Health inspection·October 26, 2023

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS, an assessment tool used to guide resident care) were completed and submitted within the required timeframes for three of 22 sampled residents (Resident 17, Resident 20, and Resident 21). Resident 17, Resident 20, and Resident 21's quarterly MDS' were not completed within 14 days of the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items) and were not submitted within 14 days from the completion of the MDS Assessments. Residents Affected - Few These deficient practices had the potential to result in Resident17, Resident 20, and Resident 21 not receiving the appropriate care and services needed based on their current health status. Findings: A review of Resident 17's admission Record, printed 10/26/23, indicated Resident 3 was admitted to the facility in 2022 with diagnosis of rheumatoid arthritis (a chronic disease that causes severe inflammation of the joints). A review of Resident 20's admission Record, dated 10/26/23, indicated Resident 20 was admitted to the facility in 2022 with diagnosis of dementia (memory loss). A review of Resident 21's admission Record, dated 10/26/23, indicated Resident 21 was admitted to the facility in 2022 with diagnosis of hypertension (high blood pressure). During a concurrent interview and record review on 10/26/23, at 10:06 a.m., with the MDS Coordinator, Resident 17, Resident 20, and Resident 21's MDS Assessments were reviewed. The MDS Coordinator stated a quarterly MDS should have been completed no later than 14 days from the ARD and submitted no later than 14 days from the completion of the MDS Assessment. MDS Coordinator stated Resident 17, Resident 20, and Resident 21 had delayed completion and submission of quarterly MDS Assessments. Resident 17's quarterly MDS Assessment indicated an ARD of 8/18/23 and was 55 days overdue. Resident 20's quarterly MDS Assessment indicated an ARD of 7/29/23 and was 75 days overdue. Resident 21's quarterly MDS Assessment indicated an ARD of 8/12/23 and was 61 days overdue. During an interview on 10/26/23, at 10:34 a.m., with the MDS Resource, MDS Resource stated resident assessments should be completed and submitted in a timely fashion to effectively provide appropriate resident care. A review of the MDS Manual, Centers of Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, dated October 2023, indicated, For Quarterly Assessment (Non-Comprehensive), the MDS Completion Date must be no later than 14 days from the ARD and the Transmission Date (submission of assessment electronically) no later than 14 days from the MDS Completion Date . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555113 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the Discharge Assessment Minimum Data Set (MDS, an assessment tool used to guide resident care) were completed no later than 14 calendar days after the discharge date and submitted no later than 14 days after the MDS completion for four of 22 sampled residents (Resident 3, Resident 16, Resident 20, and Resident 23). Residents Affected - Few This failure resulted in delayed completion and submission of Resident 3, Resident 16, Resident 20, and Resident 23's MDS Discharge Assessments. Findings: A review of Resident 3's admission Record, printed 10/26/23, indicated Resident 3 was admitted to the facility in 2020 with diagnosis of heart disease. A review of Resident 16's admission Record, printed 10/26/23, indicated Resident 16 was admitted to the facility in April 2023 with diagnosis of metabolic encephalopathy (a condition in which brain function is disturbed). A review of Resident 20's admission Record, printed 10/26/23, indicated Resident 20 was admitted to the facility in 2022 with diagnosis of dementia (memory loss). A review of Resident 23's admission Record, printed 10/26/23, indicated Resident 23 was admitted to the facility in May 2023 with diagnosis of fracture of the right femur (broken thighbone). During a concurrent interview and record review on 10/26/23, at 10:06 a.m., with the MDS Coordinator, Resident 3, Resident 16, Resident 20, and Resident 23's MDS Assessments were reviewed. The MDS Coordinator stated a discharge MDS should be completed and transmitted within 14 days of a resident's discharge. MDS Coordinator stated Resident 3, Resident 16, Resident 20, and Resident 23 had delayed completion and submission of MDS Assessments. Resident 3's Discharge MDS Assessment indicated an ARD of 8/21/23 and was 52 days overdue. Resident 16's Discharge MDS Assessment indicated an ARD of 8/1/23 and was 72 days overdue. Resident 20's Discharge MDS Assessment indicated an ARD of 8/15/23 and was 58 days overdue. Resident 23's Discharge MDS Assessment indicated an ARD of 7/28/23 and was 76 days overdue. During an interview on 10/26/23, at 10:34 a.m., with the MDS Resource, MDS Resource stated resident assessments should be completed and submitted in a timely fashion for a more accurate staffing and quality measure counting. A review of the MDS manual, Centers of Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, dated October 2023, indicated, For Discharge Assessment - return not anticipated (Non-comprehensive), the MDS Completion Date must be no later than 14 days after the discharge date and Transmission Date (submission of assessment electronically) no later than 14 days after the MDS Completion . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555113 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain good personal hygiene for three of 22 sampled residents (Resident 30, Resident 234, and Resident 11). Residents Affected - Some This failure resulted in Resident 30, Resident 234, and Resident 11's missed scheduled showers and a potential to cause low self-esteem and embarrassment to the residents. Findings: 1. A review of Resident 30's admission Record, dated 10/25/23, indicated Resident 30 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a condition in which brain function is disturbed), prostate cancer, and muscle weakness. A review of Resident 30's clinical record titled, Brief Interview for Mental Status (3.0 BIMS - a brief screener that aides in detecting cognitive impairment), dated 10/9/23, indicated a score of 9 (moderately intact). A review of Resident 30's clinical record titled, Plan of Care (POC) Response History, subtitled, Task: SELF CARE: Shower/Bathe Self and mobility: Tub/Shower Transfer, 30-day look-back, dated 10/22/23, indicated only a bed/towel bath was provided. Further review of Resident 30's clinical record titled, Skin Check Sheet, resident's last recorded shower was dated 9/7/23. A review of the facility's Shower Schedule, indicated Resident 30 was scheduled to have showers two times per week during the morning shift between the hours of 7 a.m.-3:30 p.m During a concurrent observation and interview on 10/23/23, at 10:21 a.m., Resident 30 had a noticeable thick beard and mustache. Resident 30 stated he preferred to be shaved during showers but had not been showered regularly as scheduled. Resident 30 stated his last shower was two weeks ago. During a concurrent interview and record review on 10/25/23, at 9:50 a.m., with the DSD, Resident 30's clinical records were reviewed. DSD stated Resident 30 had no documented showers for at least a month. DSD also stated showers were documented either on POC Response History or Skin Check Sheet. DSD stated the CNAs needed training on documentation, either in POC or the shower sheet, and needed reminders to provide residents showers as scheduled or as needed. 2. A review of Resident 234's admission Record, dated 10/25/23, indicated Resident 234 was admitted to the facility 9/28/23 with diagnoses of metabolic encephalopathy and muscle weakness. A review of Resident 234's clinical record titled, Brief Interview for Mental Status (3.0 BIMS), dated 10/2/23, indicated a score of 12 (cognitively intact). A review of Resident 234's clinical record titled, POC Response History, subtitled, Task: SELF CARE: Shower/Bathe Self and mobility: Tub/Shower Transfer, 30-day look-back, dated 10/22/23, indicated only a bed/towel bath was provided. A review of Resident 234's Care Plan on ADL self-performance and support, initiated on 9/30/23, indicated, Self-Care Deficit as evidenced by - Requiring assistance or is dependent in .Bathing . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555113 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's Shower Schedule, indicated Resident 234 was scheduled to have showers two times per week during the evening shift between the hours of 3-11:30 p.m. During an interview on 10/23/23, at 10:30 a.m., with Resident 234, Resident 234 stated she had only showered once, which was more than three weeks ago, since admission to the facility. Resident stated she wished she had more showers, at least twice a week. During an interview on 10/25/23, at 11:27 a.m., with the Certified Nursing Assistant 1 (CNA 1), CNA 1 stated regular showers were important to keep the residents refreshed, to check the resident's skin, and to moisturize and avoid skin breakdown. During an interview on 10/24/23, at 2:10 p.m., with the Director of Staff Development (DSD), DSD stated residents were showered at least two times a week, during morning or evening shift, and were provided bed baths during non-shower days. A review of the facility's policy and procedure (P&P) titled, Shower Policy, indicated, It is the policy of this facility to shower or bathe residents at least two times per week and identify any pertinent skin issues with residents during routine inspections of residents at shower/bath times . 3. A review of Resident 11's admission Record [face sheet] indicated, Resident 11 was admitted to the facility on [DATE] with multiple diagnosis including liver cancer. During an interview on 10/24/23, at 09:59 a.m., Resident 11 stated she did not have any shower since admitted to the facility and she is concerned about her hygiene. A review of Resident 11's Shower Schedule indicated Resident 11 should have received a shower twice a week. During a concurrent record review and interview on 10/25/23, at 11:00 a.m., with the Director of Staff Development (DSD), DSD reviewed the POC Response History [shower sheet] and confirmed that the Certified Nurse Assistant (CNA) documented two times showers not applicable on 10/11/23 and 10/17/23. DSD stated CNAs should document resident's shower every time and not document not applicable, instead documenting the showers in detail. DSD was not able to provide any other documents that showed Resident 11 had a shower twice a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555113 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week when the facility did not have RN in all weekends since August/2023. This failure resulted in not following the CMS regulation and not having RNs to do the staff supervision, emergency coordinator, physician liaison, as well as direct resident care. Findings: A review of RN schedule for weekends indicated the RN was missing on the schedule for four days on the weekends for the dates of 10/21/23, 10/14/23, 10/7/23 and 10/8/23. During an interview on 10/25/23, at 11:14 a.m., with the Director of Nursing (DON), DON stated that they did not have RN coverage for some days on the weekends. DON stated having an RN is important every day because they need to have supervision of the other facility staff, and that is a requirement of the Centers of Medical and Medicare Services (CMS). DON also stated the facility policy follows the CMS requirement. A review of CMS regulation for the facility's RN schedule indicated §483.35(b) Registered nurse §483.35(b)(1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555113 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612 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 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. Based on observation, interview, and record review the facility failed to: 1. maintain an accurate accountability sheet that documented the number of controlled substances (Diazepam tablets) that should be available for destruction and 2. provide pharmaceutical services including the provision of routine medications to meet the needs of one of seven (Resident 19) sampled Residents. These failures had the potential to cause diversion of controlled medication (illegal use of medication not intended by the provider) and adverse health outcomes related to incorrect medication administration. Findings: 1. A review of Resident 19's Controlled Drug Record indicated that Resident 19 was discharged from the facility on 10/10/23 with sixteen tablets of diazepam (controlled medication for treatment of anxiety) 5 mg tablets. During a concurrent observation and interview on 10/24/23, at 2:32 pm, with the DON (Director of Nursing), in the DON's office, it was observed there were additional diazepam tablets for Resident 19 stored in her office cabinet for destruction. The DON counted a total of 30 diazepam tablets, but there was no controlled accountability sheet associated with the medication. The DON stated that every controlled drug medication should have an accountability sheet, but she could not find one for the diazepam tablets belonging to Resident 19. During a concurrent interview on 10/24/23, at 2:37 pm, the DON stated when a controlled medication is in need of destruction, both the nurse and the DON would review and fill out the accountability sheet to verify the quantity to be destroyed. The DON stated when the medication is given to the DON for destruction, the accountability sheet and the medication are then kept in a locked cabinet in the DON's office to be verified and destroyed with their pharmacist later. During a review of the facility's policy and procedure (P&P) titled, Controlled Medication Storage, dated 8/2014, the P&P indicated, Current controlled medication accountability records are kept at nursing station. When completed, accountability records are kept on file for 1 year at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555113 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and document reviews, the facility failed to ensure its medication error rate was less than 5% for two of seven sampled residents (Resident 22 and Resident 234) when the medication error rate was 16/67%. Residents Affected - Some This failure had the potential for adverse health outcomes related to incorrect medication administration. Findings: 1. During an observation on 10/23/23, at 10:06 a.m., Licensed Vocational Nurse 1 (LVN 1) administered a Multi-vitamin with Mineral Tablet, Aspirin (reduces pain, swelling and inflammation) 81 mg chewable tablet to Resident 22, but did not administer Solifenacin Succinate (used to treat bladder problems) Oral Tablet 5 mg to Resident 22. During a record review of Resident 22's Order Summary Report, dated 10/23/23, the Order Summary Report indicated, Multivitamin & Mineral Oral Liquid (1 ml by mouth one time a day), Solifenacin Succinate Oral Tablet (5 mg by mouth one time a day), and [NAME] Aspirin Oral Tablet (no strength in mg noted, 1 tablet by mouth one time a day). During a record review of Resident 22's Medication Administration Record (MAR), dated October 2023, the MAR indicated, [NAME] Aspirin Oral Tablet (no strength listed) and Multi-vitamin & Mineral Oil Liquid was administered to Resident 22 on 10/23/23 at 9:00 a.m. The MAR also indicated, Solifenacin Succinate Oral Tablet was administered to Resident 22 at 10/23/23 at 9:00 a.m. During an interview on 10/23/23, at 2:17 p.m., with LVN 1, LVN 1 stated the facility did not carry [NAME] Aspirin so she gave what she assumed to be correct (Aspirin 81 mg) to Resident 22. LVN 1 stated she should have confirmed the strength of the medication with the physician. LVN 1 also stated that the facility did not have Multi-Vitamin Liquid & Mineral Oil Liquid on hand, so she gave the caplet form so that the resident received the medication. LVN 1 stated she thought she gave Solifenacin Succinate Oral Tablet to Resident 22 and stated, I must have missed that one. A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated December 2012, the P&P indicated, Medications must be administered in accordance with the orders, including any required time frame. 2. During an observation on 10/23/23, at 10:51 a.m., with LVN 1, LVN 1 gave Resident 234 Calcium + Vitamin D (maintains bone and heart health) 500 mg/200 IU Caplet but did not give 10 mg Prednisone (reduces inflammation) Oral Tablet or Lovenox (prevents formation of blood clots) injection as ordered. LVN 1 also applied a Lidocaine 5% (prevents pain) patch to Resident 234's right shoulder. During a record review of Resident 234's Order Summary Report, dated 10/23/23, the Order Summary Report indicated, Lidocaine External Patch (5% apply to left ankle topically one time a day for pain and remove per schedule), Lovenox Injection Solution Prefilled Syringe (40mg/0.4ML inject subcutaneously one time a day), Oyster Shell Oral Tablet (500 mg 2 tablets by mouth two times a day) and Prednisone Oral Tablet (10 mg 1 table by mouth one time a day for pain). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555113 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a record review of Resident 234's Medication Administration Record (MAR), dated October 2023, the MAR indicated Lovenox Injection and Prednisone Oral Tablet was not administered to Resident 234 on 10/23/23 at 9:00 a.m. The MAR also indicated the Lidocaine Patch 5% was applied to Resident 234's right shoulder and Resident 234 was administered Oyster Shell Tablet 500 mg at 9:00 a.m. on 9/23/23. During an interview on 10/23/23, at 2:27 p.m., LVN 1 stated that although there is no order for Lidocaine Patch to be placed on right shoulder, she applied it there because the resident requested it. LVN 1 stated she could not administer the Lovenox and the Prednisone to Resident 234 because the facility did not have it in stock. She stated that the medications were ordered from the pharmacy, but they did not always arrive timely, especially prior to weekends. LVN 1 stated that she gave Calcium 500 mg + Vitamin D to Resident 234 (instead of the ordered medication Oyster Shell 500 mg), because that is what the facility had on hand. During an interview on 10/24/23 at 10:36 a.m., Licensed Vocational Nurse 2 (LVN 2) stated medications for Resident 234 (Lovenox Injection and Prednisone tablet) were not yet received from pharmacy, and Resident 234 had not received the medications again on this date. LVN 2 stated that she often had to call the pharmacy to prompt them to send medications in a timely manner. A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated December 2012, the P&P indicated, Medications must be administered in accordance with the orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555113 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612 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 - Immediate jeopardy to resident health or safety Residents Affected - Many 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 records review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 18 out of 18 sample selected residents (Resident 234, 22, 30, 8, 237, 236, 10, 235, 21, 27, 17, 134, 137, 11, 135, 136, 31 and 138) who were residing at the facility and receiving food from the facility's kitchen when: 1. Facility did not ensure food temperatures were checked before serving to all 18 residents (IJ). 2. Multiple Dietary staff did not wear hair nets and beard nets while working in the kitchen. 3. A Dietary staff did not wash hands upon entering the kitchen. 4. 24 plated foods were stored in the refrigerator without covers and three of three-gallon tub ice creams with no lids were stored in the freezer. 5. Ice Cream freezer had frost around the rim and inside the freezer. 6. Multiple items in the walk-in freezer were undated and unlabeled. 7. [NAME] used water instead of nutrient fluids for making pureed food. These failures had the potential to result in the outbreak of foodborne illness that affected the 18 residents who resided in the facility. On 10/24/23, at 1:16 p.m., the facility Administrator (ADM), Director of Nursing (DON) and Operation Director (OD) were informed of an Immediate Jeopardy situation (IJ - a situation in which the provider's noncompliance with requirements has caused or is likely to cause serious injury, harm, impairment, or death to a resident), for failure to ensure adequate cooking and proper holding temperatures. (Poorly cooked food or food that is not held at appropriate temperatures may promote the growth of pathogens that cause food-borne illness). The IJ lifted on 10/25/23 at 10:30 a.m., when the facility submitted an acceptable plan of action; Dietary manager finished in-servicing kitchen staff on checking food temperature before serving and set up the system in place to record the food temperature for each meal in the kitchen. Findings: A review of the facility's Diet Type Report, dated 10/25/23, indicated 18 residents received food from the facility's kitchen. 1. During a concurrent observation and interview on 10/24/23, at 11:00 a.m., the Head [NAME] (HC) prepared food on plates to pass to staff for serving to residents, and HC did not check the food's temperature before putting the food on the plates. HC stated, we don't check the food temperature, and the facility did not have a temperature log to record the food temperature. During an interview on 10/24/23, at 11:00 a.m., with [NAME] 2, [NAME] 2 stated the facility did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555113 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612 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 check the food's temperature and did not have a temperature log to record the food temperature. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 10/24/23, at 11:00 a.m., with the Dietary Manager (DM), DM confirmed that HC did not check the food temperature before serving, the facility did not have a food temperature log and checking the food temperature before serving was important to prevent foodborne illnesses in the residents. Residents Affected - Many During a concurrent observation and interview on 10/24/23, at 11:30 a.m., with DM, surveyor checked the food temperature inside the chafing dishes and the following food items with the following temperatures were observed: the temperature of cooked chicken for chicken sandwiches was 110 degrees Fahrenheit (F-a scale of temperature), the temperature of cooked shrimp for shrimp sandwiches was 85 degrees F, the temperature of cooked sweet potatoes was 100 degrees F, the temperature of cooked spinach was 150 degrees F, and the temperature of the soup was 140 degrees F. A review of the facility menu titled, Lake Park Healthcare Center Weekly Menu: Fall/Winter 2023 Week 2, indicated the menu for the date of 10/24/23 for lunch was Ham and bean soup, Coleslaw, Grilled shrimp po boy or chicken patty sandwiches, sweet potato rounds, southern style spinach, southern fudge pie. A review of the facility's policy and procedure P&P titled, Food Temperatures, undated, indicated . 6. the following range of temperatures is recommended for food at point of tray assembly. a. Broth, soup, hot beverages: 180-190 degrees F, b. Meat, portioned for service: 160 degrees F, Casserole dishes, creamed items, creamed soups: 160 degrees F, Potatoes and vegetables: 160 degrees F, . 2. During an observation on 10/23/23, at 10:14 a.m., [NAME] 1, [NAME] 2 and Chef were not wearing a hairnet/beard net while preparing lunch in the kitchen, and on 10/24/23, at 10:30 a.m., HC was working in the kitchen with a long beard and without wearing a beard net. During an interview on 10/24/23, at 10:30 a.m., with HC, HC stated wearing a beard net and hairnet is important for infection control. A review of the facility policy and procedure (P&P) titled, Personal Hygiene, undated, indicated . if hair is long and not covered properly with the cap, a hair net must be worn . 3. During a concurrent observation and interview on 10/23/23, at 10:14 a.m., Chef entered the kitchen and started to move food out of a shopping bag without washing his hands. Chef confirmed he had not washed his hands prior to moving food out of the shopping bag. A review of the facility policy and procedure (P&P) titled, Personal Hygiene, undated, indicated . Hands must always be washed prior to beginning work . 4. During a concurrent observation and interview on 10/23/23, at 10:14 a.m., 24 plated foods (including: boiled eggs, cheese, ham and vegetables) were stored in the refrigerator without covers, and three-three gallon ice cream tubs had no lids and were stored in the freezer. Chef confirmed the food items were not covered and stated those items needed to be covered for infection control. A review of the facility (P&P) titled, Lake Park Healthcare Center Weekly Menu: Fall/Winter 2023 Week 2, indicated the menu for the date of 10/23/23 for breakfast was scrambled egg or boiled egg, bacon, cream of wheat, breakfast bread, seasonal fruit and Jelly/Margarine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555113 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612 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 - Immediate jeopardy to resident health or safety Residents Affected - Many A review of the facility policy and procedure (P&P) titled, Food Storage, undated, indicated . 15. Leftover food is stored in covered containers or wrapped carefully and securely . A review of the facility policy and procedure (P&P) titled, Procedure for Refrigerated Storage, dated 2018, indicated . 5. Food should be covered and stored loosely to permit circulation of air . 5. During a concurrent observation and interview on 10/23/23, at 10:14 a.m., with Chef, ice cream freezer had frost around the rim and inside the freezer. Chef confirmed there was frost around the rim and inside the freezer and stated there should not be any frost in the freezer. DM was not able to provide any policy related to freezer with frost. 6. During a concurrent observation and interview on 10/23/23, at 10:14 a.m., with Chef, three packages of pork and two bags of bread were found undated and unlabeled in the walk-in freezer. Chef confirmed the pork and two bags of bread were undated and unlabeled and stated they should have dates and labels. A review of the facility's policy and procedure (P&P) titled, Procedure for Refrigerated Storage dated 2018, indicated . 9. Food items should be arranged so that older items will be used first. Dating the packages or containers will facilitate this practice . 7. During a consecutive interview and observation on 10/24/23, at 11:00 a.m., with HC, HC added water instead of nutritive fluid such as milk or broth to shrimp sandwiches to make puree. HC stated he did not know that he could not add water to make puree. A review of the facility recipe titled, Shrimp Grilled Po Boy-4484, Recipe Summary card, indicated . Puree steps: Remove desired number of servings and add nutritive liquid, milk, broth . A review of the facility policy and procedure (P&P) titled, Pureed Food Preparation, undated, indicated . never use water. Only use nutritive liquids such as broth, milk . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555113 If continuation sheet Page 12 of 12