three bed room, A bed, with two roommates. 056280 Page 40 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0883 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 52's MAR and IR, the MAR and IR indicated no documentation PNA and Flu vaccines were offered or refused by Resident 52 and/or RP. During a review of Resident 67's MAR and IR, the MAR and IR indicated no documentation of PNA vaccine offered or refused by Resident 67 and/or RP. Residents Affected - Few During a review of Facility Policy and Procedure (P&P), titled Influenza Prevention and Control, Purpose . To prevent and control the spread of influenza in the facility . Policy . The facility will follow infection prevention and control policies and procedures to minimize the risk of Residents acquiring, transmitting or experiencing complications from influenza . B. Residents are offered an influenza immunization every year during flu season, unless the immunizations medically contraindicated, or the Resident has already been immunized during the current flu season . The Resident or representative must give consent prior to receiving the vaccine. They can refuse the immunization-with such refusal being noted in the Resident's medical record . D. The Resident's medical record will include documentation that indicates, at a minimum, the following . v. Whether the Resident received the influenza vaccine, could not receive the vaccine due to a medical contraindication or refused the vaccine. During a review of Facility Policy and Procedure (P&P), titled Pneumococcal Disease Prevention, the P&P indicated Purpose . to minimize the risk of Residents acquiring transmitting or experiencing complications from pneumococcal disease . Policy . The Facility will offer pneumococcal immunization to each Resident, according to Center for Disease Control and Prevention (CDC) recommendations, unless it is medically contraindicated, or the Resident has already been immunized . Procedure . Pneumonia vaccination is recommendation for the following Residents: . C. Anyone 2 - [AGE] years old who has a disease condition that lowers the lowers the body's resistance to infection, Hodgkin's disease, lymphoma or leukemia, kidney failure, multiple myeloma, nephrotic syndrome . F. Residents of nursing homes or long term care facilities . VI. Documentation . A. The Resident's medical record shall include documentation that indicates, at a minimum, the following: . v. A completed copy of C -20 - Form B - Pneumonia Vaccination, informed Consent or Refusal placed in the Resident's medical record . vi. Whether the Resident received the PCV13 or the PPSV23 vaccine, or did not receive either because of medical contraindications or refusal. 056280 Page 41 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop and maintain an effective training program for all new and existing staff consistent with their expected roles based on the facility assessment when Licensed Vocational Nurse (LVN) 3 did not have annual competency training and two of three Certified Nursing Assistants (CNAs) did not have dementia training since hire date. Residents Affected - Few This failure had the potential to result in providing poor quality and unsafe resident care. Findings: During a review of facility's Facility Assessment Tool, undated, the Facility Assessment Tool indicated the facility is accepting and treating residents with the following conditions: psychiatric and mood disorders like depression ( common and serious medical illness that negatively affects how you feel, think, act, and perceive the world, often causing persistent sadness, loss of interest, and difficulty with daily activities), impaired cognition, psychosis (a condition where individuals experience a loss of contact with reality, often involving symptoms like delusions (false beliefs) and hallucinations (seeing or hearing things that aren't there)), schizophrenia (a serious mental illness that disrupts how a person thinks, feels, and behaves, often leading to a disconnection from reality, and can include symptoms like hallucinations, delusions, and disorganized thinking), post-traumatic stress disorders (a mental health condition that can develop after experiencing or witnessing a traumatic event, leading to persistent symptoms like intrusive memories, avoidance behaviors, negative thoughts, and changes in arousal and reactivity), and behavior that needs interventions; heart/circulatory system disorders like congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively, leading to fluid buildup in the body), risk for bleeding, blood clots, Deep Venous Thrombosis (DVT, is a condition that occurs when a blood clot forms in a vein deep inside a part of the body); neurological system disorders like non-Alzheimer's dementia (a decline in mental ability, affecting memory, thinking, and behavior, and interfering with daily life), seizure disorders, Tourette's syndrome (a neurodevelopmental disorder characterized by repetitive, sudden, and involuntary movements or vocalizations called tics); metabolic disorders like diabetes (a chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), thyroid disorders, hypo/hypernatremia (a condition where the sodium concentration in the blood is too low or too high); Genitourinary System Disorders like renal insufficiency (a condition where the kidneys do not function properly, resulting in a decreased ability to filter waste products from the blood), nephropathy (the deterioration of kidney function), renal failure (a condition where the kidneys lose their ability to filter waste products from the blood), end stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant to maintain life); integumentary like skin ulcers and pressure ulcers (a localized area of skin damage that develops when prolonged pressure is applied to the body); infectious diseases like skin and soft tissue infections, respiratory infections, tuberculosis (an infectious disease caused by the bacterium Mycobacterium tuberculosis), infections with multi drug-resistant organisms (MDRO, which are microorganisms (primarily bacteria) that have developed resistance to one or more classes of antimicrobial agents, making infections they cause difficult to treat), and HIV (a virus that attacks the body's immune system. Without treatment, it can lead to AIDS (acquired immunodeficiency syndrome). The Facility Assessment Tool also indicated the facility offer the following services and care that included nutrition (hydration, tube feeding, assistive devices, fluid monitoring or restrictions), management of medical, conditions (heart failure, UTI (an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra), pneumonia (a lung infection, often 056280 Page 42 of 43 056280 03/28/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few caused by bacteria, viruses, or fungi, that causes the air sacs in the lungs to become inflamed and fill with fluid or pus, making it difficult to breathe), infection prevention, mental health and behavior (anxiety (a common mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life), cognitive impairment). During a concurrent interview and record review on 3/28/25 at 12:21 p.m. with Director of Staff Development (DSD), DSD stated CNA 3 was hired 8/25/24 and Restorative Nursing Assistant (RNA) 2 was hired 7/10/24. DSD stated both employees did not have dementia training as of date. DSD also stated LVN 3 had skills/competency evaluation dated 2/8/24 on blood glucose monitoring, pressure ulcer management, medication administration, parenteral medication (drugs given by routes other than the digestive tract. The term parenteral is usually used for drugs given by injection or infusion), catheter and tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe (trachea)) care. DSD stated she would look to see LVN 3's hire date and if she has had skills/competency evaluation prior to 2024. DSD stated she started her role as DSD in December 2024 and has not organized the training records. During a follow-up interview on 3/28/25 at 1:40 p.m. with DSD, DSD stated LVN 3 was hired 9/13/2019 and stated only the skills/competency in 2024 were found in the records. During a follow-up review of the facility's Facility Assessment Tool, the Facility Assessment Tool indicated the staff training and competencies that are necessary included: required in-service training for nurse aides included dementia ,management, training and resident abuse prevention training, providing services to individuals with cognitive impairments, also address the care of the cognitively impaired, infection control, caring for residents with Alzheimer's or dementia, specialized care and caring for residents with mental and psychosocial disorders and implementing nonpharmacological interventions (healthcare treatments and strategies that do not involve the use of medications). 056280 Page 43 of 43