Health inspection·July 29, 2022

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to issue a notice of Transfer/Discharge to one of three closed record sampled residents (Resident 61) or the resident's representative and to the Office of the Ombudsman when Resident 61 was transferred to the acute care hospital. This failure had the potential to result in the lack of coordination and support for Resident 61 while he was in the acute care hospital. Findings: During a review of Resident 61's admission Record, dated 7/29/22, the admission Record indicated Resident 61's original admission date was 3/31/22 and current admission date was 6/15/22. During a review of Resident 61's Census List, dated 7/29/22, the Census List indicated, Resident 61 was Transferred Out to hospital on 6/7/22. During a review of Resident 61's Health Status Note, dated 6/7/22, the Health Status Note indicated Resident 61 had an episode of nausea, vomiting and diarrhea. The Health Status Note also indicated a doctor's order to monitor and to send Resident 61 to the emergency room (ER) if Resident 61 was unresponsive. During a review of Resident 61's eINTERACT SBAR (situation, background, assessment and recommendation) Summary for Providers, dated 6/7/22, the eINTERACT SBAR Summary for Providers, indicated that Resident 61 had abdominal pain, abnormal vital signs (blood pressure: 101/66; Pulse Rate: 121 beats per minute; respiratory rate: 23 cycles per minute), behavioral symptoms, diarrhea, gastrointestinal bleeding, nausea/vomiting, uncontrolled pain, tired, weak, confused or drowsy. The eINTERACT SBAR Summary for Providers also indicated, the recommendation of the doctor is if change of condition gets worse sent to the ER. During a review of Resident 61's Health Status Note, dated 6/9/22, the Health Status Note indicated, Resident 61 was sent to the emergency room before midnight on 6/7/22 due to tachycardia (an abnormally rapid heart rate) and altered mental status. During a concurrent interview and record review on 7/28/22, at 2:30 p.m., with Case Manager (CM), Resident 61's chart was reviewed. The chart did not have the form Notice of Proposed Transfer and Discharge in it. CM stated the completed form should be in the chart and if it is not in the chart, it was not done. Page 1 of 30 555313 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some During an interview on 7/29/22, at 7:15 a.m., with Social Service Director (SSD), SSD stated, she had a binder for the Notice of Proposed Transfer and Discharge forms for residents who discharged home but not for residents who transferred to the hospital. During a review of the facility's policy and procedure (P&P) titled, Notice of Transfer/Discharge, dated October 2017, the P&P indicated, A facility representative will retrieve the completed Notice of Proposed Transfer and Discharge form from the clinical record and mail/fax it to the resident, responsible party and Ombudsman, and document in the clinical record that the notice was mailed/fax, to whom it was mailed/fax and the date of the mailing/fax. A copy of the notice will be maintained in the medical record. The P&P also indicated, Exceptions to the thirty (30) day requirement apply when the transfer is effected because of: When a resident's urgent medical needs require immediate transfer. In these cases, the notice must be provided as soon as practicable prior to discharge. 555313 Page 2 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) to provide a written bed hold agreement notice to one of three closed record sampled residents (Resident 61) when Resident 61 was not provided the Bed Hold Agreement before being transferred to the hospital. This failure had the potential for Resident 61 to not be informed of the rights and benefits of bed hold and return policy to the facility. Findings: During a review of Resident 61's admission Record, dated 7/29/22, the admission Record indicated Resident 61's original admission date was 3/31/22 and current admission date was 6/15/22. During a review of Resident 61's Census List, dated 7/29/22, the Census List indicated, Resident 61 was Transferred Out to hospital on 6/7/22. During a review of Resident 61's Health Status Note, dated 6/7/22, the Health Status Note indicated Resident 61 had an episode of nausea, vomiting and diarrhea. The Health Status Note also indicated a doctor's order to monitor and send Resident 61 to the emergency room (ER) if Resident 61 was unresponsive. During a review of Resident 61's Health Status Note, dated 6/9/22, the Health Status Note indicated, Resident 61 was sent to the ER before midnight on 6/7/22 due to tachycardia (an abnormally rapid heart rate) and altered mental status. During a concurrent interview and record review on 7/28/22, at 2:30 p.m., with Case Manager (CM), Resident 61's chart was reviewed. The chart did not have the Bed Hold Agreement form for Resident 61's hospital transfer on 6/7/22 in it. CM stated the agreement form should be in the chart and if it is not in the chart it was not done. During a review of the facility's P&P titled, Bed Hold, dated July 2017, the P&P indicated, The Facility notifies the resident and/or representative, in writing, of the bed hold option, any time the resident is transferred to an acute care hospital or requests therapeutic leave. The P&P also indicated, Bed Hold Agreement will be kept in the resident's medical record. The completed form will remain in the medical record with a copy placed in the resident's financial folder in the Business Office. 555313 Page 3 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

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 4. A review of Resident 12's medical record indicated Resident 12's diagnoses included paralysis to the right side of his body and needed assistance with personal care. Resident 12's Brief Interview for Mental Status (BIMS, an assessment tool to measure mental status) score of 4, indicated severe mental impairment. Resident 12's Minimum Data Set (MDS- an assessment tool to guide care) for activities of daily living (ADL) indicated Resident 12 was dependent on staff to perform his personal hygiene. Residents Affected - Some A review of Resident 12's care plan titled, Potential for Impaired Skin Integrity, dated 4/25/22, indicated staff education on the importance of keeping Resident 12's skin clean and moisturized. During an observation on 7/26/22, at 10:13 a.m., at Resident 12's bedside with CNA 4, Resident 12's fingernails were long with thick black matter underneath. Resident 12's lower extremities were inspected. Above the ankles, Resident 12's skin was dry, cracked, and scaly. When CNA 4 removed resident's socks, flakes of skin scattered into the air and onto Resident 12's bed. Resident 12's heels were covered in a thick layer of dry and cracked skin. During an interview on 7/26/22, at 10:15 a.m., with CNA 4, CNA 4 stated she did not clean Resident 12's fingernails. CNA 4 further stated it was best to clean Resident 12's skin during a shower. CNA 4 stated she had not given Resident 12 a shower or a bed bath. CNA 4 stated did not know when Resident 12's shower days were scheduled. A review of the Resident Daily Shower Schedule indicated Resident 12's shower days were Monday mornings. During an interview on 7/28/22, at 10:48 a.m., with Director of Staff Development (DSD), DSD stated inspection of the skin was completed on shower days and documented by the CNAs and licensed nurses. DSD stated she would review the skin assessments for accuracy. The DSD stated she was unable to locate Resident 12's shower sheet form. DSD stated if it was not documented, it was not done. A review of the facility's policy and procedure on Grooming, dated 1/1/12, outlined the process of performing Nail Care and indicated a nail brush can be used to gently remove any particles under the nails. Based on observation, interview, and record review, the facility failed to provide personal care and grooming for four of 24 residents (Residents 165, 265, 6, and 12) who were unable to perform activities of daily living when: 1. Resident 165's fingernails and toenails were long, jagged, with brown substances underneath them; 2. Resident 265's fingernails were long with dark brown substances underneath them, and Resident 265 had dried food crumbs around his mouth and clothes; 3. Resident 6's fingernails were very long, with dark brown substance underneath his nails; and 4. Resident 12's fingernails were long with thick black matter underneath and Resident 12's legs were dry, cracked, and scaly. 555313 Page 4 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some These deficient practices had the potential for unmet personal care needs for Residents 165, 265, 6, and 12. Findings: 1. A review of Resident 165's admission Record indicated Resident 165's diagnoses included need for assistance with personal care. During a concurrent interview and observation on 7/25/22, at 10:15 a.m., at Resident 165's bedside, Resident 165's fingernails were long, jagged with dark brown substances underneath them. Resident 165's toenails were also long, jagged and with brown substances underneath them. Resident 165 removed his socks to reveal both his feet were covered with thick, dark, dry scales shedding off his feet. Resident 165 stated he has not had a shower for almost two months. 2. A review of Resident 265's admission Record indicated resident 265's diagnoses included need for assistance with personal care. During an observation on 7/25/22, at 10:50 a.m., Resident 265 was observed lying down in bed with his hands over his linens. Resident 265's fingernails were long with dark brown substance underneath his nails. Resident 265's clothes was observed covered with food crumbs. Resident 265's had dried crusts of food around his mouth. 3. Review of Resident 6's medical record indicated Resident 6's diagnoses included hemiplegia and hemiparesis (weakness or loss of strength on one side of the body). Resident 6's Minimum Data Set (an assessment tool to guide care) indicated Resident 6 was totally dependent on staff for personal hygiene. During an observation on 7/25/22, at 11:00 a.m., at Resident 6's bedside, Resident 6's fingernails were observed being very long, with dark brown substance underneath his nails. During an interview on 7/25/22, at 12:40 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Residents 165, 265 and 6 had very long nails and need their fingernails to be trimmed and cleaned. During an interview on 7/26/22, at 8:45 a.m., with Acting Director of Nursing (ADON), ADON stated the CNAs were supposed to trim non-diabetic residents' fingernails and toenails during their shower days and report their skin condition to the charge nurse. During a concurrent interview and record review on 7/26/22, at 11:00 a.m., with Case Manager (CM), CM was unable to provide the shower records for Residents 165, 265 and 6. 555313 Page 5 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

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 conduct a timely performance review and in-service training program for two of three sampled Certified Nursing Assistants (CNA 1 and 4) when CNA 1 and 4 did not complete their CNA skills observation checklist and 12-hour mandatory in-services within the past 12 months. Residents Affected - Some This failure had the potential for residents to receive incompetent care from CNA 1 and 4. Findings: During a record review of CNA 1's employee file, CNA 1 did not have a completed CNA skills observation checklist and the 12-hour mandatory in-services within the past 12 months. CNA 1's file indicated CNA 1 was hired on 12/2/05. During a review of CNA 4's employee file, CNA 4 did not have a completed CNA skills observation checklist and the 12-hour mandatory in-services within the past 12 months. CNA 4's file indicated CNA 4 was hired 4/21/20. During an interview on 7/27/22, at 1:05 p.m., with Quality Regional Management Consultant (QRMC) 2, QRMC 2 confirmed there were no CNA skills observation checklists completed within the past 12 months for CNA 1 and CNA 4. During a review of the facility's policy and procedure (P&P) titled, In-Service and Record Keeping, dated 2/20/20, indicated I. An in-service training program shall be developed, implemented, and maintained by the facility to ensure the continuing competency of all CNAs. The P&P further indicated a. Training program shall address specific needs of the facility's resident population, address areas for improvement determined through annual nurse performance reviews, facility deficiencies and annual facility assessment. 555313 Page 6 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Based on interview and record review, the facility failed to provide dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes and impaired reasoning) training to three of three sampled certified nursing assistants (CNA 1, 4 and 5) when mandatory dementia training was not completed by CNA 1, 4, and 5 in the last 12 months. This failure had the potential for unmet care needs of residents with dementia by CNA 1, 4 and 5. Findings: During a record review of the employee files CNA 1, 4, and 5, on 7/27/22, at 9:05 a.m., all three employee files did not have in-service records of the mandatory dementia training completed in the last 12 months. During an interview with the Director of Staff Development (DSD) on 7/27/22, at 10:30 a.m., DSD stated she was new and did not know where the training records were in the facility. The facility's policy and procedure titled, In-Service Training and Record Keeping, dated 2/20/20, indicated, The purpose of the policy and procedure was to establish guidelines for the facility staff to complete required in-service education in accordance with Federal and State regulations .Five (5) hours of instruction on dementia-specific in-service training is required every year per California Health and Safety Code 1263. 555313 Page 7 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

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 store refrigerated medications, in accordance to facility policy which requires storage of medications between 36-46 degrees Fahrenheit (F). The medications were stored at temperatures that were too cold. This failure exposed patients to compromised medications. Findings: A review on 07/26/22 of the facility policy titled, STORAGE OF MEDICATIONS, dated April 2008, indicated, Medications requiring refrigeration or temperatures between 2 C (36F) and 8 C(46 F) are kept in a refrigerator. During an observation on 07/26/22 at 1:15 PM in the nursing station, two-medication room refrigerator was 30 F. There were multiple medication storage within the refrigerator. The manufacturer required all these medications (Tuberculin test, Humalog, Flu vaccine, etc.) were to be stored between 36-46 F. A review on 7/26/22 of the Medication Refrigerator Log, a log that had documented daily refrigerator temperatures, indicated for 7/26/22 that the refrigerator was at 30 F. During an interview on 7/26/22 at 2:15 PM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she did not know the refrigerator was too cold. LVN 2 stated she was not aware of anyone working on the refrigerator to raise the temperature of the refrigerator. LVN 2 acknowledged the importance of maintaining appropriate temperatures to prevent reducing the potency of drugs due to excess cold. 555313 Page 8 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure the Pharmacy Consultant (PC)'s monthly recommendations were acted upon for five of 24 sampled residents (Resident 12, 13, 19, 22 and 37) when the PC's recommendations were not reviewed for Resident 12, 13, 19, 22 and 37 who were prescribed psychotropic drugs (medications used to stabilize or improve mood, mental status or behavior) for five consecutive months, from March through July 2022. This failure had the potential for unnecessary medications to be given to Resident 12, 13, 19, 22, and 37. Findings: During a review of the Consultant Pharmacist's Medication Regimen Review, dated 6/14/22, for Resident 12, it indicated, to monitor appropriate behavior and side effects of the medication sertraline (medication for depression) for depression on the Medication Administration Record (MAR). Resident 12's MAR indicated the monitoring of Resident 12's behaviors and medication side effects started 42 days later, on July 26, 2022. During a review of the Consultant Pharmacist's Medication Regimen Review, dated 6/14/22, For Resident 13, it indicated to monitor for a behavior and side effect of the medication mirtazapine (medication for depression) for depression and trazadone (medication for depression or aids in sleep) for sleep. Review of the MAR did not indicate to observe behavior(s)for the use of the antidepressant (medication to help depression). Also, no side effects were monitored for the use of sleep aid. Review of the Note to Attending Physician/Prescriber, dated 6/14/22, indicated Resident 19 had a medication order for metformin (medication to help control blood sugar) to treat elevated blood sugar levels. The use of metformin cautions against its use for impaired kidneys (defined as serum creatinine [SCr] >/or =1.5 in males, >/or = 1.4 in females, or creatinine clearance less than 60 ml/min.). The pharmacist noted Resident 19's most recent SCr level was high at 1.7 mg/dL and the estimated creatinine clearance was 17 ml/min. The pharmacist's recommendation indicated to re-evaluate continuous use of metformin, discontinue and initiate [linagliptin, medication to help control blood sugar] 5 mg everyday if appropriate for resident. A section of the form for Physician/Prescriber Response was not completed to agree, disagree, or other comments and did not include a signature or a date that it was reviewed by the physician. Review of the Note to Attending Physician/Prescriber dated 5/10 22, indicated Resident 22 was prescribed quetiapine (antipsychotic medication) and there were no recent laboratory results (there is an association of increase of clogged arteries with the use of quetiapine). The pharmacist recommended to monitor Resident 22's lipids (fat levels) and glucose (sugar level) the next lab day. A section of the form for Physician/Prescriber Response was not completed to agree, disagree, or other comments and did not include a signature date it was reviewed by the physician. During an interview on 7/29/22 at 9:50 a.m., with the Assistant Director of Nursing (ADON), the ADON stated when the pharmacist completes the medication regimen review (MRR, a review of all medications the resident was currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance with drug therapy), it is reviewed by the physician. The 555313 Page 9 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ADON stated the physician did not verify the pharmacist's recommendations for Resident's 12, 13, and 19 because there were no signatures and dates. During a review of Resident 37's admission Record, dated 7/29/22, the admission Record indicated, Resident 37 had a diagnosis of Benign Prostatic Hyperplasia (prostate gland enlargement) without Lower Urinary Tract Symptoms During a review of the facility's MRR binder, MRR was done for Resident 37 on 3/25/22 with the recommendation: Resident take [tamsulosin] (drug used to treat symptoms of an enlarged prostate) 0.4 mg BID (twice a day) which is more frequent than recommended by the manufacturer. Please give consider administering total dose of 0.8 mg daily 30 minutes after same meal every day or at bedtime. The same recommendation was given during the MRR on 4/12/22. During a review of Resident 37's Order Summary Report, for July 2022, the Order Summary Report indicated, the order for tamsulosin 0.4 mg cap give 1 capsule orally two times a day related to Benign Prostatic Hyperplasia (enlarged prostate) Without Lower Urinary Tract Symptoms was still active. During an interview on 7/28/22, at 1:45 p.m., with Case Manager (CM), CM stated MRR recommendations are given to the doctor for them to sign if they agree or disagree with the recommendation given. CM stated a copy of the signed recommendation should be placed in a binder and the original goes to the chart to be carried out. During an interview on 7/29/22, at 8:03 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, MRR recommendations are reviewed with the Director of Nursing before communicated to the doctors and once the doctors have reviewed the recommendations, orders are carried out in the chart or documented. During a review of the facility's policy and procedure (P&P) titled, Pharmacy Services Committee-Composition and Duties, dated January 01, 2012, the P&P indicated, Duties and Responsibilities may consist of, but are not limited to the following: Monthly review of each resident's drug regimen, including irregularities, and update previously noted irregularities. 555313 Page 10 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and document reviews the facility failed to be free of medication error rates of five percent or greater when two medication errors were observed out of 32 opportunities. The medication error rate was calculated as followed: two divided by 32 then multiplied by 100, which was equal to 6.2 percent. This failure resulted in multiple medication errors. Residents Affected - Some Findings: 1. A review on 07/26/22 of the facility policy dated October 2017 entitled Medication Administration-General Guidelines indicated Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicated a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. During an observation on 07/26/22 at 9:20 AM LVN 1 was preparing Resident 43's Metoprolol for oral administration. LVN 1 did not compare the MAR with the medication label. LVN 1 did not check the physician's orders for a correct dosage. LVN 1 prepared three 75 mg tablets for administration. During an interview on 07/26/22 at 9:24 AM LVN 1 was asked why she had prepared three 75 mg tablets for administration. LVN 1 said my bad, after reviewing the MAR, LVN 1 was supposed to prepare three 25 mg tablets for 75 mg instead of three 75 mg tablets which would be three times the prescribed dose. She stated the physician orders were for Metoprolol 75 mg twice daily. If she had not be questioned, she would have given 225mg. During an interview on 7/26/22 at 11:05 AM LVN 1 stated that she primarily looked at the MAR when preparing the Metoprolol. The MAR showed that three tablets needed to be prepared so she prepared three 75 mg tablets because she did not look at the medication label which indicated 75 mg tablets instead of 25 mg tablets. She said she would be more careful in the future. 2. A review on 07/26/22 of the Fluticasone Propionate Nasal Spray manufacturers insert dated indicated USING FLUTICASONE PROPIONATE NASAL SPRAY Step 1. Blow your nose to clear your nostrils Step 2 Close one nostril. Tilt your head forward slightly and, keeping the bottle upright, carefully insert the nasal applicator .Step 3 Start to breath in through your nose and WHILE BREATHING IN press firmly and quickly down on the applicator Step 4 Breath out through your mouth .Step 7 Wipe the nasal applicator with a clean tissue . During an observation on 07/26/22 at 9:20 AM LVN 1 administered Fluticasone Propionate Nasal to Resident 43. LVN 1 inserted the medication and did not follow any of the steps listed above. LVN X sprayed in each nostril and did not instruct Resident 43 to follow only of the directions listed above. During an interview on 7/26/22 at 11:05 AM LVN 1 stated she did not follow the manufacturers insert guidelines when administering the Fluticasone Propionate Nasal. She said she was not aware of the appropriate technique required by manufacturer. She stated in the future she would follow the manufacturers steps to appropriately administer the Fluticasone Propionate Nasal. 555313 Page 11 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Minimal harm or potential for actual harm Based of observation, interview, and facility document review, the facility failed to ensure: Residents Affected - Many 1. There was adequate supervisory oversight for the Food and Nutrition Department; 2. Food was ordered in the right quantity for the planned menu; and 3. The RD inspected the resident food refrigerator located in the nursing station. These failures had the potential to result in unsafe and unsanitary practices in regard to food storage, food preparation, and food service, as well as result in an inadequate supply of food for the planned menu to meet the nutritional needs of the residents all of which could in turn affect the safety and wellbeing of 52 residents who ate food by mouth out of a facility census of 54. Findings: Review of the undated job description titled Director of Nutrition Services (DNS), indicated this position was responsible overseeing the day-to-day operation of the Food and Nutrition Services department. An example of areas the DNS was responsible for according to the job description included ensuring nutritious meals to all residents, maintaining a safe and sanitary working environment, maintaining inventory of food and supplies to meet resident needs and according to the planned menus, monitoring staff performance through coaching and takes direct corrective action after coaching if needed, evaluating quality and quantity of services accomplished by staff. Review of the job description titled Registered Dietitian dated 11/27/17, indicated the Registered Dietitian (RD) was to work with the DNS to ensure that quality food, service and nutritional care was provided to residents. 1. During the recertification survey from 7/25/22 - 7/29/22 it was noted there was no full-time supervisory guidance by either a Registered Dietitian or a Director of Nutrition Services resulting in identification of issues related to: food safety and sanitation in the kitchen (Cross-reference F812), lack of ingredient availability for the approved menu, ensuring the dish machine was in safe operating condition (Cross-reference F908), and staff competency regarding their job functions (Cross-reference F802). On 7/25/22 at 10:12 a.m., during the initial tour of the kitchen the Assistant Dietary Manager (Asst DM) introduced herself and stated she was new to this facility, started just over a week ago, and functioned as both the Assistant Dietary Manager and a daily cook. She confirmed there was currently no Dietary Manager at the facility. In an interview with the Regional Dietary Manager (RDM) and a concurrent observation on 7/26/22 at 8:50 a.m., RDM stated there was no Supervisor at the facility yet today and did not know who was in charge. In an interview with Director of Nutrition Services 1 (DNS 1) on 7/26/22 at 1 p.m., DNS 1 stated he came into the facility 4-5 times a week when he could, but he was also going to school. DNS 1 stated he came into the facility yesterday evening. DNS 1 stated he would try to come into the facility 555313 Page 12 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the next day for an interview. DNS 1 was not on site when the surveyors were present for the remainder of the survey. In an interview with the RD and a concurrent observation on 7/27/22 at 9:30 a.m., RD stated she started working for the facility in June and she came into the facility once a week. It was identified that ceiling fans and the floor around the stove were not clean (Cross-reference F812). RD stated the DNS was supposed to report or request help for cleaning from maintenance when there were things that could not be cleaned by kitchen staff. She confirmed she reported the dirty fans and the floor on her monthly inspection report. She said her reports were available to the DNS and the Administrator. In an interview with the Administrator (ADM) on 7/27/22 at 10:30 a.m., ADM stated DNS 1 was still in charge of the department and he came in almost every day. She stated he was usually at the facility in the morning and sometimes in the afternoon if he was able to make it. She said he put in his resignation a month ago and she put out a general add for the DNS position. She said the Asst DM was not a kitchen manager and she just started working for this facility On 7/28/22 at 11:39 a.m., review of staff time records showed the DNS 1 was at the facility from 7/3/22 7/10/22 for a total of 10.25 hours, from 7/11/22 - 7/17/22 for a total of 6 hours, from 7/18/22 - 7/24/22 a total of 5 hours. Centers for Medicare/Medicaid Services, State Operations Manual, Guidance to Surveyors, Section 483.60(a)(1)-(2) defines full time as 35 or more hours per week. In an interview with [NAME] 2 on 7/28/22 at 9:16 a.m., she stated her job was frustrating and hard right now. She said with no supervisor she felt like she was in charge, but she did not want to be in charge because she did not want to tell people what to do. She said it was hard to get everything done and it was a big help when there was a supervisor around to help if needed. She said right now it was complicated because food deliveries came in on Tuesdays and Thursdays and she did not know who was in charge to help. She stated DNS 1 left as a manager the first week of June and now he came in twice a week just to do the food ordering, but he did not do anything else in the kitchen. In an interview with Dietary Aide 1 (DA 1) on 7/28/22 at 10:13 a.m., she stated she had to stay extra hours to clean every shift and that sometimes she did not have time to take a break. She said there was no supervisor. In an interview with [NAME] 1 on 7/28/22 at 10:25 a.m., she stated there was not enough food to be able to follow recipes for the menu all the time. She stated when DNS 1 was supervising, she told him she did not have the right ingredients to follow recipes, and he told her to just cook something anyway. She said often times food was either not available because it was not ordered, or it was expired. She said she did not have the all the bananas to make the dessert tonight. She stated DNS 1 still ordered the food. She confirmed there was no supervisor for about a month. In an interview with the Asst DM on 7/28/22 at 11:55 a.m., she stated she did not have a regular schedule at the facility yet. She said she felt like staffing was extremely short. She stated that food was not always available to follow recipes. She said in the last 48 hours she had to go to the store to buy ingredients. She said she did not have all the ingredients for dinner last night, for dessert for lunch today, and for the dessert tomorrow. She stated DNS 1 ordered the food and either missed ordering some food or ordered too much of some food. She stated there was too much work and it would be a lot easier if there was a supervisor. She said there had to be a supervisor because when she cooked, she could not focus on cooking if she also had to do supervisor work. She said there are 555313 Page 13 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many some tasks she did that she thought was the supervisor's job, such as printing the tray tickets and was also responsible for the diet changes. She said she had to contact DNS 1 for his password to make diet changes or they would not be made until he came in. She stated she did not know about therapeutic diets and needed more training. In an interview with the RD on 7/28/22 at 12:35 p.m., she stated she put her monthly inspection reports into the computer system and the DNS and the Administrator had access to them. She stated she still delegated tasks to the DNS position on her reports even though there was not anyone in that position. For instance, she stated she delegated in-services for kitchen staff to the DNS position when she identified training was needed. The RD stated she did not think the cleaning schedule was being followed in the kitchen because there was no supervisor. In an interview with the RDM on 7/28/22 at 2:40 p.m., she stated she was not aware the facility did not have a full-time DNS before arriving to the facility to help support staff during the survey. She stated she was not asked by the Administrator to help with ideas for recruiting a full-time DNS. She stated she would have helped if she was asked. 2. During a concurrent observation and interview on 7/26/22 at 9 :30 a.m., with RDM, a hotel pan of apricot dessert was in freezer for cool down. RDM stated the apricot dessert was for lunch that day. Review of facilities cook spreadsheet, titled, SUMMER MENUS, for week 4, Tuesday 7/26/22 indicated glazed Apple square on the lunch menu. During an observation on 7/26/22 at 12:17 p.m., [NAME] 2 served mixed vegetables during the lunch trayline. Review of the cook spreadsheet, titled, SUMMER MENUS, for week 4, Tuesday 7/26/22 indicated Broccoli with Garlic was on the menu for lunch. During an interview on 7/27/22 at 2:55 p.m., RDM the said the DNS was responsible for ordering the food for the menu including the vegetables. She also said stated there were no canned apples available to prepare the glazed apple squares on 7/26/22, so she used apricots to prepare the dessert. During an interview on 7/28/22 at 9:16 a.m., [NAME] 2 stated on 7/26/22, she did not have enough Broccoli for lunch, so she substituted Broccoli with Garlic indicated on the menu with mixed vegetables. During an interview on 7/28/22 at 10:25 a.m., [NAME] 1 stated she did not follow the recipe /menu sometimes because the ingredients were not available or were expired. During an interview on 7/28/22 at 11:55 a.m., Assistant. Dietary Manager/Lead cook (Asst. DM) stated she did not have ingredients for dinner on 7/27/22, dessert for lunch for 7/28/22, dessert for dinner on 7/28/22 and dessert for 7/29/22. Some of the ingredients she did not have included egg noodles, tomato sauce, whipping topping, cottage cheese, and watermelon. She stated the DNS missed ingredients for the planned menu when he ordered food. 3. During a concurrent observation and interview on 7/25/22 at 1:10 p.m., it was found that staff were not following the facility policy and procedure for safely storing food in the resident 555313 Page 14 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0801 Level of Harm - Minimal harm or potential for actual harm refrigerator brought into the facility by visitors and/or family when food was not labeled with resident names, food was not dated when it came into the facility or opened, and items were not discarded when expired or in the refrigerator longer than what the policy and procedure stated. There was a total of 2 resident refrigerators designated for resident food. One in nursing station 1 and one in nursing station 2. Only the refrigerator in nursing station 1 contained food. (Cross-reference F813), Residents Affected - Many Review of 2 of the RD's monthly inspection reports titled Dietary Quality Control Review dated 6/27/2022 and 7/25/2022 indicated under section Resident Living G. Nursing Station and Staff Room Refrigerators are clean, with logs in place and up to date Any Patient food is dated and labeled. None is open and more than 72 hours, her note under observation on the 6/27/22 report read No refrigerators in nursing stations Staff room refrigerator is strictly for employee food - NO patient food. In this section on the 7/25/22 report, the RD's note read NA [not applicable] - no refrigerators in nursing stations. Staff room refrigerator is strictly for employees only - NO patient food storage. In an interview on 7/27/22 at 9:40 a.m., with RD, RD stated she worked at the facility 1 day a week and started in June. In an interview on 7/28/22 at 12:35 p.m., with RD, RD stated she just found out today there was a resident refrigerator located in the nursing station. She said she did not know who monitored it and guessed it was nursing. RD stated the Food and Nutrition services department would be responsible for training nursing regarding safe food storage for the residents and she did not know if nursing was trained. 555313 Page 15 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and facility record, the facility failed to ensure kitchen staff were competent for job duties performed when Certified Nursing Assistant/Diet Aide 1 (CNA 1) washed dishes in the kitchen and did not know the appropriate sanitizer strength and did not ensure appropriate wash water temperature for the dish machine (Cross-reference F812). This failure had the potential to result in contamination of dishware, utensils, and food leading to illness for 52 residents who received food from the kitchen out of a facility census of 54. Findings: Review of the job description titled, Dietary Aide, published March 2012, indicated the Dietary Aide position was responsible for maintaining daily care of the dishwasher and washing dishes. In an interview with CNA 1 and a concurrent observation of the dish machine on 7/26/22 at 9:10 a.m., indicated CNA 1 washed dishes using the dish machine. CNA 1 stated she was usually a CNA but washed dishes today because the diet aide went home, so she helped out. CNA 1 stated she was responsible for testing the sanitizer of the dish machine before washing dishes. CNA 1 demonstrated how she tested the sanitizer. CNA 1 removed a chlorine sanitizer test strip from the container and placed it on a dish that just went through a wash/rinse cycle in the dish machine. The test strip turned dark purple. She compared the test strip to the color chart inside the test strip container and said it was 200 parts per million (ppm). She stated the sanitizer had to be at least 200 ppm and 100 ppm would not be okay. Then she stated she also looked at the water temperature dial of the dish machine to make sure the wash and rinse cycle temperature was appropriate when washing dishes. She stated the temperature for both rinse and wash had to be 120 degrees Fahrenheit (F). CNA 1 ran the dish machine to show how she checked the dish machine water temperature. The dial showed the was cycle was 100 degrees F and the rinse cycle was 110 degrees F. CNA 1 ran the dish machine again because she said the water temperature was too low. The second time the dial showed the wash cycle water was 110 degrees F and the rinse water cycle was 120 degrees F. CNA 1 stated the water temperatures were okay. The information plate attached to the front of the dish machine showed the wash temperature was to be a minimum of 120 degrees F, the rinse temperature was to be a minimum of 120 degrees F, and the chlorine sanitizer was to be at least 50 ppm. Review of the facility's policy and procedure (P&P) titled, Dish Machine Operation and Cleaning, dated October 1, 2014, indicated the dish machine when operating the equipment the water temperature gauge needed to be checked and proper temperatures had to be reached upon startup. The wash water temperature had to be between 120 degrees and 160 degrees F. The P&P also indicated if the temperature of the machine failed to reach these temperatures, the machine was to be turned off and reported to the supervisor. Review of the P&P titled, Dish Machine Temperature Recording, dated October 1, 2014, indicated the dish machine would be routinely monitored during use to ensure appropriate temperatures. The wash temperature was to be from 120 degrees F to 150 degrees F and the rinse temperature was to be between 120 degrees F and 150 degrees F. In addition, the concentration of the chlorine sanitizer solution during the rinse cycle had to be 50 ppm. 555313 Page 16 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. The dish washing machine not reaching the required minimum temperature for the wash cycle and leaking. (Cross reference F908) 2. Hand Hygiene protocol was not followed. 3. Expired food items were found in the dry storage room. 4. Multiple dry food items did not have a use by date or open date on them. 5. Sanitizer strength for food contact surface using red bucket was not an appropriate strength. 6. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for food preparation sink. 7. Toaster was not cleaned regularly and had buildup of black and brown residue. 8. Microwave was not cleaned and had food residue on the top inside surface. 9. Industrial Can opener was not clean with sticky yellow and black residue build up and the blade coating was peeled off. 10. Kitchen vents and surrounding ceiling were dirty with black residue. 11. Kitchen ceilings were not cleaned. 12. Kitchen floor surrounding stove was not cleaned and had black/white/brown debris and residue buildup. 13. Kitchen wall near back door had crumbling dry wall. 14. Grease trap (a plumbing fixture that contains decomposing food waste, bettering the sewer system) under 3-compartment sink had thick yellow/brown greasy residue build up on top and around edges. 15. Three frying pans used for cooking food were not in good condition. 16. One Cutting board was scratched with black residue on surface. 17. A reach-in freezer door handle was broken, covered with tape, and not a smooth surface. These failures had the potential to cause food borne illnesses for 52 residents who received food from the kitchen for a facility census of 54. 555313 Page 17 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0812 Findings: Level of Harm - Minimal harm or potential for actual harm 1. Residents Affected - Many During a concurrent observation and interview on 7/26/22 at 9 :18 a.m., Certified Nursing Assistant/Dietary Aide 1 (CNA 1) washed dishes using the dish machine. CNA 1 demonstrated the dishwashing procedures and explained the operation of the machine. During the dishwashing process, water was pouring from dish machine catch tray onto the Kitchen floor. CNA 1 also stated that it was a low temperature machine and has specific temperature ranges for the operation of the machines. Concurrent review of the manufacturer's guidelines, printed on a sticker affixed to the front of the machine noted the minimum manufacturer recommended wash and rinse temperature was minimum 120 degrees Fahrenheit (*F). Additionally review of 2 wash and rinse cycles, revealed that during the observation the machine did not reach manufacturer's recommendations, rather the maximum temperature for wash was only 110*F. CNA 1 confirmed the wash temperature reached a maximum of 110* F and stated the temperature was okay (Cross-reference F802). During a concurrent observation and interview on 7/26/22 at 9:49 a.m., Regional Dietary Manager (RDM), RDM confirmed the dish machine wash cycle was not reaching 120-degree Fahrenheit. During a review of the facility's Policy and Procedure (P&P) titled, Dish machine Operation and Cleaning, revised on 10/1/2014, the P&P indicated, Policy- The dietary staff will use the dish machine according to the manufacturer's guidelines .II. Operation of equipment. A Check water temperature gauges. (Wash must be between 120 * and 160* F.) to reach proper temperatures upon startup, several empty racks should be sent through the machine. If the machine fails to reach the proper temperature, turn off the machine and report the incident to the supervisor. Review of the P&P titled, Dish Machine Temperature Recording, dated October 1, 2014, indicated the dish machine would be routinely monitored during use to ensure appropriate temperatures. The wash temperature was to be from 120 degrees F to 150 degrees F and the rinse temperature was to be between 120 degrees F and 150 degrees F. In addition, the concentration of the chlorine sanitizer solution during the rinse cycle had to be 50 ppm. 2. During an observation on 7/25/22, at 10:13 a.m., [NAME] 2 entered kitchen and did not perform hand hygiene. [NAME] 2 put on gloves and checked on potatoes that were defrosting. Then [NAME] 2 took off her gloves and put on new gloves without performing hand hygiene. Next cook 2 took out turkey from the freezer and placed it in a sink to defrost it. Then [NAME] 2 took off her gloves and put on new gloves without performing hand hygiene. Next cook 2 peeled onions. During an interview on 7/25/22, at 12:24 p.m., with Regional Dietary Manager (RDM), RDM stated staff should have performed hand hygiene when they entered the kitchen and when they changed gloves, to prevent cross contamination. During a review of the facility's P&P titled, Hand Hygiene, revised September 1, 2020, the P&P indicated, Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, Residents, volunteers and visitors. The following situations require appropriate hand hygiene . Before and after food preparation. 555313 Page 18 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0812 Level of Harm - Minimal harm or potential for actual harm According to the 2017 Federal Food Code food employees are to wash hands immediately before engaging in food preparation including exposed food and clean equipment and utensils, before donning gloves to initiate a task that involves working with food, and after engaging in other activities that contaminate hands. 3. Residents Affected - Many During a concurrent observation and interview on 7/25/22 at 11:21 a.m., with RDM, the dry storage room had 7 X 16-ounce bags of tortilla chips with use by date 1/25/22. RDM stated the tortilla chips were expired and should be removed. During a concurrent observation and interview on 7/25/22 at 10:35 am, with Assistant Dietary manager/lead [NAME] (Asst. DM), the preparation table storage had 16 oz- chocolate sauce - 16 oz with use by date of April 2022. Asst. DM stated it is expired and she is not sure if it is still ok to use. A review of facility's document titled, Dry goods storage guidelines, indicated, chips, potato, tortilla unopened on shelf should be stored for one month. The document indicated, Do check expiration dates on boxes of foods to be sure the length of time is correct. 4. During a concurrent observation and interview on 7/25/22 at 10:35 a.m., with Asst. DM, a bag of opened crouton and 16 oz beef broth were noted to have no use by date. Asst. DM stated they should have an open date and use by date/expiration date on them. During a concurrent observation and interview on 7/25/22 at 11:21 a.m., with RDM, the dry storage room had six bags of croutons removed from original boxes with [NAME] codes (These codes are used to indicate the date when a food item was packaged. The code represents the year and what day of the year out of 365 days. For example, 22-165 represents the year 2022 and the165th day of the year) and no expiration/use by dates. RDM stated she does not know what the [NAME] codes mean and will contact the vendor to find out the expiration dates. During a concurrent observation and interview on 7/26/22 at 8:45 a.m., with RDM, blue plastic bag with pasta with no dates or labels. RDM stated she has never seen them before and removed them. During a concurrent observation and interview on 7/26/22 at 9:00 a.m., with RDM, two unopened and one opened all Bran cereal with no manufacturer expiration date was found. RDM stated the supervisor was supposed to check daily and discard any expired items. During a concurrent observation and interview on 7/29/22 at 10:31 a.m., with [NAME] 2, [NAME] 2 was not able to find use by dates on bag of cereals, croutons, and a bag of sugar substitute. [NAME] 2 stated the dates on the crouton bags were received dates and it did not show the expiration dates. [NAME] 2 stated the expiration dates are on the boxes and when things are taken out of the boxes, she does not know the expiration dates. [NAME] 2 stated she has no idea what the codes [[NAME] codes] on the crouton bags mean. During a concurrent observation and interview on 7/29/22 at 10:35 a.m., with Registered Dietician (RD,) the RD stated the bag of cereals and crouton only had received dates and [NAME] codes. RD stated the expiration dates might be on the boxes that the food bags/boxes are removed from. RD stated 555313 Page 19 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many they should go by expiration date of manufacturer and the information should be transferred when food item is taken out of original boxes. During a review of the facility's P&P titled, Food Storage, revised on 11/1/2014, the P&P indicated, PolicyFood and supply items will be stored, thawed, and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated . Procedure- XII. Dry Storage Guidelines . H. Label and date all storage products. 5. During a concurrent observation and interview on 7/27/22 at 9:32 a.m., with [NAME] 2, [NAME] 2 stated she refills the red buckets every four hours with sanitizer solution used to clean food contact surfaces such as preparation tables. [NAME] 2 stated she changed the sanitizer solution at 9 a.m. and used the sanitizer to sanitize the food preparation area. [NAME] 2 demonstrated how to test the sanitizer strength with a test strip. The test strip indicated 100 PPM and turned yellow in color. [NAME] 2 stated the strength was too low. [NAME] 2 repeated the testing process by refilling the red bucket with fresh sanitizer and the strength test strip turned dark green and indicated a reading of 300 and the strength was appropriate. [NAME] 2 stated she did not test the strength of the solution of the sanitizer at 9 a.m. During a concurrent interview and record review of facilities document titled, Red bucket sanitizer log, with RD and RDM, the log indicated they test and log the strength of sanitizer for breakfast, lunch, and dinner and not every time they change the sanitizer solution. RDM stated she tested and logged the strength at 7/27/22 at 6 am and the strength was 300 ppm. During a follow up interview on 7/28/22 at 9:16 a.m., cook 2 stated she did not know that she was supposed to test the red bucket sanitizer strength every time she changed the solution. [NAME] 2 stated she was using the sanitizer that was 100 ppm in strength on 7/27/22 at 9 a.m. During a review of the facility's undated P&P titled. Quaternary ammonium log policy, the P&P indicated, Procedure; The dietary worker will record the ammonium level on the log prior to sanitizing the counters or washing pots and pans daily to assure the level is at least 200 ppm 6. During a concurrent observation and interview on 7/25/22 at 12:35 p.m., with Maintenance Director/Housekeeping (MD/HSK), the drainpipe from the sink connected directly into the wall so there was no air gap (a gap of air between the floor and a drainpipe) for food preparation sink. MD/HSK confirmed that it is pumped directly into wastewater system/sewer. During an interview on 07/28/22 at 12:29 p.m., with RD, RD stated she did not see a proper air gap under the food preparation sink in kitchen. According to the 2017 Federal Food Code, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. 7. 555313 Page 20 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent observation and interview on 7/25/22 at 10:31 a.m., with [NAME] 2, the toaster was observed to have significant amount of black and brown residue resembling crumbs on tray that pulls out and are under the rolling compartment. [NAME] 3 stated it was not clean and was not cleaned today. [NAME] 3 stated they are supposed to clean it after every use. During an interview with on 7/25/22 at 10:35 a.m., the Asst. DM stated toaster oven was not clean and was supposed to be cleaned after every use. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .9. All utensils, counters, shelves, and equipment shall be kept clean. 8. During a concurrent observation and interview on 7/25/22 at 10:50 a.m., with Asst. DM, the microwave was noted to have spots of orange residue on the inside top and inside side surface. There was build up of black and brown residue resembling crumbs on the hinge of microwave door. Asst. DM stated the microwave was not clean and is not aware of the cleaning schedule. During an interview on 7/28/22 at 12:29 p.m., with RD, RD stated the microwave should be cleaned after each use. RD stated cleaning schedule was not being followed as there was no supervisor to oversee it. During a review of the facility's P&P titled, Microwave oven- Operation and Cleaning, revised on 10/1/2014, the P&P indicated, Policy- The microwave oven will be cleaned after each use . Sanitation of equipment .A. The microwave will be cleaned after each use. 9. During a concurrent observation and interview on 7/25/22 at 10:34 a.m., with Asst DM, the blade of industrial can opener was observed to have orange/red and yellow residue. The coating of the blade was peeling off and thick black residue in space between cog wheel and base, sticky yellow residue on slide-insert on can opener holder attached to counter. The surveyor easily wiped off residue on the white tissue paper towel. Asst.DM stated the blade and base were not clean and she did not know how often they needed to be cleaned. During an interview on 7/28/22 at 12:29 p.m., with RD, RD stated opener can be cleaned after each use. RD stated cleaning schedule is not being followed as there is no supervisor to oversee. During a review of the facility's P&P titled, Can Opener Use and Cleaning, revised on 10/1/2014, the P&P indicated, Policy- The dietary staff will use the can opener according to the manufacturer's guidelines. The can opener will be sanitized between uses 10. During a concurrent observation and interview on 7/26/22 at 10:11 a.m., with MD/HSK, the ceiling vents /fans were noted with black residue on surface and surrounding ceiling surfaces in proximity. MD/HSK stated the vents were dirty and needed to be cleaned. MD/HSK stated he was not responsible for cleaning areas in kitchen unless kitchen staff requested it. MD/HSK stated there is no schedule to clean anything in kitchen. 555313 Page 21 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of facility's document titled, Dietary Quality Control review, dated 6/27/22, by RD, the dietary quality control review indicated the standard I. Ceiling vents in good repair, clean and with adequate paint was Not met. During an interview with RD on 7/27/22 at 9:40 a.m., RD stated cleaning were done by kitchen staff but if cleaning involved difficult to reach areas, then dietary manager should contact maintenance to help with cleaning. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .4. The maintenance department will assist dietary as necessary in maintaining equipment and in doing janitorial duties which the dietary employees cannot do .14. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over stove, which will be cleaned by the maintenance staff. According to the 2017 Federal Food Code, physical facilities are to be cleaned as often as necessary to keep them clean. 11. During an observation and interview on 7/26/22 at 10 a.m., with [NAME] 2, [NAME] 2 confirmed there were spots of orange residue splattered on the ceiling above the microwave. [NAME] 2 stated she did not know what the residue was. During an observation and interview on 7/26/22 at 10:11 a.m., with MD/HSK, ceiling above the microwave was noted with orange residue. MD/HSK stated he was not responsible for cleaning areas in kitchen unless he was asked by kitchen staff either verbally or through maintenance log. During a concurrent observation and interview on 07/27/22 at 9:40 a.m., with RD, RD stated cleaning was done by kitchen staff but if cleaning involved difficult to reach areas, then dietary manager should contact maintenance to help with cleaning. During an interview on 7/28/22 at 12:35 p.m., RD stated any maintenance requests should be put in maintenance logbook and there is no entry in logbook since February 2022. During a review of the facility's P&P titled, Cleaning schedule, revised on 10/1/2014, the P&P indicated, Policy- The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the dietary manager. Review of the Daily Quality Control Review dated 6/27/22 provided as the monthly tool the RD used to ensure the kitchen was safe and sanitary showed the standard was for kitchen ceilings to be clean. According to the 2017 Federal Food Code, physical facilities are to be cleaned as often as necessary to keep them clean. 12. During an observation on 07/25/22 at 10:39 a.m., floor surrounding stove was observed with black/white/brown debris resembling pieces of food and crumbs and had dark black residue build up. 555313 Page 22 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0812 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 7/27/22 at 9:35 a.m., with RD, RD stated the floor around the stove is not clean and looks like food crumbs from food preparation. RD stated she reported floor needed general cleaning in her inspection report. RD stated Kitchen staff were responsible for cleaning except for hard-to-reach areas, then Kitchen manager would contact maintenance Dept for help with cleaning. Residents Affected - Many During a review of facility's undated P&P titled, General appearance of dietary department, the P&P indicated, Floors and walls must be scheduled for routine cleaning and maintained in good condition .8. Mop under and around equipment, along the walls and in corners. Wipe all splash and soil marks from baseboards and walls. According to the 2017 Federal Food Code, physical facilities are to be cleaned as often as necessary to keep them clean. 13. During a concurrent observation and interview on 7/25/22 at 12:25 p.m., with MD/HSK, wall on the lower side near back door had missing and crumbling drywall-1.5 feet by 3 inches. MD/HSK stated he was not aware of the crumbling drywall by back door. MD/HSK stated Kitchen staff notified maintenance department if there were things needed to be fixed in kitchen either verbally or writing in the maintenance log. During a review of facility's document, Dietary Quality Control review, dated 6/27/22, by RD, the dietary quality control review indicated, the standard B. Kitchen walls, floors, baseboards and ceilings in good repair and clean was Not met and the observation indicated, wall has damage next to door outside back area. During a concurrent interview on 7/28/22 at 12:35 p.m., with RD, RD stated any maintenance requests should be put in maintenance logbook and there were no entry in logbook since February 2022. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .4. The maintenance department will assist dietary as necessary in maintaining equipment and in doing janitorial duties which the dietary employees cannot do. During a review of the facility's P&P titled, Maintenance service, revised on 10/1/2014, the P&P indicated, Policy-The maintenance Department maintains all areas of the building, grounds, and equipment. According to the 2017 Federal Food Code, walls shall be constructed so they are smooth and easily cleanable. 14. During a concurrent observation and interview on 7/25/22 at 12;25 p.m., with MD/HSK and Asst. DM, the grease trap under the sink was noted with thick yellow/brown greasy residue build up. Asst.DM stated grease trap was not clean. MD/HSK stated it was grease on top and was probably full and overflowing and kitchen staff should have notified him, so he could call the vendor company to empty the grease trap. MD/HSK stated grease trap was cleaned every two weeks and the last cleaning was done on 7/18/22 by the vendor. 555313 Page 23 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .4. The maintenance department will assist dietary as necessary in maintaining equipment and in doing janitorial duties which the dietary employees cannot do. According to the 2017 Federal Food Code, physical facilities are to be cleaned as often as necessary to keep them clean. 15. During a concurrent observation and interview on 07/26/22 at 9:41 a.m., with [NAME] 2, two non-stick pans were noted to have coating of the entire cooking surface, scratched and coming off. In addition, one stainless steel pan had black residue build-up along inside surface and the cooking surface was significantly scratched with brown residue on scratched surface. [NAME] 2 stated the non-stick pans were scratched and not okay to be used and should be replaced. [NAME] 2 stated the stainless-steel pan had black residue and needed more thorough cleaning. During an interview on 7/28/22 at 12:35 p.m., with RD, RD stated surface of pans should be smooth and coated pans should not be peeling. RD stated condition of pans was not on her inspection but RD should still look at and notify Dietary manager to replace it. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .9. All utensils ., and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas. According to the federal food code, food-contact surfaces are to be smooth and clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulations. 16. During a concurrent observation and interview on 7/26/22 at 9: 45 a.m., with RDM, one cutting board in color green had black residue on surface. RDM confirmed that there is residue on cutting board and it was scratched. During an interview on 7/28/22 at 12:35 p.m., RD stated condition of cutting board should not be worn and should not be stained. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .17. Separate chopping boards are to be used for preparing means and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized. According to the federal food code, food-contact surfaces are to be smooth and clean to sight and touch. 17. During an observation on 07/26/22 at 8:45 a.m., the door handle on a reach-in freezer had plastic 555313 Page 24 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0812 Level of Harm - Minimal harm or potential for actual harm broken off/missing part over three inches with clear tape over the area broken off. The tape surface had crevices and creases and was not smooth. During a concurrent observation and interview on 07/27/22 9:40 a.m., with RD, RD stated the handle was a concern, but she did not report it yet. Residents Affected - Many During an interview on 07/27/22 12:10 p.m., with MD/HSK, MD/HSK stated he called the vendor to fix the freezer two months ago but did not have any documentation about it. MD/HSK stated he put the tape on it, so staff did not cut themselves on the broken handle. MD/HSK stated the door handle was not sharp. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, 9. all . equipment shall be . maintained in good repair and shall be free from breaks, corrosions, open seem, cracks and chipped areas. According to the 2017 Federal Food Code, Nonfood-contact surfaces are to be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. 555313 Page 25 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow its policy and procedure to ensure safe and sanitary storage and consumption of food brought in for residents from outside the facility when outside food belonging to 52 residents were not labeled upon storage or discarded after two days. Residents Affected - Many This failed practice had the potential for consumption of unsafe food and cause foodborne illness to 52 residents who ate food by mouth out of a census of 54 residents. Findings: During an interview on 7/25/22 at 12:45 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the resident refrigerator in the facility was used for storing resident food only and expired food was cleaned out every week by the Housekeeping Department. During a review of facilities document titled, Attention all Staff:, affixed to the resident refrigerator, the document indicated, All perishable food placed in this refrigerator MUST have a room number and date marked on it and can ONLY be held for TWO days (48 hrs.). Any expired Dates will be thrown out. During a concurrent observation and interview on 7/25/22 at 1:10 p.m., with Assistant maintenance supervisor (Asst.MS), the resident refrigerator at Nursing Station 1 was observed to have multiple food items without room number, resident name, or room number on it. Items with no resident name, room number, or date, included: an open can of whipped cream, an open container of almond milk, two hard boiled eggs in brown bag, a container of left-over veggies, meat and fried rice in a disintegrating cardboard container, container of blueberries, container from restaurant with chicken wings, and cooked pasta The following items had a date but no resident name: a can of Oat milk with a best by date of 6/11/22, and a bag of rotisserie chicken with a sell be date of 6/29/22 but no date for when it arrived in the facility. There was also a bag with rice meat/veggies in container and chocolate cake in container from restaurant with resident name but no date on it, and a ceramic bowl with room number and resident name, dated 6/16/22 had bad odor when lid was removed and white fuzz resembling mold on surface of food noted. Asst. MS stated the food was moldy. Asst. MS also stated the rotisserie chicken should be discarded. During a concurrent observation, interview with Asst. MS on 7/25/22 at 1:15 p.m., and record review of the facility's health record, the health record indicated the resident whose name was on the moldy food was discharged from the facility on 7/14/22. As the observation of the resident food refrigerator continued, a container with macaroni and cheese with a name but no date. Asst. MS stated he had no idea who it belonged to in the facility. Asst.MS stated he goes through the refrigerator every Friday and cleaned it out. Asst. MS stated food can be held in the refrigerator for two days only or until it's manufacturer expiration date. Asst. MS stated certified nursing assistants and nurses are supposed to label and date food items when they place it in refrigerator. Asst. MS confirmed the items in the refrigerator were not labeled and dated. During an interview on 7/28/22 at 1:57 p.m., with Case Manager, CM confirmed the name on the macaroni and cheese was from their previous interim Director of Nursing, who left the faciity on 6/6/2022. 555313 Page 26 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0813 Level of Harm - Minimal harm or potential for actual harm During an interview on 7/28/22 at 2:20 p.m., with Director of Staff Development (DSD), DSD stated nurses needed to label resident food with a room number, name, and date when they put it in the refrigerator. DSD stated all expired resident food should be tossed after 72 hours and inform the resident. DSD stated she did not provide any in-services on resident refrigerator food storage and handling and did not have documentation indicating nurses were trained prior to her being the DSD at the facility. Residents Affected - Many During a review of facilities Policy and Procedure (P&P) titled, Food brought in by Visitors, revised on 6/2018, the P&P indicated, Procedure .II. Perishable food requiring refrigeration will be discarded after two (2) hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours. 555313 Page 27 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

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 medical record review, the facility failed to ensure 37 of 74 sampled residents received or were offered the pneumococcal vaccine when 37 of 74 residents did not have a record of the pneumococcal vaccine in their records. Residents Affected - Some This failure had the potential risks of spreading bacterial infection and causing respiratory complications to residents. Findings: During a review of the facility's undated pneumonia vaccination log, the log indicated 37 of 74 residents did not have a record of pneumonia vaccine administration. During an interview on 7/28/22, at 9:25 a.m., with Infection Preventionist (IP), IP stated he has been the IP for a month. IP stated he picked up where the previous IP last recorded pneumonia vaccines. IP state he was still reviewing patient charts to verify if residents had their pneumonia vaccine and was working to update the incomplete pneumonia vaccine list. Review of the facility's policy and procedure (P&P), titled, Policy for Pneumonia Vaccine (New), dated 10/2014, indicated, on admission, all residents will be evaluated for pneumococcal vaccination needs. The pneumonia vaccination status of the resident will be determined and vaccines will be offered based on a criteria established by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. 555313 Page 28 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

F 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on interview and document review, the facility failed to ensure registry staff were vaccinated for COVID-19 (a serious respiratory disease) when 8 of 23 registry staff did not receive the COVID-19 booster immunization and one vaccine exempt registry staff did not meet the religious exemption criteria. Residents Affected - Many This failure had the potential for unvaccinated staff to increase the spread of COVID-19 and its complications of severe illness, hospitalization and/or death to residents they cared for and other staff that worked in the facility. Findings: During an interview and concurrent document review on 7/28/22 at 9:25 a.m., the logs for staff vaccination logs were examined. The Registry staff log indicated, 8 of 23 did not have COVID-19 booster vaccinations. One of two exempt registry staff identified on the log did not meet the religious justification criteria. The IP stated registry staff were from out-of-state where they were not required to have COVID boosters. During an interview on 7/29/22 at 10:30 a.m., the [NAME] President of Operations (VPO) stated all staff, including registry staff, needed to be vaccinated of COVID-19 unless they were exempt, meaning to have a medical or religious justifications. Review of the facility's undated COVID-19 Vaccination History, log indicated 23 staff members. The log indicated six registry staff did not receive the COVID-19 booster vaccine and two staff had vaccine exemptions. Review of Registry Staff (RS) 1's vaccine exemption documents indicated RS 1 was not authorized by a a clergy to validate the religious exemption. Review of facility's COVID-19 Mitigation Plan, revised 6/22/22, indicated, Exemption to Vaccination . For a religious exemption, the worker must provide the employer with a written request for exemption and a qualified-religious belief exemption. Review of the facility's policy on COVID-19 Staff Vaccination Program, dated 09/02/21, indicated, All personnel providing services or performing work at the facility, including but not limited to paid and unpaid employees, physicians, contracted personnel/vendors, students and volunteers, regardless of work location (Personnel), are required to be vaccinated against COVID-19. Only those who have a medical or religious reason will be granted an exemption. 555313 Page 29 of 30 555313 07/29/2022 The Rehabilitation Center of Oakland 210 40th Street Way Oakland, CA 94611

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 maintain essential equipment when there were issues with dish washing machine not reaching the required minimum temperature for the wash cycle and leaking. (Cross reference 812) Residents Affected - Many This failure had the potential for equipment not functioning as per manufacturers guidance resulting in ineffective ware washing processes and in turn could cause contamination of food, leading to foodborne illness for 52 residents who received food from the kitchen and negatively affect residents ' well-being out of a census of 54 Findings: An observation during the initial tour of the kitchen on 07/25/22 at 10:12 a.m., showed the dish machine was dripping water from the catch tray onto to floor. During a concurrent observation and interview on 7/26/22 at 9 :18 a.m., the dishwashing procedure were reviewed with Certified nursing Assistant/ Dietary aide (CNA 1). CNA 1 explained the operation of the machine. The dishwashing process, water was pouring from dish machine catch tray onto the Kitchen floor. CNA 1 also stated that it was a low temp machine and has specific temperature ranges for the operation of the machines. Concurrent review of the manufacturer's guidelines, printed on a sticker affixed to the front of the machine noted the minimum manufacturer recommended wash and rinse temperature was minimum 120 degrees Fahrenheit (*F). Additionally review of two loads revealed that during the observation the machine did not reach manufacturer's recommendations, rather the maximum temperature for wash was only 110*F. During a concurrent observation and interview on 7/26/22 at 9:49 a.m., Regional Dietary Manager (RDM) confirmed the dish machine wash cycle was not reaching 120-degree Fahrenheit. During a concurrent observation and interview on7/26/22 at 10:11 a.m., with Maintenance Director/ Housekeeping (MD/HSK), MD/HSK stated he was aware the dishwashing machine was leaking for past two days but did not call the dishwashing machine company for repair yet. During an interview on 7/29/22 at 9:15 a.m., CNA 1 stated the dish machine was overflowing since it was installed about a month ago. Stated MD/HSK was on vacation so reported to the administrator multiple times as they did not have a Dietary manager. Stated she also reported to MD/HSK about three times after he returned from vacation. During a review of the facility's undated Policy and Procedure (P&P) titled. Sanitation, the P&P indicated, 4.6. The maintenance department will assist dietary as necessary in maintaining equipment and in doing janitorial duties which the dietary employees cannot do . During a review of the facility's Policy and Procedure (P&P) titled. Maintenance service, revised on 1/1/2012, the P&P indicated, Policy- The maintenance Department maintains all areas of the building, grounds, and equipment in a safe and operable manner at all times . According to the 2017 Federal Food Code, equipment, including warewashing machines (dish machine), is to be maintained in a state of repair. 555313 Page 30 of 30