Health inspection·February 10, 2022

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the food quality and integrity of stored food items when: Residents Affected - Some 1. In the kitchen's dry storage room, there were eight bags of marshmallows dated 8/25/21, three months past the recommended storage guideline of two months. 2. In the kitchen's dry storage room, there were two bags of hotdog buns dated 10/20/21, 14 weeks past the recommended storage guideline of seven days. This failure had the potential to result in the residents being offered less palatable food, which could result in less food intake and weight loss, or potentially developing food-borne illness. Findings: During a concurrent observation and interview in the kitchen on 2/7/22, at 11:30 a.m., with the Director of Food and Nutrition Services/Dietary Manager (DM), the DM confirmed the dry storage room contained the following items: 1. There were eight bags of marshmallows with a handwritten date of 8/25/21. Three of the eight packages had marshmallows stuck together along the inside of the bags with a texture not as soft as the rest of the contents. 2. There were two bags of hotdog buns with a handwritten date of 10/20/21. Parts of some of the hotdog buns were not as soft and tender as the other hotdog buns. The DM stated the dates on the bags of marshmallows and hotdog buns indicated the items should have already been discarded. During a concurrent interview and record review on 2/7/22, at 11:45 a.m., with DM, the facility food storage policies and procedures were reviewed. The DM stated the facility policy and procedure (PNP), RDs [registered dieticians] for Healthcare, Inc. 2018, Dry Goods Storage Guidelines, dated 2018, indicated the storage length guidelines for dry good storage. The DM confirmed the PNP indicated the recommend shelf storage time for unopened bread was 5-7 days; the recommended shelf storage time for unopened bags of marshmallows was two months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056457 If continuation sheet Page 2 of 4 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 056457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenridge Post Acute 2150 Pyramid Drive El Sobrante, CA 94803 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 3. During a continuous observation on 2/8/22, from 4:30 p.m. to 4:45 p.m., Licensed Vocational Nurse 2 (LVN 2) stood at the medication cart in the doorway to Resident 25's room and prepared medications for Resident 25. LVN 2 carried the prepared medications in a cup into Resident 25's room and handed Resident 25 the medication cup. Resident 25 took the medications and returned the empty cup to LVN 2, who threw the cup in a trash can, and exited the room without performing any hand hygiene. Residents Affected - Some 4. During a continuous observation from 4:45 p.m. to 5 p.m., LVN 2 left Resident 25's room and went directly to the medication cart, without performing hand hygiene. LVN 2 moved the medication cart down the hall to the doorway of Resident 8's room, and without performing hand hygiene, LVN 2 crushed pills and mixed them into applesauce in a small cup. LVN 2 took the applesauce cup into Resident 8's room and fed Resident 8 the applesauce-medication mixture. LVN 2 discarded the empty applesauce cup and exited Resident 8's room without performing any hand hygiene during the observation. During a telephone interview on 2/10/22, at 11:30 a.m., with LVN 2, LVN 2 stated the residents were not on any special isolation precautions and she believed she had followed all infection control measures when passing medications to Resident 25 and Resident 8. During an interview on 2/9/2022, at 1:44 p.m., with DSD/IP, DSD/IP stated staff were to wash their hands or use hand sanitizer each time they changed gloves and before and after resident care. A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated 8/2015, indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . Before and after direct contact with residents; Before preparing or handling medications; . Before handling clean or soiled dressings, gauze pads, etc.; .After handling used dressings, contaminated equipment, etc. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Based on observation, interview, and record review, the facility failed to ensure three nursing staff performed required hand hygiene (handwashing or use of an alcohol-based hand sanitizer) for four of 12 sampled residents (Residents 39, 2, 8, and 25) when: 1. The Director of Nursing (DON) failed to perform hand hygiene between doffing soiled gloves and donning new gloves during Resident 39's wound dressing changes for two separate wounds. 2. Licensed Vocational Nurse 1 (LVN 1) failed to perform hand hygiene between doffing soiled gloves and donning new gloves during Resident 2's wound dressing change. 3. Licensed Vocation Nurse 2 (LVN 2) failed to perform hand hygiene before and after direct contact with Resident 8 to administer medication. 4. Licensed Vocation Nurse 2 (LVN 2) failed to perform hand hygiene before preparing medication for Resident 25, and before and after direct contact with Resident 25 to administer medication. These failures had the potential to cause infection or spread infection which could result in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056457 If continuation sheet Page 3 of 4 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 056457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenridge Post Acute 2150 Pyramid Drive El Sobrante, CA 94803 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 hospitalization for Resident 2, Resident 39, Resident 8, and Resident 25. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Some 1. During a concurrent observation and interview on 2/8/2022, at 10:00 a.m., with the Director of Nursing (DON), in Resident 39's room, Resident 39 lay on her left side with one dressing on her mid-back, and one dressing on her coccyx (commonly called the tailbone). The DON performed a dressing change on Resident 39's mid-back wound: the DON removed the soiled dressing from Resident 39's wound, changed gloves, cleaned the wound, changed gloves, measured the wound, changed gloves, applied ointment to the wound bed, changed gloves, and placed a new dressing over the wound. The DON did not perform hand hygiene between any glove change during the dressing change procedure. The DON changed her gloves and repeated the process on Resident 39's coccyx wound, without any intervening hand hygiene between the mid-back and coccyx wound dressing changes. The DON stated hand hygiene was not necessary between glove changes during a procedure on the same resident. 2. During a concurrent observation and interview on 2/10/2022, at 12:11 p.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 2's room, Resident 2 lay on her right side with a dressing on her coccyx. LVN 1 performed a dressing change on Resident 2's coccyx wound: LVN 1 removed the soiled dressing, applied powder to the wound edges, changed gloves, and placed a new dressing over the wound. LVN 1 did not perform hand hygiene when she changed gloves during the dressing change. LVN 1 stated hand hygiene was not necessarily done with the glove change since she had worked between two areas she considered clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056457 If continuation sheet Page 4 of 4