Health inspection·February 4, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an observation and concurrent interview on 2/1/11 at 10:44 a.m., Resident 10's call light was observed to be wrapped around a wheelchair handle and out of Resident 10's reach. The Infection Preventionist (IP) unwrapped the call light from the handle and placed it on Resident 10's bed and stated that the call light should be placed within Resident 10's reach at all times. Review of the facility's undated policy, titled, Answering the Call Light, showed that, When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. Event ID: Facility ID: 555767 If continuation sheet Page 2 of 13 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 555767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellaken Skilled Nursing Center 2780 26th Avenue Oakland, CA 94601 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 0574 The resident has the right to receive notices in a format and a language he or she understands. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to post Ombudsman Program information and contact information for the State Long-Term Care Ombudsman Program. Residents Affected - Few This deficient practice has the potential to prevent residents from contacting the State Ombudsman for services if needed. Findings: During an interview on 2/2/22 at 10:00 a.m., both Residents 22 and 7 stated they did not know about the State Long-Term Care Ombudsmanm program. Resident 22 & Resident 7 further stated they have not seen information on how to contact the local ombudsman either. During a concurrent observation and interview on 2/2/22 at 10:40 a.m. with Social Services Director (SSD), the SSD was not able to find the contact information of the Ombudsman in the dining room. The SSD stated the Ombudsman contact information should be in a prominent location where residents can easily find it, such as the resident's dining room. The SSD further stated it is important for the residents to know the contact information of the Ombudsman because the Ombudsman program provides assistance to any resident with care and quality of life issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 3 of 13 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 555767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellaken Skilled Nursing Center 2780 26th Avenue Oakland, CA 94601 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to inform and give reasonable notice to one (Resident 32) of three sampled residents (or to his Responsible Party) that Resident 32's Medicare services were ending and what his rights were to appeal. Residents Affected - Few This failure resulted in Resident 32 not being able to appeal for an extension of Medicare coverage which had the potential to impact his care. Findings: During a review of Resident 32's admission Record, on 2/4/22, indicated Resident 32 was admitted to the facility in 2018 and was re-admitted in 2020. A review of Resident 32's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review indicated, Resident 32's Last covered day of Part A service (Part A - Medicare services terminated/denied or a resident was discharged ) was 9/7/21. A review of Resident 32's Notice of Medicare Non-Coverage (NOMNC) showed the NOMNC was signed by Resident 32's Responsible Party (RP) on 9/7/21. During a concurrent interview and record review of the SNF Beneficiary Protection Notification Review and NOMNC, on 2/4/22, at 10:42 a.m., with Social Worker (SW), SW indicated, Resident 32's RP was not given written notification within 72-hours that Medicare services were ending which indicated that notification should have been by 9/4/21. The SW also stated Resident 32 and Resident 32s RP did not have enough time to file an appeal. Review of the facility's undated policy and procedure (P&P), titled, Demand Billings, showed, that, Within 72-hours prior to the change of Medicare A payer status, a representative of the facility will inform the resident of his or her right to submit demand bills to the Medicare intermediary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 4 of 13 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 555767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellaken Skilled Nursing Center 2780 26th Avenue Oakland, CA 94601 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 podiatry services to one of 17 sampled residents (Resident 17) for a period of five (5) months when Resident 17's toenails were observed to be long, thick, and curvy. Residents Affected - Few This failure had the potential for skin injuries/wound development for Resident 17. Findings: Review of Resident 17's admission Record dated 2/3/22., showed Resident 17 was originally admitted to the facility on [DATE]. Review of Resident 17's Minimum Data Set (MDS - a resident assessment tool used to guide care) dated 11/15/21, showed Resident 17 required staff's assistance to maintain personal hygiene and grooming. During an observation and concurrent interview on 2/1/22 at 9:55 a.m., Certified Nursing Assistant 3 (CNA 3), stated Resident 17 had long, thick, and curvy toenails on both feet. CNA 3 stated there was a risk of Resident 17 hurting himself due to the long toenails. During an interview 2/3/22 at 11:12 a.m., Licensed Vocation Nurse 2 (LVN 2) stated Resident 17 required podiatry services for his toenails, because it was too hard for the staff to cut Resident 17's toenails. During a concurrent interview and record review with the Social Worker (SW) on 2/3/22 at 10:55 a.m., Resident 17's Podiatry Notes dated 9/14/21 were reviewed. The podiatry notes indicated Resident 17 received toenail care last on 9/14/21. The SW stated she was responsible for scheduling the podiatrist visits for residents who required podiatry services. The SW stated Resident 17 was not treated by the podiatrist since 9/14/21, indicating Resident 17 did not receive podiatry services for a period of almost five (5) months. During a concurrent interview and record review with the SW on 2/3/22 at 11:30 a.m., Resident 17's Weekly Summary Skin Check, dated 1/26/22 was reviewed. The skin check sheet indicated Resident 17 received toenail care and clipping on 1/26/22. During a telephone interview with Certified Nursing Assistant 4 (CNA 4) on 2/4/22 at 10:47 a.m., CNA 4 stated she did not cut Resident 17's toenails on 1/26/22. CNA 4 also stated she must have documented in error that she cut Resident 17's toenails on 1/26/22. Review of Resident 17's Nursing Care Plan - CVA [Cerebrovascular Accident- commonly known as Stroke] with Rt [Right] hemiparesis [one sided weakness], revised on 2/2/22, showed staff were to assist Resident 17 with ADL care [Activities of Daily Living, including but not limited to nail care] as needed. Review of the facility's undated Policy and Procedure (P&P) titled, Care of Fingernails/Toenails, the P&P indicated, Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .Refer to Podiatrist for toenail care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 5 of 13 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 555767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellaken Skilled Nursing Center 2780 26th Avenue Oakland, CA 94601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Range of Motion (ROM) exercises were provided according to the physician's order, for one (Resident 50) of four sampled residents reviewed for limited ROM. This failure had the potential to result in a decline in Resident 50's ROM/mobility. Findings: 1. Review of Resident 50's admission record, dated 12/27/21, showed Resident 50 was admitted to the facility in 2018 and was re-admitted in 2021. Review of Resident 50's Minimum Data Set (MDS - an assessment tool used to guide care), Resident 50 had a Brief Interview for Mental Status (BIMS) score of 15, meaning Resident 50 was cognitively intact; able to understand, be understood, and make decisions for her care. Continued review of Resident 50's MDS showed, Resident 50 had multiple diagnoses which included cerebral palsy (disorder affecting a person's ability to move), paraplegia (paralysis of lower legs and lower body), quadriplegia (paralysis from neck down to all four limbs) and traumatic brain injury (injury that causes damage to the brain). Review of Resident 50's Order Summary Report, dated November 29, 2021, showed a physician's order for an RNA (Restorative Nurse Aide) to perform BUE (bilateral upper extremities) PROM (passive range of motion) three times per week or as tolerated, to prevent decline in function/strength and to prevent further contractures. Review of Resident 50's Occupational Therapy Patient discharge instructions, dated [DATE], showed occupational therapy patient discharge instructions as, Discharge to RNA for BUE PROM to prevent decline in ROM and function. During an interview and concurrent record review with the Restorative Nurse Aide (RNA) on 2/3/22 at 2:16 p.m., the RNA stated Resident 50 did not receive ROM exercises for the month of January 2022. The RNA confirmed by review of the record that she did provide RNA services for Resident 50 for January 2022. In an interview with Resident 50 on 2/4/22 at 9:20 a.m., Resident 50 stated she no longer receives ROM exercises from RNA. Resident 50 also stated she wished for the RNA to continue ROM exercises because she needed it. Resident 50 further added she asked the RNA to do ROM exercises, but RNA did not do it. During an interview and concurrent record review with the Director of Nursing (DON) on 2/4/22 at 9:38 a.m., Resident 50's Order Summary Report dated November 29, 2021, was reviewed. The DON acknowledged the RNA order for Resident 50's ROM was active, but not done by the RNA. The DON further stated that ROM for Resident 50 should have been done for the month of January 2022. Review of the facility's undated policy and procedure (P&P), Restorative Nursing Care, showed, Assisting residents with their routine range of motion exercises, and as prescribed be the reisdents's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 6 of 13 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 555767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellaken Skilled Nursing Center 2780 26th Avenue Oakland, CA 94601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Attending Physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 7 of 13 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 555767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellaken Skilled Nursing Center 2780 26th Avenue Oakland, CA 94601 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care consistent with professional standards of practice for one (Resident 21) of two residents that require dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood). for Resident 21, staff did not perform complete assessments before Resident 21 recieved dialysis treatments. Residents Affected - Few This deficient practice resulted in incomplete assessments of Resident 21's dialysis access site (site on a person that attaches to the dialysis machine via soft tubing; important to assess the access site for patency) or of her weights (checking weights help determine if dialysis is working/or how much fluid needs to be removed) and had the potential for any access site or excess fluid concerns not being identified before Resident 21's dialysis treatments began. Findings: A review of the document titled, admission Record, dated 2/3/22 indicated Resident 21 was admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (ESRD - longstanding disease of the kidneys leading to renal failure). A review of Resident 21's Minimum Data Set (MDS- an assessment tool used to guide care needs) dated 11/19/21 indicated Resident 21 is on dialysis. A review of Resident 21's Order Summary Report dated 2/3/22 indicated Resident 21 has dialysis treatments on Tuesdays, Thursdays and Saturdays. During an interview and concurrent record review on 2/3/22 at 11:30 a.m. with the Administrator (ADM), Resident 21's Nurses Dialysis Communication Record for her dialysis treatments on 1/22/22, 1/25/22, 1/27/22 and 1/29/22 were reviewed. The Nurses Dialysis Communication Records for the aforementioned dates showed nursing staff did not perform complete assessments of Resident 21's dialysis access site or check her weights before her dialysis treatments. The ADM acknowledged for Resident 21's treatments on 1/22/22, 1/25/22, 1/27/22 and 1/29/22, the nurse's assessments were incomplete. The ADM stated nurses did not document Resident 21's access site and Resident 21's weight prior to her dialysis treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 8 of 13 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 555767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellaken Skilled Nursing Center 2780 26th Avenue Oakland, CA 94601 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain an informed consent from the residents and or their Family Representatives (FR) prior to use of bed side rails for four of four sampled residents (Resident 64, 41, 25 and 30). This failure resulted in Resident 64's Family Representative (FR 1) to be unaware of risks and benefits of bed side rails. This failure had the potential for Resident 41, 25 and 30 and their FR's to be unaware of risks and benefits of bed side rails use. Findings: During a record review of Resident 64's admission Record dated 2/3/22, the admission Record indicated Resident 64 was admitted to the facility on [DATE]. During a record review of Resident 64's Minimum Data Set (MDS- An assessment tool used to guide care) dated 1/10/22 indicated Resident 64's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was six (6) out of 15. During an interview on 2/3/22 at 1:02 p.m., with MDS Coordinator (MDSC), MDSC stated a BIMS score of six (6) indicated Resident 64 had severe mental impairment. MDSC stated Resident 64 was able to make medical decisions with the help of family. During an observation on 2/1/22 at 10:00 a.m., Resident 64 was sleeping in his room. Resident 64 had a ¾ side rail up on the left side of his bed. During a concurrent observation and interview while in the presence of Registered Nurse 1 (RN 1) on 2/3/22 at 11:48 a.m., Resident 64 was lying in bed with a ¾ side rail up on the left side. RN 1 stated Resident 64 used the bed side rails for repositioning while in bed. RN 1 stated the facility kept both side rails up at all times for Resident 64 to prevent him falling out of bed. RN 1 then raised the right-side rail up on Resident 64's bed before leaving the room. During a record review of Resident 64's Side Rail Utilization Assessment- V 4 dated 10/05/21, indicated Resident 64 was to have two half side rails instead of ¾ bilateral bed side rails while in bed. The assessment also indicated Resident 64 required side rails due to: non ambulatory status, inability to voluntarily get out of bed, alteration in safety awareness, poor bed mobility and difficulty with balance and poor trunk control. During an interview on 2/3/22 at 1:02 p.m., the MDSC stated Resident 64's original bed had two half side rails. MDSC stated Resident 64 was moved to his current bed with ¾ bilateral side rails on 1/28/22 because the original bed was not functional. During a concurrent interview and record review on 2/3/22 at 12:00 p.m., with the Director of Nursing (DON), when asked if the facility obtained an informed consent from Resident 64 and or his FR, the DON pointed at Resident 64's side rail assessment dated [DATE]. However, Resident 64's side rail assessment did not indicate if the facility explained the risks and benefits of having side rails and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 9 of 13 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 555767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellaken Skilled Nursing Center 2780 26th Avenue Oakland, CA 94601 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 0700 or if an informed consent was obtained from Resident 64 and or FR. Level of Harm - Minimal harm or potential for actual harm During a telephone interview with Resident 64's Family Representative on 2/3/22 at 3:40 p.m., FR1 stated no facility representative ever explained the risks and benefits of having side rails. FR1 denied being aware of any risks related to the use of bed side rails. FR 1 denied giving a verbal or a written consent to use side rails for Resident 64's bed. Residents Affected - Some During a record of Resident 64's Physician orders dated 10/6/21, the orders indicated Resident 64 was to use two half side rails while in bed, however 3/4 bilateral bed side rails were in place. During a record review of Resident 25's admission Record dated 2/4/22 the admission Record indicated Resident 25 was originally admitted to the facility on [DATE]. During a concurrent observation and interview with Licensed Vocational Nurse (LVN 2) on 2/4/22 at 8:42 a.m., Resident 25 was lying in bed with half side rails up on each side of the bed. During a record review of Resident 25's Physician orders dated 11/18/21, the orders indicated Resident 25 was to use two half side rails. During a record review of Resident 41's admission Record dated 2/4/22, the admission Record indicated Resident 41 was originally admitted to the facility on [DATE]. During a concurrent observation and interview on 2/4/22, at 8:44 a.m., with LVN 2 in Resident 41 was lying in bed with both half side rails up. LVN 2 stated Resident 41 was not able to lower the bed side rails without staff's assistance either. During a record review of Resident 41's Physician's orders dated 10/29/20, the orders indicated Resident 41 was to use two half side rails while in bed. During a record review of Resident 30's admission Record dated 2/4/22, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE]. During a concurrent observation and interview on 2/4/22 at 8:47 a.m., with Certified Nursing Assistant (CNA 5), Resident 30 was lying in bed with both half side rails up on each side of the bed. During a record review of Resident 30's Physician orders dated 11/19/21, the orders indicated Resident 30 was to use half side rails while in bed. During an interview on 2/4/22 at 8:50 a.m., the MDSC stated the facility did not discuss the risks and benefits of side rail use with the resident or families and did not obtain an informed consent for bed side rail use from Residents 64, 25, 41 or 30 and/or their FR. The MDSC also stated facility the only considered the bed side rail assessment as a means of deciding if bed side rails should be placed or not. During an interview on 2/4/22 at 12:00 p.m., the DON stated one of the risks of using bed side rails included the resident could climb over the side rails, resulting in physical injury. The DON stated that all side rails used were used to enable mobility for the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 10 of 13 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 555767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellaken Skilled Nursing Center 2780 26th Avenue Oakland, CA 94601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure staff followed proper infection control standards and transmission-based precautions to prevent the spread of infection during an active COVID-19 (commonly known as Coronavirus; a mild to severe, and an highly infectious respiratory illness) outbreak when the following occurred: Residents Affected - Some 1. The facility did not have enough Personal Protective Equipment (PPE) including gowns and gloves readily available to direct care staff to provide resident care to those who were known/suspected to have been exposed to the COVID-19 virus. The facility had only one isolation cart containing four isolation gowns available for direct care staff to provide care to 15 residents in eight different rooms in the Yellow Zone area (designated area for those residents that were known or supected to be exposed to COVID-19). 2. Licensed Vocational Nurse (LVN 1) and Registered Nurse (RN 1) did not perform hand hygiene prior to administering medications to Resident 31 and Resident 57 respectively. The failure to follow proper infection control standards and transmission-based precautions in the yellow zone had the potential to result in cross contamination and spread COVID-19 infection among other residents. Findings: 1. During an observation on 2/1/22 at 8:40 a.m., resident rooms including Resident 37 and Resident 31's room had yellow colored signs on the doors, which read as, Yellow Zone: Gown and gloves should be used prior to entry and remove before exit and placed in the disposal bin. During an observation on 2/1/22 at 8:44 a.m., the Housekeeper (HSKP) walked in the resident care hallway, dragging a large black garbage bag with gloved hands. The HSKP entered Resident 37's room without performing hand hygiene, and with the same gloved hands, touched Resident 37 on her shoulders, maneuvered Resident 37's wheelchair and collected the contaminated garbage plastic liner from the disposal bin by Resident 37's bed. The HSKP put the contaminated garbage liner in the large black garbage bag sitting in the hallway outside Resident 37's room. The HSKP again without performing hand hygiene and removing the contaminated gloves entered Resident 31's room next. During a concurrent observation and interview on 2/2/22 at 8.57 a.m., with the Director of Nursing (DON) and the HSKP, the DON stated the HSKP did not speak English and proceeded assist with interpretation. The HSKP stated she looked for isolation gowns to change in between rooms, but she could not find them. The HSKP also stated she was aware that she also needed to change gloves between different residents, but she does not like to waste gloves. The DON stated the facility kept isolation gowns in the utility room at Nursing Station 1. The DON and the HSKP then walked to the end of Nursing Station 1's hallway, to the utility room to find isolation gowns. The DON stated he could not find gowns in the utility room. During an interview on 2/1/22 at 9:03 a.m., with DON at Nursing Station 1, the DON stated staff who worked in the Yellow Zone were expected to don and doff (proper way of putting on and removing PPE in order to prevent further spread of infectous diseases) every time they went in and out of each room. The DON stated staff were required to follow proper donning and doffing of PPE to minimize the spread of COVOD-19 virus among residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 11 of 13 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 555767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellaken Skilled Nursing Center 2780 26th Avenue Oakland, CA 94601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 2/4/22 at 9:34 a.m., Certified Nursing Assistant 2 (CNA 2) came out of Resident 64's room wearing an isolation gown and gloves. CNA 2 had linens and contaminated briefs in his gloved hands. CNA 2 disposed the linens and the contaminated briefs in a cart outside of the room in the hallway. CNA 2 removed his gloves, then his isolation gown and disposed of them both into a disposal bin outside of the room in the hallway. CNA 2 stated he assisted Resident 64 with incontinent care and changed the bed linen. CNA 2 stated he came out of Resident 64's room with the isolation gown and gloves on, because he did not want to carry contaminated briefs with his bare hands. CNA 2 also stated all resident rooms,( including Resident 64's room) did not have extra pairs of gloves available inside the room. CNA 2 stated the facility needed to make extra gloves available inside the resident rooms. During a concurrent observation and interview on 2/1/22 at 11:10 a.m., a clear plastic container with three drawers was kept at Nursing Station 2 hallway. The Infection Preventionist (IP) stated that was a PPE isolation cart. The IP then counted the number of isolation carts containing PPE in the corridor designated as a Yellow Zone. The IP stated there was only one isolation cart available for direct care staff for eight resident rooms (with 15 residents). The isolation cart had four isolation gowns and no gloves stored in it. During an interview on 2/4/22 at 8:00 a.m., with the administrator (ADM), the ADM stated the facility had enough PPE supply to last over two months at the facility. The ADM stated the facility was able to make available enough PPE to the direct care staff to provide resident care during COVID-19 outbreak at the facility. During a review of the facility's undated Policy and Procedure (PNP) titled, Covid-19, Prevention and Control- Droplet Precautions, showed that, gown will be removed, and hand hygiene performed before leaving the resident's environment. During a review of facility's undated PNP titled, Personal Protective Equipment- Using Gowns indicated, if gown is disposable, discard it into the waste receptacle inside the room. If the gown is reusable (washable), discard it into the soiled laundry container inside the room. During a review of facility's undated PNP titled, Personal Protective Equipment- Using Gloves indicated, discard gloves into designated waste receptacle inside the room. 2. During a concurrent observation and interview on 2/2/22 at 8:40 a.m., in Residents 31's room, LVN 1 administered medications to Resident 31. LVN 1 put Resident 31's prepped medications on his bed side table. LVN 1 wore a clean pair of gloves, held onto Resident 31's right side bed rail. Without changing gloves and performing hand hygiene, LVN 1 administered morning medications via Resident 31's Gastrostomy (an opening in the stomach used to administer medication and nutrition via a tube). LVN 1 stated she did not perform hand hygiene prior to administering medications to Resident 31. LVN 1 also stated hand hygiene was required to prevent cross contamination. During a concurrent observation and interview on 2/2/22 at 9:23 a.m., in the hallway outside Resident 57's room, RN 1 wore gloves, pour Resident 57's medications in the medication cup, locked the medication cart. RN 1 then opened Resident 57's room by rotating the doorknob with the same gloved hands. RN 1 entered Resident 57's room, pulled Resident 57's wheelchair. RN 1 then, without changing gloves and performing hand hygiene, administered Resident 57's oral medications. RN 1 stated her pair of gloves was dedicated to prepare and administer Resident 57's medication. RN 1 also stated she considered the high touch areas including medication cart, doorknob, and wheelchair as clean surfaces. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 12 of 13 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 555767 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellaken Skilled Nursing Center 2780 26th Avenue Oakland, CA 94601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 2/4/22 at 10:07 a.m., Infection Preventionist (IP) stated licensed nurses needed to remove gloves and wash hands after touching the high touch surfaces including bedside rails, doorknobs, wheelchair; and before administering medications to Resident 31 and 57. The IP stated hand hygiene was important to prevent cross contamination and spread of infections. Review of facility's undated PNP titled, Medication Administration General Guidelines (California specific) indicated, Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral .medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations . Event ID: Facility ID: 555767 If continuation sheet Page 13 of 13