Health inspection·November 16, 2023

F 0688 9/8/23 - F (Friday) - Blank (no RNA staff initials) Level of Harm - Minimal harm or potential for actual harm 9/11/23 - M (Monday) - Blank (no RNA staff initials) 9/15/23 - F (Friday) - Blank (no RNA staff initials) Residents Affected - Few 9/18/23 - M (Monday - Blank (no RNA staff initials) 9/22/23 - F (Friday) - Blank (no RNA staff initials) 9/27/23 - W (Wednesday) - Blank (no RNA staff initials) 9/29/23 - F (Friday) - Blank (no RNA staff initials) October 2023 10/18/23 - W (Wednesday) - Blank (no RNA staff initials) 10/23/23 - M (Monday) - Blank (no RNA staff initials) 10/25/23 - W (Wednesday) - Blank (no RNA staff initials) 10/30/23 - M (Monday) - Blank (no RNA staff initials) November 2023 11/10/23 - F (Friday) - Blank (no RNA staff initials) 11/13/23 - M (Monday) - Blank (no RNA staff initials) During a concurrent interview and record review on 11/14/23, at 3:48 p.m., with RNA 1 present, RNA 1 stated the blanks or empty spaces corresponding with the dates on Resident 24's records indicated that the RNS were not done. RNA 1 confirmed there were no resident refusals recorded on Resident 24's RPs from 9/1/23 through 11/13/23. 2. Resident 40 was admitted to the facility with diagnoses that included spastic quadriplegic cerebral palsy (abnormal development or damage to the brain that affects movement, posture, and coordination), severe intellectual disability, and contracture of muscle, multiple sites (a condition wherein muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). During an observation on 11/13/23, at 11:25 a.m., Resident 40 was in bed, eyes open and unable to speak. Resident 40's hands were both contracted and rested on the chest. During a review of Resident 40's physician order for November 2023, the order indicated: Restorative Nursing Assistant to continue PROM to right upper extremity 10 REPS (repetitions) x 2 sets 3x/week . Start Date - 8/11/23 . Restorative Nursing Assistant to continue PROM to right lower extremity 10 REPS (repetitions) x 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 2 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 sets 3x/week . Start Date - 8/11/23 . Level of Harm - Minimal harm or potential for actual harm Restorative Nursing Assistant to continue PROM to left lower extremity 10 REPS (repetitions) x 2 sets 3x/week . Start Date 3/9/23 . Residents Affected - Few During a concurrent interview and record review on 11/16/23, at 9:52 a.m, with the Director of Nursing (DON), present, Resident 40's Restorative Records (RP), for September 2023 and October 2023 were reviewed. The RP records indicated: Restorative Nursing Assistant to continue PROM to right upper extremity 10 REPS (repetitions) x 2 sets 3x/week. Restorative Nursing Assistant to continue PROM to right lower extremity 10 REPS (repetitions) x 2 sets 3x/week. Restorative Nursing Assistant to continue PROM to left lower extremity 10 REPS (repetitions) x 2 sets 3x/week. September 2023 Week of 9/15/23 to 9/21/23 - Two RNS sessions (9/19/23 and 9/21/23) for each extremity were recorded. There was no record a third RNS session for each extremity, was provided to Resident 40, as ordered by the physician. Week of 9/22/23 to 9/28/23 - Two RNS sessions (9/25/23 and 9/27/23) for each extremity were recorded. There was no record a third RNS session for each extremity, was provided to Resident 40, as ordered by the physician. October 2023 Week of 10/22/23 to 10/28/23 - Two RNS sessions (10/24/23 and 10/26/23) for each extremity were recorded. There was no record a third RNS session for each extremity, was provided to Resident 40, as ordered by the physician. During a concurrent interview and record review on 11/16/23, at 9:55 a.m, with the DON, DON acknowledged Resident 40's had missed RNS sessions for September 2023 and October 2023. DON also stated that both Resident 40 and Resident 24's physician orders for RNS were not implemented consistently. Review of the facility's Policy and Procedures (P&P), titled, Restorative Nursing Services, revision 7/2017, the P&P indicated, Policy Statement - Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation - 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 3 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's Policy and Procedures (P&P), titled, Charting and Documentation, revision dated 7/2017, the P&P indicated, Policy Statement - All services provided to the resident . shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation . The following information is to be documented in the resident medical record . c. Treatments or services performed . Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting . Event ID: Facility ID: 056350 If continuation sheet Page 4 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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. Based on observation, interview, and record review, the facility failed to provide care according to professional standards of practice for one of one sampled residents (Resident 40), when Licensed Vocational Nurse (LVN) 2 did not check the placement of Resident 40's enteral feeding tube (a tube placed through the skin of the abdomen directly into the stomach to deliver medication) and did not check the amount of residual (undigested stomach contents) in the stomach before medications were administered through the feeding tube. This failure placed Resident 40 at risk of aspiration (the intake of foreign matter into the lungs) and medications not being administered into the stomach. Findings: During medication pass observation and concurrent interview on 11/14/2023, at 12:20 p.m,. with LVN 2, LVN 2 administered medication through Resident 40's feeding tube. LVN 2 confirmed, she did not check placement and did not check residual content remaining in Resident 40's stomach. LVN 2 further added, she should have checked the placement using stethoscope (a medical instrument for listening to sound) so medication does not go in the wrong place that could result in aspiration. During an interview on 11/14/2023, at 2:46 p.m., with Director Of Nursing (DON), DON stated, it was important to check for placement of the feeding tube by listening to sound before administration of medication due to potential for aspiration. DON further added, if placement was not checked, medication might go to lungs instead of stomach. During a review of Resident 40's face sheet, dated 11/14/23, the face sheet indicated Resident 40 was admitted to the facility in August 2022. During a review of Resident 40's Physician Order, dated 8/4/23, the physician order showed, GTube feeding; . check for placement and patency . During a review of the facility's policy and procedure (P&P), titled Administering Medications through an Enteral Tube, dated, November 2018, the P&P indicated under Equipment and Supplies: .12. Stethoscope. Under steps in the procedure: .6. Verify placement of feeding tube. a. If you suspect improper tub positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 5 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure two of five sampled nursing staffs (Registered Nurse (RN) 1 and Certified Nursing Assistant (CNA) 2 were provided with competencies and skills necessary to perform their work roles safely and successfully. This failure had the potential to not provide appropriate nursing services to meet the needs of residents and promote the residents' physical, mental and psychosocial well-being. Findings: 1. During an interview on 11/15/23, at 7:36 a.m, with RN 1, RN 1 stated she worked the night shift on 11/14/23 beginning at 11 PM to 11/15/23 ending at 7:30 AM. RN 1 stated she was hired as a full-time nurse recently and had completed a two-week training with two nurses on different work shifts. During a concurrent interview and record review on 11/15/23, at 7:38 a.m, with RN 1, Resident 48's medical records were reviewed. When asked, RN 1 stated she was not aware Resident 48 had an indwelling urinary catheter (a device that is inserted into the bladder to drain the urine). RN 1 confirmed she had not checked Resident 48's urinary catheter. When asked to verify if there was a physician or treatment order on Resident 48's urinary catheter, RN 1 was unable to show the surveyor how to look up Resident 48's treatment order in the electronic record system. RN 1 said, the facility's electronic record system was a little complicated. RN 1 added, she was not super familiar with the electronic system for the resident's TAR [Treatment Administration Record]. During a concurrent interview and record review on 11/15/23, at 7:54 a.m, with RN 1 and the Director of Nursing (DON) present, the DON confirmed Resident 48 had treatment orders indicated in the electronic record system. Review of Resident 48's Treatment Record, as reflected in the facility's electronic record system, for November 2023, indicated, Indwelling Catheter: Cleanse with Normal Saline, Pat Dry, Cover with Dry Dressing QD (daily), Start Date - 9/29/23. Review of Resident 48's Treatment Record, as reflected in the facility's electronic record system, for November 2023, indicated, Indwelling Catheter: Monitor Peri-Area and Bag for cleanliness and placement of tubing with security strap, Start Date - 9/29/23. During an interview on 11/15/23, at 8:01 a.m, the DON stated it was unfortunate that resident TARs in the electronic record system was not captured in RN 1's training. DON stated this training was important so that nurses were aware on how to provide care and carry out treatment orders for the residents. 2. During a concurrent interview and record review on 11/16/23, at 12:50 p.m., with the DON and the Acting Director of Staff Development (DSD) present, CNA 2's personnel records were reviewed. CNA 2's Nursing Assistant Orientation & Competency Evaluation Nursing Skills Performance Satisfactory Completion, record was last evaluated on 6/3/22. DON and DSD confirmed CNA 2's Competency and Skills Evaluation was due in June 2023 and was not completed. Review of the facility's Policy and Procedures (P&P), titled, Competency of Nursing Staff, revision (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 6 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dated 5/2019, the P&P indicated, Policy Statement - 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. 2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care. Policy Interpretation and Implementation . Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary on the facility assessment . Event ID: Facility ID: 056350 If continuation sheet Page 7 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure an employee performance review was conducted at least every 12 months for one of five sampled nursing staffs (Certified Nursing Assistant (CNA) 2). Residents Affected - Few This failure had the potential to affect the quality of nursing services rendered to residents in the facility when staff performance reviews remain unchecked. Finding: During a concurrent interview and record review on 11/16/23, at 12:27 p.m., with the Director of Nursing (DON) and the Acting Director of Staff Development (DSD) present, CNA 2's personnel records were reviewed. CNA 2's personnel records indicated a hire date of 5/9/16. CNA 2's Employee Performance Review, record was last completed on 6/3/22. DSD confirmed CNA 2's performance review was not completed within the past 12 months. Review of the facility's Policy and Procedures (P&P), titled, Performance Evaluations, revision dated 6/2020, the P&P indicated, Policy Statement - The job performance of each employee shall be reviewed and evaluated at least annually. Policy Interpretation and Implementation - 1. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 8 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to post the daily nurse staffing information on 11/13/23. Residents Affected - Few This failure resulted in nurse staffing information and posting requirements that were not readily available to residents and visitors. Findings: During a concurrent observation and interview on 11/13/23, at 12:12 p.m., with the Director of Nursing (DON) present, the DON confirmed the required nurse staffing data information for 11/13/23, was not posted on the clear poster board by the nursing station. The Daily Nurse Staffing Information sheet posted on 11/13/23 was for 11/9/23. It was also noted that several sheets filed on the clear poster board included Nurse Staffing Information for 11/8/23, 11/7/23, 11/6/23, 11/2/23, 11/1/23 and 10/27/23. When asked, the DON stated there was no nurse staffing information sheets for the past three days. The DON stated nurse staffing information should be posted daily. Review of the facility's Policy and Procedures (P&P), titled, Staff Posting Requirements, dated 2/2017, the P&P indicated, Policy - It is the policy of the Facility that residents, prospective residents, employees, visitors and job applicants are provided the information about staffing daily for direct patient care according to State and Federal guidelines. Fundamental Information - To implement this policy, the postings will be visible and available for review for public information. Responsible Discipline: The Director of Nurses is responsible for implementation of the policy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 9 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure medication error rate was below five percent (%). When: Residents Affected - Some 1. Registered Nurse (RN) 1 administered medication late to (Residents 255, 26, 13 and 44). 2. Losartan (medication to treat high blood pressure) was not given to Resident 44. 3. RN 1 did not wait five minutes in between administration of eye drop treatment as ordered by the physician. These deficient practices placed Residents 255, 26, 13 and 44 at risk of developing complications related to error in medication administration. Findings: 1. During concurrent medication administration observation and interview on 11/13/23, at 10:26 a.m., with RN 1, RN 1 was doing morning medication pass. RN 1 stated, she was delayed passing medications for Residents 255, 26, 13 and 44. When asked regarding the standards of practice. RN 1 stated, 10:00 a.m. was supposed to be the latest she can administer morning medications. RN 1 also stated, any time after 10:00 a.m. was considered late because it would be too close to next dose if Residents had same medications. RN 1 further added, Residents will end up with more medications in their system. During a concurrent interview and review of Medication Pass Hours on 11/14/23, at 10:23 a.m., with the Director Of Nursing (DON), DON stated, medication administration schedule in the morning was from 8:00 a.m - 10:00 a.m. DON further added, medication pass after 10:00 a.m., was considered late. DON acknowledged RN 1 was delayed with morning medication pass on 11/13/23. DON further added, there should have been no reason acceptable for delayed medication pass. 2. During a concurrent interview and medication administration observation on 11/13/23, at 11:33 a.m., with RN 1, RN 1 did not give Losartan 50 milligrams (mg) to Resident 44. RN 1 stated, there was no available medicine to give. RN 1 also stated, she will contact the pharmacy for order. During a review of Resident 44's Administration Record, dated 11/15/23, it indicated, Losartan 50mg tablet: .scheduled for 11/13/23 9:00 a.m., was not administered . During a review of Resident 44's Medication Administration Record (MAR) dated 11/13/23, the MAR showed, Losartan 50mg tablet: Take 1 tablet by mouth 9AM every very day for Hypertension (HTN, high blood pressure) day .The MAR also showed, Losartan was not given. During a review of Resident 44's Care Plan dated 11/2/23, it indicated Resident 44 was at risk for Hypertension. One of the approaches was to give medication as ordered (Losartan) . 3. During a concurrent medication observation and interview on 11/13/23, at 11:11 a.m., with RN 1, RN 1 instilled Dorzolamide (eye drop to treat eye pressure to Resident 13's right eye. RN 1, then instilled Maxifloxacine (medication to treat eye infection) immediately without waiting for five minutes to Resident 13's eye. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 10 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 RN 1 stated, she was not aware she had to wait 5 minutes in between. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 13's Physician Orders, dated 11/11/23, it indicated Dorzolamize 2% eye drops: Instill 1 drop to right eye . Wait 5 minutes before instilling other ophthalmic agents. Residents Affected - Some During a review of Resident 13's MAR for November 2023, it indicated Dorzolamide 2% eye drops: instill 1 drop to right eye 3x daily. Wait 5 minutes before instilling other ophthalmic agents. During a review of facility's Policy and Procedure (P&P) titled, Administering Medications, dated April 2019, it indicated .7. Medications are administered within one (1) hour of their prescribed time . During a review of facility's P&P titled, Medication and Treatment Orders, dated July 2016, it indicated, Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 11 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 one resident of 26 sampled residents observed during medication administration pass (Resident 44) was free from significant medication error when: Residents Affected - Few Losartan (medication to treat high blood pressure) was not administered as prescribed by the physician. This deficient practice had the potential for increased blood pressure and possible for stroke. Findings: During a review of Resident 44's face sheet, dated 11/14/23, it indicated, Resident 44 was admitted to the facility in November 2023 with multiple diagnoses that included Essential Primary Hypertension (high blood pressure). During a concurrent interview and medication administration observation on 11/13/23, at 11:33 a. m., with RN 1, RN 1 did not give Losartan 50 milligrams (mg) to Resident 44. RN 1 stated, there was no available medicine to give. RN 1 also stated, she will contact the pharmacy for order. During a review of Resident 44's Administration Record, dated 11/15/23, it indicated, Losartan 50mg tablet: .scheduled for 11/13/23 9:00 a.m., was not administered . During a review of Resident 44's Medication Administration Record (MAR) dated 11/13/23, the MAR showed, Losartan 50mg tablet: Take 1 tablet by mouth 9AM every very day for Hypertension. The MAR also showed, Losartan was not given. During a review of Resident 44's Care Plan dated 11/2/23, it indicated Resident 44 was at risk for Hypertension. One of the approaches was to give medication as ordered (Losartan) . During an interview on 11/15/23, at 1:41 p.m., with the DON, DON indicated she was not aware Resident 44 missed Losartan due to unavailability of the medication. DON further added, the risk for Resident 44 was possibly stroke or heart attack. During a review of facility's P&P titled, Medication and Treatment Orders, dated July 2016, it indicated, Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 12 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to properly secure medications when two of two Licensed Staff did not keep medication cart 2 locked or under direct observation of authorized staff. This failure had the potential for residents, unauthorized staff, and visitors to have access to medications. Findings: During medication administration observation, on 11/13/23, at 10:26 a.m., with Registered Nurse (RN) 1, RN 1 left medication cart two unlocked and unattended, with medication drawers facing the hallway. RN 1 entered resident room, and the left unlocked medication cart out of her view. An unauthorized staff was observed walking by the medication cart twice. During a concurrent observation and interview on 11/13/23, at 11:28 a.m., Licensed Vocational Nurse (LVN) 1, LVN 1 left medication cart two drawer unlocked and unattended in the hallway outside a resident room and across from activity room. LVN 1 entered the activity room leaving medication cart out of her view. One resident walked pass the unlocked medication cart two. LVN 1 acknowledged, she had left medication cart one unlocked. LVN 1 further stated, it was important to keep medication cart locked at all times so that residents will not take medications that did not belong to them. During an interview on 11/14/2023, at 10:50 a.m., with the Director Of Nursing (DON), DON stated, medication carts must be kept locked at all times when not attended by a licensed nurse. DON further added, it was especially important due to frequency of residents walking around unattended. DON also added, this was potential for unauthorized individuals to take medications from the unlocked medication carts. During a review of the facility's policy and procedure (P&P) titled, Security of Medication Cart, dated April 2007, the P&P indicated under policy statement, The medication cart shall be secured during medication passes. 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3.the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurses' view. During a review of the facility's P&P titled, Storage of Medications, dated April 2019, the P&P indicated, .8. Compartments . containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 13 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed store food and maintain the ice machine and ice scooper in a sanitary manner when: Residents Affected - Some 1. Unlabeled, and outdated food were available for use in the kitchen freezer and dry storage. 2. Unlabeled, and expired food were available for use in the resident refrigerator. 3. Ice machine and ice scooper were not sanitized after the ice scooper was left in the ice machine. These failures had the potential to put residents at risk for infection and food borne illnesses. Findings: 1. During a concurrent observation and interview on 11/13/23, at 9:35 a.m., with Dietary Manager (DM), freezer 3 was observed. DM verified an opened package of sliced ham and 12 pie crusts out of its original package, were not labeled with received, opened, or used by dates, were in freezer 3. DM verified an opened plastic bag with 3 waffles had a use by date of 11/6/23 and an opened plastic bag with 5 French toasts had a use by date of 11/7/23, were found in freezer 3. DM removed the food items and stated they shouldn't be there, and they needed to be thrown away. During a concurrent observation and interview on 11/13/23, at 9:44 a.m., with DM, the dry food storage area was observed. DM verified an opened bag of dry gravy mix with a use by date of 10/12/23 and an opened bag of dry mashed potatoes mix without a received, opened or used by date, were in the dry storage area. DM removed the food items and stated they shouldn't be there, and they needed to be thrown away. During an interview on 11/16/23 , at 1:22 p.m., with DM, DM stated their policy was to label all food in the refrigerator, freezer, and dry food storage area with the date it was received, when it was opened and when is should be used by. DM stated they should not have kept unlabeled, incorrectly labeled, outdated and expired food in the freezer or dry food storage. DM stated labeling food was important so they could have identified food that was old or bad. DM stated residents were elderly and weaker and old or outdated food had the potential to cause them food sickness. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, revised December 2014, the P&P indicated, All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed form cases for storage . Expiration dates on unopened food will be observed and 'use by dates indicated once food is opened. 2. During a review of Resident 23's admission Record, dated 11/14/23, the record indicated Resident 23 was admitted 06/2023 with a diagnosis of Quadriplegia (partial or complete paralysis of both the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 14 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some arms and legs), unspecified. During a review of Resident 22's admission Record, dated 11/16/23, the record indicated Resident 22 was admitted 02/2021 with a diagnosis of Hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain) affecting right dominant side. During a review of Resident 31's admission Record, dated 11/16/23, the record indicated Resident 31 was admitted 09/2023 with a diagnosis of Cerebral infarction due to thrombosis (a condition where one or more blood clots form in your blood vessels or heart) of right posterior cerebral artery (one of a pair of arteries that supply oxygenated blood to part of the back of the human brain). During a concurrent observation and interview on 11/13/23, at 1:02 p.m., with Certified Nursing Assistant 1 (CNA), the resident refrigerator was observed. CNA 1 verified left over pizza, French fries, and an opened can of partially consumed expresso were not labeled with resident name or received or use by dates. CNA 1 verified left over Chinese food, an opened package of sliced cheese, and an opened package of sliced turkey meat were labeled with Resident 23's room number but did not have a received or use by date. CNA 1 verified a bottle of strawberry milk labeled with Resident 22's room number, had a manufacturer's expiration date of 9/4/23. CNA 1 verified a papaya labeled Resident 31, did not have a received or use by date. CNA 1 stated the papaya was mushy, old and rotten. CNA 1 stated all food should be labeled with resident name, received, and use by dates. CNA 1 stated unlabeled, undated, expired, and rotten food items could have caused the residents to get sick. During an observation on 11/13/23, on 1:35 p.m., the resident refrigerator was observed with a document posted on the refrigerator door titled, Food Safety Guide For Food And Beverages brought In From Outside And Stored In Facility Pantry/Refrigerator, undated, the document indicated, All food and beverage items being stored in the facility pantry or refrigerator must be: .Labeled with the resident's name . Labeled with the date brought in . The document also indicated, All food and beverage items stored in the facility pantry / refrigerator must be thrown out: . On the manufacturer's expiration date . 72 hours after the date it was brought in . Upon spoiling. During an interview on 11/16/23, at 11:28 p.m., with DM, DM stated their policy was to label all food and beverages in the resident refrigerator with resident name, received date and opened date. DM stated opened foods and beverages should have been thrown out after 3 days, when it expired or when it became rotten. DM stated the importance of labeling food and throwing away old or expired food was to prevent residents from getting food poisoning. During an interview on 11/16/23 , at 11:50 a.m., with Director of Nursing (DON), DON stated their policy was to label all food and beverages in the resident refrigerator with resident name, received date and opened date. DON stated all opened food and drinks should have been thrown out after 72 hours. DON stated incorrectly labeled, unlabeled and expired food and beverages could have caused residents to get food poisoning. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised July 2014, the P&P indicated, Food items and snacks kept on the nursing units must be maintained as indicated below: . All foods belonging to residents must be labeled with the resident's name, the item and the use by date . Beverages must be dated when opened and discarded after twenty-four (24) hours . Partially eaten food may not be kept in the refrigerator. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 15 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 11/14/23 at 3:00 p.m., with Maintenance Director (MD), the ice machine was observed with the ice scooper inside the ice machine, laying on top of ice and unattended. MD stated the ice scooper should never be left in the ice machine, after use staff should have placed it in the ice scoop container with cover. During an observation on 11/14/23, at 3:10 p.m., the ice scooper was observed inside the ice scoop container. During an interview on 11/14/23, at 3:14 p.m., with CNA 2, CNA 2 stated they found the ice scooper inside the ice machine, laying on top of ice, but didn't know who left it there or how long it was there. CNA 2 stated they removed the ice scooper from inside the ice machine, rinsed it with water, then placed it into the ice scoop container and left it without telling anyone. CNA 2 stated it was a mistake and they should have notified kitchen staff that the ice scooper was left inside the ice machine so they could have sanitized the ice scooper and clean out the ice machine. CNA 2 stated they put the residents at risk for infection when the ice scooper and ice machine was not properly cleaned after they found the ice scooper inside the ice machine. CNA 2 stated they would notify the kitchen immediately. During an interview on 11/15/23, at 2:00 p.m., with DM, DM stated it was their policy to place the ice scooper in the closed ice scoop container when not in use. DM stated that the kitchen should have been notified when the ice scooper was left in the ice machine so they could have sanitized the ice scooper and cleaned the ice machine. DM stated they cleaned and sanitized the ice scoop and ice machine yesterday after they were aware the ice scoop was left in the ice machine. DM stated the residents were placed at risk for infection and cross contamination when the ice scooper and ice machine were not properly cleaned and sanitized after the ice scooper was left inside the ice machine. During an interview on 11/15/23, at 2:13 p.m., with DON, DON stated the ice scoop should have never been left in the ice machine because it was a risk for infection. DON stated staff should have reported to the kitchen that the ice scooper was left inside the ice machine so they could have cleaned and sanitized the ice scooper and ice machine. During a review of the facility's policy and procedure (P&P) titled, Ice Machines and Ice Storage Chests, revised January 2012, the P&P indicated, To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: . Keep the ice scoop/bin in a covered container when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 16 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement their infection prevention and control program when: Residents Affected - Few 1. Licensed staff did not sanitize portable blood pressure machine before and after each resident use. 2. Two licensed staff did not sanitize tray used to deliver medications to residents during medication administration. 3. Two licensed staff touched a resident's medication with bare hands. 4. Licensed staff touched inside resident's right eye twice with dropper tip during medication administration. 5. Licensed staff did not wash hands before administration of medication via gastronomy tube (G-tube, a tube inserted through the belly that brings nutrition or medications directly to the stomach). 6. Nasal cannulas (a device used to deliver supplemental oxygen) worn by 2 residents (Resident 2 and Resident 12) were not labeled with dates when it was initially used or with date of replacement. 7. There was no appropriate water management program and control measures to prevent the growth of Legionella (a type of bacteria), and other opportunistic waterborne pathogens (bacteria, virus or other microorganism that can cause disease) in the facility's building water systems. 8. The trash bin in the laundry room had no lid cover. 9. Laundered mopheads, cleaning towels and dusters were not properly air dried and stored in a sanitary manner. 10. Soiled and unlabeled clothes were not placed in a covered laundry hamper. These failures have the potential to not prevent the development and transmission of communicable diseases and infections among residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 11/13/2,3 at 10:38 a.m., with Registered Nurse (RN) 1, RN 1did not sanitize blood pressure machine before taking Resident 255's blood pressure reading. RN 1 acknowledged, she did not sanitize shared equipment and stated she was supposed to sanitize shared equipment before and after resident use for infection prevention. 2. a. During a concurrent medication administration observation and interview on 11/13/23, at 10:45 a.m,. with RN 1, RN 1 came out of a Resident room with medication tray. RN 1 did not sanitize medication tray then proceeded to prepare medications. RN 1 then used the same unsanitized tray to deliver medications to Resident 26. When asked regarding infection control practices, RN 1 stated, she knew she was supposed to sanitize the shared try for each Resident. RN 1 further stated, there was no sanitizing wipes available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 17 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. b. During medication administration observation on 11/13/23, at 12:20 p.m., RN 2 placed insulin filled syringe with needle attached and alcohol wipes on tray. RN 2 entered dining room, placed tray on dining table, administered insulin to Resident 27. RN 2 returned to medication cart, did not sanitize tray. RN 2 then placed insulin filled syringe and alcohol pads to the same unsanitized tray. RN 2 entered the dining room, placed the tray on the dining table and administered insulin to Resident 35. When asked regarding infection control practices, RN 2 acknowledged she did not sanitize shared medication tray between Residents during insulin administration. 3. a. During medication administration observation on 11/13/23, at 10:46 a.m., RN 1 dropped calcium tablet on shared medication tray used to deliver medications. RN 1 picked up tablet with bare hands then placed the tablet inside medication cup. RN 1 then administered the tablet to Resident 26. 3. b. During medication administration observation on 11/14/23, at 12:20 p.m, LVN 2 held the medication capsule dispensed from the medication pack with bare hands. LVN 2 opened the capsule with bare hands, poured the content into medication cup for reconstitution. LVN 2 then administered the medication to Resident 40 via g-tube. 4. During concurrent medication administration observation and interview on 11/13/23, at 11:11 a.m., with RN 1, RN 1 instilled Dorzolamide (eye drop to treat eye pressure) to Resident 13's right eye. The dropper tip touched Resident 13's right eye. RN 1 the proceeded to instill Maxifloxacine (medication to treat eye infection) to Resident 13's right eye. Maxifloxacine dropper tip also touched inside Resident 13's right eye. RN 1 acknowledged, each of the dropper tip touched Resident 13's eye surface and stated she made mistakes. RN 1 further added, the dropper tip should not have touched Resident 13's eye due to infection risk. 5. During a concurrent observation and interview on 11/14/23, at 12:20 p.m., with LVN 2, LVN 2 did not wash hands, prepared Resident 40's medication, donned pair of gloves, touched the computer mouse and medication cart surface with gloved hands. LVN 2 then administered Resident 40's medication via G-tube.When asked about hand hygiene practices during medication treatment for G-tube, LVN 2 stated, wore gloves. During review of facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube dated, 11/2018, indicated under steps in procedure 1. Wash your hands .20. Wash hands. During a review of facility's P&P titled, SPECIFIC MEDICATION ADMINISTRATION PROCEDURES, dated, 4/2008, the P&P indicated under procedures G. Hold the dropper tip directly over the eye, taking care to avoid touching the eye or eyelid. During a review of facility's P&P titled, Administering Medications, dated, 4/2019, the P&P indicated, .25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique) for the administration of medications, as applicable. Influenza and Pneumococcal Immunizations 6. During an observation on 11/13/23, at 10:52 a.m., Resident 2 was in bed and wore a nasal cannula that was attached to an oxygen source. The nasal cannula did not indicate date of initial use or date of replacement. During an interview on 11/13/23, at 11:18 a.m., with the facility's Infection Preventionist (IP), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 18 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few IP stated nasal cannulas worn by residents had to be replaced once a week by the treatment nurse or charge nurse. IP was unable to provide information when Resident 2's nasal cannula was last replaced. During a concurrent observation and interview on 11/13/23, at 11:48 a.m., with the IP, inside Resident 12's room, IP confirmed the nasal cannula worn by Resident 12 had no label indicating when it was replaced. IP stated the nasal cannula should be labeled so that staff will know when to replace it. IP explained nasal cannulas worn by residents had to be replaced for infection control purposes. Review of the facility's Policy and Procedures (P&P), titled, Oxygen Equipment, undated, the P&P indicated, .PROCEDURE FOR OXYGEN EQUIPMENT - The following is the procedure for oxygen equipment .Tubing should be replaced every Sunday 11:00 pm - 7:00 am and/or PRN by Charge Nurse . Cannulas should be replaced every Sunday 11:00 pm - 7:00 am and/or PRN by Charge Nurse . 7. During a concurrent interview and record review on 11/15/23 at 3:13 p.m., with the Infection Preventionist (IP) and Maintenance Director (MD), the Centers for Disease and Control Prevention (CDC) Legionella Environmental Assessment Form (LEAF), was reviewed. When asked, the MD stated he filled out the LEAF for the facility on 11/6/23. MD stated the LEAF was to be done once a year. MD stated the LEAF was not done last year because he did not receive the form. When asked about the purpose of the LEAF, the MD stated he did not know. MD explained he did not know exactly what the LEAF was for. When asked how the LEAF was to be used and who should perform the assessment, the MD and the IP confirmed the LEAF was not properly completed and done by an appropriate person. During a concurrent interview and record review on 11/15/23 at 4:59 p.m., with the Infection Preventionist (IP), the facility's Legionella Risk Assessment (LRA), undated document, was reviewed. The IP stated the LRA was signed by the Maintenance Director (MD). IP confirmed the responses to the LRA were not accurate. IP stated he will discuss the matter with the MD. IP acknowledged the facility did not have a water management program to prevent Legionnaire's Disease (a type of pneumonia [lung inflammation] usually caused by infection from Legionella bacteria. During an interview on 11/16/23 at 1:37 p.m., with the Administrator (ADM) and Infection Preventionist (IP), the ADM and IP did not know the nationally accepted standards, used by the facility in their water management program, to reduce the risk of growth and spread of Legionella. Review of the facility's Policy and Procedures (P&P), titled, Policy for Legionnaire's Disease (Legionella Pneumophila, dated 06/2017, the P&P indicated, Policy: It is the policy of the facility to have a plan for the prevention of Legionnaire's disease .Process to Develop a Water Management Program - The facility will complete a Legionella Risk Assessment to determine their risk for Legionella outbreaks. This assessment will be completed annually. The facility will develop a Water Management Program which will be reviewed annually . Review of the facility's Policy and Procedures (P&P), titled, Legionella Water Management Program, revision dated 7/2017, the P&P indicated, .Policy Interpretation and Implementation .The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a Legionella water management program .The Water Management Program will be reviewed at least once a year, or sooner . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 19 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8. During a concurrent observation and interview on 11/15/23, at 10:48 a.m., with the Housekeeping Manager (HMR) present, inside facility's laundry room, there was a white trash bin, in between a washing machine and covered linen cart. The trash bin had trash inside and was not covered. The HMR stated the trash bin had to be covered. 9. During a concurrent observation and interview on 11/15/23, at 10:53 a.m., with the HMR present, inside facility's laundry room, there was an uncovered bin that contained mopheads, cleaning towels and dusters. There were mopheads hanging from the edges of the uncovered bin. When asked, HMR stated the mopheads were laundered and had to be air dried. When asked if all the other items inside the bin were dry, HMR stated some mopheads, cleaning towels and dusters inside the bin were still wet while some were completely dry. HMR confirmed the items were laundered but were not properly dried and stored. 10. During a concurrent observation and interview on 11/15/23, at 11:40 a.m., with the HMR present, inside facility's soiled linen room, there was a pile of clothing on top of a box. The HMR confirmed the items were soiled and unlabeled. The HMR stated soiled clothing items should be placed in a designated soiled bin container and covered. Review of the facility's Policy and Procedures (P&P), titled, Laundry and Linen Handling, revision dated 12/8/22, the P&P indicated, Purpose: To provide a process for safe handling, washing and storage of linen and laundry. Policy: All linen in a skilled nursing facility is considered potentially infectious and should be handled at the highest level of protection . All soiled linen must be placed directly into a covered hamper which can contain moisture . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 20 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to offer pneumococcal immunization for one of five sampled residents (Resident 31). Residents Affected - Few This failure had the potential to not help protect Resident 31 against serious illnesses like pneumonia (lung infection). Findings: During a concurrent interview and record review on 11/15/23 at 4:31 p.m., with the Infection Preventionist (IP), Resident 31's medical records were reviewed. Resident 31's Facesheet indicated an admission date of 9/10/23. IP confirmed Resident 31's Informed Consent for Pneumococcal Polysaccharide Vaccine, was not filled out. IP was unable to provide the status of Resident 31's pneumococcal immunization. IP stated informed consent for pneumococcal vaccinations should be done on admission of the resident into the facility. Review of the facility's Policy and Procedures (P&P), titled, Pneumococcal Vaccine, revision dated 10/2019, the P&P indicated, Policy Statement - All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation - 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 21 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of two washing machines in the laundry room was in operable condition. Residents Affected - Few This failure had the potential to disrupt laundry services provided to residents and staff in the facility. Findings: During an observation on 11/15/23, at 10:49 a.m., with the Housekeeping Manager (HMR) present, inside facility's laundry room, a washing machine had a white paper attached indicating OUT OF SERVICE. During an interview on 11/15/23, at 11:03 a.m., with the HMR, HMR stated the Maintenance Director (MD) was informed about a year ago, that the washing machine was not working. HMR stated she had not received an update about the washing machine from the Maintenance Department. During an interview on 11/15/23, at 11:28 a.m., with the MD, MD confirmed he was aware that one of the washing machines in the laundry room was out of service. MD stated he had called a vendor for a price quote but had not placed an order. Review of the facility's Daily Maintenance Reporting Log, dated 11/23/22, indicated a work request was made for one of washing machines in the laundry room. During an interview on 11/15/23, at 3:43 p.m., with the MD, MD stated it was not acceptable that the washing machine was not repaired or replaced for one year. MD stated the equipment should be repaired or replaced immediately or in one month. Review of the facility's Policy and Procedures (P&P), titled, Maintenance Service, revision dated 12/2009, the P&P indicated, Policy Statement - Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation - 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to . Establishing priorities in providing repair service . Providing routinely scheduled maintenance service to all areas . 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 4. A copy of the maintenance schedule shall be provided to each department director so that appropriate scheduling can be made without interruption of services to residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 22 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility had seven resident rooms (Rooms 8, 9, 10, 11, 12, 14, and 15) with multiple beds that provide less than 80 square feet (sq. ft.) per resident who occupy these rooms. The deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of the residents' belongings. Findings: During observations of care and services from 11/13/23 through 11/16/23, the following rooms and corresponding square footage per bed were identified: room [ROOM NUMBER] has three beds, total sq. ft. is 209.84 and 69.9 sq. ft. per bed. room [ROOM NUMBER] has three beds, total sq. ft. is 206.4 and 68.8 sq. ft. per bed. room [ROOM NUMBER] has two beds, total sq. ft. is 159.46 and 79.7 sq. ft. per bed. room [ROOM NUMBER] has two beds, total sq. ft. is 148.74 and 74.4 sq. ft. per bed. room [ROOM NUMBER] has three beds, total sq. ft. is 211.06 and 70.3 sq. ft. per bed. room [ROOM NUMBER] has three beds, total sq. ft. is 209.33 and 69.8 sq. ft. per bed. room [ROOM NUMBER] has three beds, total sq. ft. is 208.12 and 69.4 sq. ft. per bed. During random observations of care and services from 11/13/23 through 11/16/23, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/ or safety concerns in the seven rooms. Granting of room size waiver recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 23 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of 13 sampled residents (Resident 23), had a call light that was easily accessible. This failure had the potential to neglect Resident 23's call for help in an emergency. Residents Affected - Few Findings: During a review of Resident 23's admission Record, dated 11/14/23, the record indicated Resident 23 was admitted 06/2023 with a diagnosis of Quadriplegia (partial or complete paralysis of both the arms and legs), unspecified. During a review of Resident 23's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 8/14/23, the MDS indicated Resident 23's 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. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15. During a concurrent observation and interview on 11/13/23, at 2:35 p.m., with Resident 23, in Resident 23's room, their call light was observed under the bed. Resident 23 stated they couldn't reach the call light. Furthermore, Resident 23 stated they couldn't use the call light because they had to keep pressure on the call light button with their head and neck or it would shut off. Resident 23 stated he couldn't hold it long enough for staff to see it because it made him tired. Resident 23 stated he used his personal cell phone to call the front desk when he needed help since he couldn't use his call light. During a concurrent observation and interview on 11/13/23, at 2:41 p.m., with Certified Nursing Assistant 1 (CNA), in Resident 23's room, Resident 23's call light was observed hanging under the bed. CNA 1 stated the call light was not reachable and clipped it on Resident 23's pillow. CNA 1 stated the call light only came on with pressure, and when the pressure was released, the light went off. CNA 1 stated staff wouldn't know if Resident 23 needed help, unless Resident 23 applied pressure to the call light with his head and left it there till staff saw the light. CNA 1 stated Resident 23 didn't want to use the call light because he didn't want to constantly lean on it. CNA 1 stated call lights were important when residents needed help and for emergencies. During an interview on 11/14/23, at 11:14 a.m., with Director of Nursing (DON), DON stated Resident 23's call light was replaced. DON stated call lights should be easily accessible and were important because it allowed residents to call for help. During a concurrent observation and interview on 11/16/23, at 8:38 a.m., with Resident 23, in their Resident 23's room, Resident 23's call light was observed next to them on their pillow. The call light turned on and remained on with one tap and turned off after staff reset it. Resident 23 stated the new call light was ok. During an interview on 11/16/23, at 8:48 a.m., with Licensed Vocational Nurse 3 (LVN), LVN 3 stated Resident 23 used their cell phone to call the front desk when they needed help. LVN 3 stated their cell phone may not have been effective to call for help because the phone line could have been busy. LVN 3 stated call lights should have been easily accessible so residents could have called for help in an emergency. LVN 3 stated Resident 23 had a hard time with his old call light because he was a quadriplegic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056350 If continuation sheet Page 24 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of Residents 23's care plan Fall Risk Prevention & Management, revised 09/2023, the care plan indicated Resident 23 was a fall risk and interventions included Call light within reach . Remind resident to use call light. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised October 2010, the P&P indicated The purpose of this procedure is to respond to the resident's requests and needs . When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Event ID: Facility ID: 056350 If continuation sheet Page 25 of 25