Health inspection·December 14, 2023

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admitted to the facility on [DATE] with multiple diagnoses that included Acute Respiratory Failure with Hypoxia. During a concurrent observation and interview on 12/11/23 at 11:12a.m. with LVN 1, in Resident 215's room, Resident 215 was receiving oxygen via NC set at a flow rate of 1.5L per minute. LVN 1 stated, Resident 215's had an order for oxygen at flow rate of 2L. LVN 1 then changed the flow rate setting to 2L and stated, I will pay more attention to the oxygen order from now on. During a review of Resident 215's order summary report, dated 12/11/23, it indicated a physician's order, O2, 2LPM via NC continually for conform every shift. During a review of Resident 215's care plan, dated 12/11/23, it indicated Resident 215 had the potential/actual ineffective airway clearance Dx of Respiratory failure with hypoxia . The care plan also indicated, one of the interventions were to administer O2 per order. During a review of Resident 215's care plan, dated 12/11/23, it indicated Resident 215 had altered respiratory status/difficulty breathing related to acute respiratory failure . The care plan also showed one of the interventions were to administer oxygen per order. During an interview on 12/11/23, at 2:38 p.m. with the Director of Nursing (DON), DON indicated, LVN 1 must follow standards of practice regarding following doctor's orders. DON also indicated, the LVN 1's responsibility included making sure oxygen was in right titration and must reflect doctor's order. If oxygen was not in the flow rate it was ordered by the doctor, then LVN 1 did not follow the doctor's order. DON further added, oxygen order was important to follow especially Residents 9 and Resident 215 had respiratory problems, oxygen supplement will help with respiration, energy and alertness. During a review of facility's policy and procedures (P&P) titled, Oxygen Administration, undated, indicated the purpose is to provide guidelines for safe oxygen administration. The first step of preparation indicated to verify that there is a physician's order for the procedure and to review the physician's orders or facility protocol for oxygen administration. The P&P also showed under Steps in the Procedure .8. Turn on the oxygen. Administer oxygen per physician's orders.10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 2 of 19 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 12/14/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm 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 ensure safe and accountable medication handling, and implementation of pharmaceutical services procedures when: Residents Affected - Some 1. Quality control tests for blood glucose meters (a device used to measure and display the amount of sugar [glucose] in your blood) used in the facility were not done consistently. 2. There were no remedial actions taken for quality control test results, that were out of range, for a blood glucose meter used in the facility. 3. Unused or discontinued medications were disposed without signatures of a pharmacist or nurse and one other witness. These failures could contribute to unsafe medication use and practices in the facility. Findings: 1. During a concurrent observation and interview, on 12/12/23, at 3:04 PM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated quality control tests were conducted on blood glucose meters used in the facility. LVN 2 showed the surveyor the Glucose Monitoring System Daily Quality Control Record, for nursing station 1. The Glucose Monitoring System Daily Quality Control Record (GMSDQCR), indicated the following: Month: December 2023 Meter [Blood Glucose] Serial Number: T08654698 Date, Time, Operator Initials, Meter Cleaned, Battery Changed, Test Strip Expiration Date, Low Lot Control Range, Low Lot Control Result, High Lot Control Range, High Lot Control Result and Remedial Action The GMSDQCR document, for Meter [Blood Glucose] Serial Number: T08654698, for December 2023 (12/1/23 up to 12/12/23), had no information for the following dates: 12/2/23, 12/3/23, 12/4/23 and 12/11/23. LVN 2 confirmed and acknowledged the findings, and stated daily quality control tests of the blood glucose meters were not done for those dates. During a concurrent interview and record review on 12/13/23, at 9:40 AM with the Medical Records Director (MRD), the Glucose Monitoring System Daily Quality Control Records (GMSDQCRs), were reviewed for 2023 for nursing station 1 and nursing station 2. When asked about GMSDQCRs for the month of October 2023, for both nursing stations, the MRD stated she did not know it was missing. MRD confirmed and stated that the documents were not found on the file records. No GMSDQCR records were available for review for October 2023. During a concurrent interview and record review on 12/14/23 at 8:53 AM, with the Director of Nursing (DON), Glucose Monitoring System Daily Quality Control Records (GMSDQCRs), provided by the facility for nursing station 1 and nursing station 2, for year 2023, were reviewed. DON stated quality (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 3 of 19 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 12/14/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some control testing of blood glucose meters used in the facility were done daily by nurses. DON stated the nurses assigned in the night shift, were responsible and expected to perform the quality control tests to ensure the device reads the blood glucose test results correctly. Review of the manufacturer's manual for the blood glucose meter used in the facility, indicated, True Metrix Self Monitoring Blood Glucose System Owner's Manual . Quality Control Testing - To assure you are getting accurate and reliable results, TRUE METRIX offers two kinds of quality Control Tests. These tests let you know that your System is working properly and your testing technique is good . How To Test Control Solution .11. Compare meter result to Control Test range printed on test strip vial label for level of control solution you are using. If result is in range, System can be used for testing blood. If result does not fall within range, repeat test using a new test strip. Caution! If Control Test result is outside range, test again. If result is still outside range, system should not be used for testing blood . 2. Review of the GMSDQCR document, for Meter [Blood Glucose] Serial Number: T08654698, for December 2023 and November 2023, indicated the following: Date: 1 [12/1/23] . High Lot: Control Range: 241-327, Control Result: 329, Remedial Action - 0 [zero]. Date: 6 [12/6/23] . High Lot: Control Range: 241-327, Control Result: 334, Remedial Action - 0 [zero]. Date: 9 [11/9/23] . High Lot: Control Range: 241-327, Control Result: 329, Remedial Action - 0 [zero]. Review of the manufacturer's manual for the blood glucose meter used in the facility, indicated, True Metrix Self Monitoring Blood Glucose System Owner's Manual . Quality Control Testing . How To Test Control Solution .11. Compare meter `result to Control Test range printed on test strip vial label for level of control solution you are using. If result is in range, System can be used for testing blood. If result does not fall within range, repeat test using a new test strip. Caution! If Control Test result is outside range, test again. If result is still outside range, system should not be used for testing blood . During a concurrent interview and record review on 12/14/23 at 8:56 AM, with the DON, the GMSDQCR documents, for Meter [Blood Glucose] Serial Number: T08654698, for December 2023 and November 2023 were reviewed. DON confirmed and acknowledged that the control test results indicated on the records were out of range and did not indicate remedial actions by staff. DON explained that quality control tests had to be re-done when control test results were out of range. DON added, if out of range, look at solution [test control solution], maybe get another solution, or replace the glucometer. DON also acknowledged the findings that blood glucose meter daily quality control tests were not done consistently. DON stated, we will fix it. 3. During a concurrent interview and record review on 12/11/23 at 3:40 PM, with the DON present, in the medication storage room, the Medication Disposition Record (MDR) binder log was reviewed. The MDRs for 7 out of 10 of sampled residents (Resident 1, Resident A [a resident that had passed away], Resident 15, Resident B [a resident that was discharged ], Resident 51, Resident 29, and Resident 9) did not indicate two required signatures by staff for unused or discontinued medications that were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 4 of 19 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 12/14/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm disposed. DON confirmed the findings and stated the staff did not follow the facility's policy and procedures for disposal of medications. Review of Resident 1's Medication Disposition Record, indicated, medications that were written in the log, for the following dates, were destroyed without the required two signatures from staff. Residents Affected - Some 6/13/23 8/15/23 11/9/23 Review of Resident A's Medication Disposition Record, indicated, medications that were written in the log, for the following date, were destroyed without the required two signatures from staff. 10/5/23 Review of Resident 15's Medication Disposition Record, indicated, medications that were written in the log, for the following dates, were destroyed without the required two signatures from staff. 11/9/23 11/16/23 Review of Resident B's Medication Disposition Record, indicated, a medication that was written in the log, for the following date, was destroyed without the required two signatures from staff. 8/24/23 Review of Resident 51's Medication Disposition Record, indicated, medications that were written in the log, for the following dates, were destroyed without the required two signatures from staff. 10/15/23 11/11/23 Review of Resident 29's Medication Disposition Record, indicated, a medication that was written in the log, for the following date, was destroyed without the required two signatures from staff. 8/18/23 Review of Resident 9's Medication Disposition Record, indicated, a medication that was written in the log, for the following date, was destroyed without the required two signatures from staff. 11/16/23 Review of the facility's Policy and Procedures (P&P), titled, Disposal of Medications, Syringes and Needles, dated 2007, indicated, Medications not listed in Schedules II, III, IV and V (non-controlled medications) shall be destroyed by the nursing care center in the presence of a pharmacist or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 5 of 19 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 12/14/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete nurse and one other witness. Documentation of non-controlled medication may be completed on a medication administration record (MAR), a medication disposition log or form (or record provided for that purpose) and shall be retained as per federal privacy and state regulations . a. A non-controlled medication disposition log or form shall be used for documentation and shall be retained as per federal privacy and state regulations. The log shall contain the following information: Resident's name, Medication name and strength, Prescription number, if applicable, Quantity/amount disposed, Date of disposition, Signatures of the required witnesses . Event ID: Facility ID: 555767 If continuation sheet Page 6 of 19 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 12/14/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the medication room (a locked room used to store medications and supplies), one out of two medication carts (a mobile cart that stored medication and supplies for immediate use) and one treatment cart when: 1.An opened, used, multi-dose vial of influenza vaccine was not removed from the medication refrigerator after 28 days of first use. 2.Expired (outdated) medications and items were stored and not removed in the medication room, treatment cart and medication cart. These failed practices could contribute to unsafe medication use in the facility. Findings: 1.During a concurrent observation and interview on 12/11/23 at 2:41 PM, with the Licensed Vocational Nurse (LVN) 4 present, in the facility's medication room, there was an opened, used, multi-dose vial of Fluzone, (an influenza vaccine), that indicated, opened 10/20/23 found in the medication refrigerator. When asked, LVN 4 stated she was not sure when to discard the opened multi-dose vial of Fluzone once opened and used. During an interview on 12/14/23 at 12:21 PM, with the Pharmacist, the Pharmacist stated opened, multi-dose vials containing liquid had to be discarded after 28 days from open date. Review of the facility's Policy and Procedures (P&P), titled, Fluzone Multidose Vial Storage/Beyond Use Date (BUD), undated, the P&P indicated, Policy Statement - Multidose flu vials and shortened expiration dates. Policy Interpretation and Implementation . Influenza Vaccine Multi Dose Vials (MDV) have a BUD (Beyond Use Date [a date that is no longer safe to use the medication] of 28 days after first access. 2.a During a concurrent observation and interview on 12/11/23 at 2:41 PM, with the Director of Nursing (DON), in the facility's medication room, the following expired medications were found: a nasal spray with expiration dated 12/2021, and a locked IV (intravenous - medications, solutions, etc. administered directly into a person's veins) kit that contained multiple vials of medications, solutions and supplies with expiration dated 11/2023. DON confirmed and acknowledged the findings. 2.b During a concurrent observation and interview on 12/11/23 at 4:30 PM, with the Infection Preventionist (IP) present, the treatment cart located in nursing station 2 was inspected. There was a hydrogel tube (used for wound care and treatment) found in the cart, with expiration dated 11/2023. The IP confirmed and acknowledged the finding. 2.c During a concurrent observation and interview on 12/12/23 at 3:15 PM, with LVN 2 present, the medication cart located in nursing station 1 was inspected. There was a Sage Suction toothbrush with Corinz, (used for cleansing and moisturizing oral rinse that helps reduce chance of infection) found in the cart, with expiration dated 11/28/23. LVN 2 confirmed the expired item. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 7 of 19 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 12/14/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Review of the facility's Policy and Procedures (P&P), titled, Medication Storage - Storage of Medication, dated 2007, the P&P indicated, .Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . and reordered from the pharmacy . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 8 of 19 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 12/14/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to prepare and serve food under safe and sanitary conditions when: Residents Affected - Some 1. Low temperature dishwasher did not reach the proper sanitation level. 2. Dietary staff did not wear hair restraints properly to cover all hair. 3. Dietary staff entered the kitchen did not wash upon entry to the kitchen. 4. Dietary staff dropped food tray on the floor next to sink, picked it up then placed it in the cart intended to deliver food to residents. These failed practices had the potential to place residents at risk for developing foodborne illness. Findings: 1. During an observation on 12/11/23 at 10:25 a.m. with Dietary Staff (DS) 2, DS 2 demonstrated how to test for sanitizing the dishes in the low temperature dishwasher by using test paper dipped into wet part of newly washed tray. DS 2 showed, the test strip remained light blue in color when compared with color in vial indicating insufficient concentration of 25 ppm (parts per million - concentration for sanitizing). DS 2 further added test strip should be 100 ppm for dishes to be properly sanitized. During an interview on 12/11/23 at 11:35 a.m. with the Dietary Service Supervisor (DSS), DSS confirmed the chemical solution for the low temperature dish machine was inadequate because it was not reaching 50 - 100 ppm. DSS further added, this has potential for foodborne illness. During a concurrent interview and review of facility's SAFE PARAMETERS FOR DISH AND POT WASHING document, dated 2014, on 12/11/23 at 1:20 p.m. with the DSS, DSS showed under low temperature dish machine, sanitizer should reach 50 ppm Chlorine . During a concurrent interview and review of Manufacturer's Specification titled, CMA Dishmachines Owner's Manual dated 8/24/17, on 12/11/23 at 1:20 p.m. with the DSS, DSS showed under 5. Chemical Feeder: .Concentration should be 50 ppm minimum to 100 ppm maximum . During a review of facility's policy and procedure (P&P) titled, Infection Control - Ware Washing, dated 2014, the P&P indicated under Procedure: .5. Sanitizer effectiveness of the low temperature dishmachine is checked each meal. Follow manufacturer's specifications.e. Compare immediately with color chart on vial. Color of paper dipped in rinse water must compare with color on vial relating to a minimum of 50 ppm .14. Dietary Service Supervisor and dietary staff continuously monitor the effectiveness of mechanical dishwashing results . 2. During an observation on 12/11/23 at 11:36 a.m. DS 1 entered kitchen wearing hair restraint with lower part of hair exposed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 9 of 19 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 12/14/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm 3. During an observation on 12/11/23 at 11: 37 a.m. DS 1 entered, walked across the kitchen, and entered walk-in refrigerator without washing his hands. When asked regarding hand hygiene practices and hair restraint policy in the kitchen, DS 1 acknowledged he did not wear hair restraint properly and did not wash his hands because he was not working at this time in the kitchen. DS 1 further added, he just came in to grab his bottle of water inside walk-in refrigerator. Residents Affected - Some During an interview on 12/11/23 at 1:57 p.m. with the DSS, DSS stated, DS 1 should have washed his hands upon entry to the kitchen and should have worn hair restraints properly. DSS also stated, DS 1's hair could get all over the place in the kitchen. DSS further added, the policy was to wash hands at all times upon entry to the kitchen and wear hair restraint properly to cover all hair. During a review of facility's P&P titled, INFECTION CONTROL - HAND WASHING, dated, 2014. The P&P indicated under PROCEDURE: .2. When to wash hands: a. Entering the Dietary department before beginning work or returning from the other areas in the facility. During a review of the facility's IN-SERVICE HAND & HAIR SAFETY & SANITATION, dated 6/25/14, it indicated under instructions .2. Handwashing a. Basic principle of food safety. b. Can help prevent getting sick and getting others sick 3. Hairnets- Signs and hairnets at all entrances. a. ALL employees are required to wear hairnets while in the kitchen b. There is no I just need to go right here. 4. During a concurrent observation and interview on 12/12/23 at 10:58 a.m. with DS 2, in the presence of DSS, DS 2 dropped a newly washed food tray on a partially wet floor next to the sink. DS 2 then picked up the tray and placed it in food cart. When asked what was supposed be done with dirty tray. DS 2 stated, I will wash then removed the dirty tray from the cart and placed in the dirty sink. DSS then stated, DS 2 should have not picked up dirty tray and placed in food cart intended to deliver food. DSS further added, DS 2's action was not acceptable. During a review of the facility's Policy and Procedure (P&P) titled, INFECTION CONTROL - WARE WASHING, dated 2014, indicated under Procedure: .10. Clean dishes and utensils must be handled so as to prevent cross contamination via splash . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 10 of 19 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 12/14/2023 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 implement their infection prevention and control program when: Residents Affected - Some 1. One of 18 sampled residents (Resident 6) had a urinary catheter drainage bag (a device used to empty the bladder and collect urine) that touched the floor. 2. Soiled towels in the laundry room were not stored in a covered, soiled laundry hamper or container. 3. Laundry room daily task checklists were not done by staff. 4. Manufacturer's instructions for use (MIFU) was not followed for cleaning and disinfection of blood glucose meters (a device used to measure and display the amount of sugar [glucose] in your blood) used in the facility. 5. A single-patient use blood glucose meter was used on three patients (Resident 21, Resident 38 and Resident 47) in nursing station 2. These failures have the potential to not prevent the development and transmission of communicable diseases and infections among residents and staff. Findings: 1.During an observation on 12/11/23, at 10:13 AM, Resident 6 was in bed and did not respond when greeted. Resident 6 had a urinary catheter drainage bag with approximately 100 ml of clear, yellow-colored urine. Resident 6's urinary catheter drainage bag touched the floor. During a concurrent observation and interview on 12/11/23, at 10:30 AM, with Certified Nursing Assistant (CNA) 1, inside Resident 6's room, CNA 1 confirmed Resident 6's urinary catheter drainage bag touched the floor and said, it's not right. CNA 1 also stated Resident 6's urinary catheter drainage bag should be inside a blue bag [a holder for a urinary catheter drainage bag]. During a concurrent observation and interview on 12/11/23, at 10:37 AM, with the Director of Nursing (DON), inside Resident 6's room, DON confirmed that Resident 6's urinary catheter drainage bag touched the floor. DON stated this was an infection control issue and was not acceptable. DON also stated Resident 6's urinary catheter drainage bag should be covered with a dignity bag [a holder that conceals the urinary catheter drainage bag]. Review of the facility's Policy and Procedures (P&P), titled, Catheter Care, Urinary, undated, the P&P indicated, Purpose: To purpose of this procedure is to prevent catheter-associated urinary tract infections . Infection Control . b. Be sure the catheter tubing and drainage bag are kept off the floor . 2. During a concurrent observation and interview on 12/13/23, at 10:09 AM, with the Housekeeping Supervisor (HS), in the laundry room, a pile of soiled towels filled an uncovered bucket underneath a table that had unused PPEs (personal protective equipment) such as plastic, disposable gowns and a box of disposable gloves. When asked, HS stated the towels were dirty and were brought to the laundry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 11 of 19 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 12/14/2023 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 room by the kitchen staff. HS stated the soiled towels should be stored in a soiled laundry container with a cover. 3. During an observation on 12/13/23, at 10:11 AM, with the Housekeeping Supervisor (HS) and a Laundry Staff (LS1) present, the lint trap filters for the dryers used in the facility were inspected. The lint trap filter for Dryer labeled 3 was completely covered with a thick layer of lint. During a concurrent interview and record review, on 12/13/23 at 10:30 AM, with HS present, the Laundry Room Daily Tasks Checklist was reviewed for the months of December 2023, November 2023, and October 2023. HS confirmed the daily tasks checklist was not done by staff consistently. HS also acknowledged that the laundry room daily tasks checklist was not reviewed by the supervisor. The Laundry Room Daily Tasks Checklist included the following information: Date Clean lint filter after each use of washer or dryer at least daily. Vacuum lint trap. Wipe down all machines after use. Damp wipe all counters with a disinfecting solution. Clean all laundry carts with a disinfecting solution. Clean sinks. Sweep and damp mop the floor. Signature [by staff]. Supervisor Review. Please initial after completing task. Supervisor to review and sign weekly. The Laundry Room Daily Tasks Checklists, did not indicate all the daily assigned tasks were done on the following dates: 10/1/23 10/7/23 10/8/23 10/14/23 10/21/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 12 of 19 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 12/14/2023 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 10/22/23 Level of Harm - Minimal harm or potential for actual harm 10/30/23 11/1/23 Residents Affected - Some 11/4/23 11/11/23 11/18/23 12/2/23 12/9/23 Review of the facility's Policy and Procedures (P&P), titled, Laundry Room, Environmental, undated, the P&P indicated, Policy Statement - The environment of Laundry Room will be maintained according to best practices for infection prevention and control. Policy Interpretation and Implementation. Dryer Lint Filters To maintain good air flow and promote efficient operation of the dryers, clean dryer lint filter after use of the dryer, but at least daily. Doing so also reduces the risk of a lint fire. Laundry Room Cleaning Assignment: To ensure the cleanliness of the Laundry Room, at the end of the shift: vacuum dryer lint trap at the end of the day to prepare for use the next day. Wipe down all machines - washer and dryers, at the end of the day. Damp wipe all counters with disinfecting solution. Clean sinks. Sweep and damp mop the floor. Documentation: To ensure completion of required tasks, at the end of the shift: Complete and Sign: Laundry Room Daily Task Checklist . 4. During a concurrent observation and interview, on 12/12/23, at 3 PM, with Licensed Vocational Nurse (LVN) 2, the medication cart located in nursing station 1 was inspected. There was a True Metrix blood glucose meter (a device used to measure and display the amount of sugar (glucose) in your blood) including blood glucose test strips and push-button lancets found in one of the drawers of the medication cart. LVN 2 was asked how she cleans and disinfects the blood glucose meter. LVN 2 stated she uses a Microkill [blue top] Germicidal Bleach Wipe to clean and disinfect the device with a contact time (the amount of time a disinfectant need to sit on a surface, without being wiped away or disturbed, to be effective) of one minute. On 12/12/33 at 4:15 PM, a copy of the blood glucose meter manufacturer's instructions for use was requested from the facility. The facility provided a copy of the Manufacturer's Owner's Manual for True Metrix blood glucose meter on 12/13/23 at around 4 PM. Review of the Manufacturer's Owner's Manual for True Metrix blood glucose meter, indicated, Meter Care, Cleaning and Disinfecting - Cleaning removes blood and soil from the meter. Disinfecting removes most, but not all possible infectious agents (bacteria or virus) from the meter, including blood-borne pathogens. Clean and disinfect immediately after getting any blood on the meter or if meter is dirty. Clean and disinfect meter at least once a week. Meter may be cleaned and disinfected once a week for up to 5 years. If the meter is being operated by a second person who provides testing assistance, the meter and lancing device should be cleaned and disinfected prior to use by the second person. Do not clean the meter during a test. Cleaning (step 2) must occur before disinfecting (steps #3 and #4). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 13 of 19 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 12/14/2023 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 To Clean and Disinfect the Meter: Level of Harm - Minimal harm or potential for actual harm 1. Wash hands thoroughly with soap and water. Residents Affected - Some 2. To Clean: Make sure meter is off and a test strip is not inserted. With ONLY Super Sani-Cloth Wipes (EPA reg.no. 9480-4), rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter. Discard used wipes. 3. To Disinfect: Using fresh wipes, make sure that all outside surfaces of the meter remain wet for 2 minutes. Make sure no liquids enter the Test Port or another opening in the meter. 4. Let meter air dry thoroughly before using to test. 5. Wash hands thoroughly again after handling meter. 6. Verify that the System is working properly by performing an Automatic Self-Test. Note: Other disinfectants have not been tested. The effect of other disinfectants used interchangeably has not been tested with the meter. Use of disinfectants other than Super Sani-Cloth Wipes may damage meter. Note: Super Sani-Cloth Wipes have been tested on the meter for a total of 260 cleaning and disinfecting cycles, which is equal to cleaning and disinfecting the meter once a week for a 5 year period. The use life of the meter is 5 years. During an interview on 12/14/23 at 8:06 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was assigned to patient rooms located in Nursing Station 2. When asked about cleaning and disinfection, of the True Metrix blood glucose meter used for patients in nursing station 2, LVN 1 stated he cleans and disinfects the True Metrix blood glucose meter before and after use. LVN 1 stated, he puts on gloves, uses the Microkill Germicidal Bleach Wipe and wipes it around the device. LVN 1 stated he keeps the device wet for 30 seconds to 3 minutes to kill the bacteria, etc. LVN 1 stated he would allow a contact time for a minimum of 30 seconds and would let the blood glucose meter to air dry. During an interview on 12/14/23 at 8:36 AM, with LVN 3, LVN 3 stated she was assigned to patient rooms located in Nursing Station 1. When asked about cleaning and disinfection of the True Metrix blood glucose meter used for patients in nursing station 1, LVN 3 stated she would clean and disinfect the device before and after use to kill the virus and bacteria. LVN 3 explained she uses a Microkill Germicidal Bleach Wipe, and wipes each side, back and front and the gray opening [test port - where test trips are inserted] of the device. LVN 3 stated she allows a minimum contact time of 3 minutes to kill the virus as indicated on the label of the bleach wipe. During an interview on 12/14/23 at 9:48 AM, with the Infection Preventionist (IP), IP stated that blood glucose meters used in the facility had to be cleaned after every patient use to prevent infection just in case the device is contaminated. When asked, IP explained that the facility uses Microkill Germicidal Bleach Wipes to clean and disinfect the entire surface of the device. IP stated contact time allowed was 3 minutes, to disinfect the blood glucose meters. IP explained this was to give enough time for the disinfectant to work to kill the microorganisms as recommended on the label of the Microkill Germicidal Bleach Wipes. IP also stated that the facility follows the manufacturer's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 14 of 19 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 12/14/2023 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 label on the Microkill Germicidal Bleach Wipes when cleaning and disinfecting the blood glucose meters used in the facility. IP stated she did not know and had not read the instructions on the manufacturer's manual of the True Metrix blood glucose meters used. When asked, IP stated it was important to follow the manufacturer's manual for use of the blood glucose meter to not damage the machine and to ensure to kill the bacteria as recommended by manufacturer. IP stated she had not inquired from the manufacturer if it was acceptable to use a different type of cleaning and disinfecting wipe for use on the device. During an interview on 12/14/23 at 10:34 AM, with the Infection Preventionist (IP), IP stated she had worked at the facility for 21 years. IP stated that the facility uses the True Metrix blood glucose meter on multiple residents that had orders for blood glucose checks since the beginning of the year. IP stated she had not seen the staff use a dedicated blood glucose meter for each resident that required blood glucose checks. Review of the facility's Policy and Procedures (P&P), titled, Maintenance, Cleaning and Disinfection and Care of Glucometer, undated, the P&P indicated, Glucometers, a resident-care equipment will be maintained, cleaned and disinfected between patient use . Cleaning and Disinfection of Glucometer 1. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to the manufacturers' instructions . 5. Review of the Manufacturer's Manual for the True Metrix blood glucose meters, used in the facility, indicated, Self-Monitoring Blood Glucose System Owner's Manual . TRUE Metrix Self Monitoring Blood Glucose System is intended to be used by a single person and not to be shared . IMPORTANT INFORMATION . Read all product instructions for use before testing. Use of . TRUE METRIX Self Monitoring Blood Glucose System in a manner not specified in this Owner's booklet is not recommended and may affect ability to determine true blood glucose levels . TRUE METRIX Self Monitoring Blood Glucose System is for one person use ONLY. DO NOT share your meter or lancing device with anyone . Do not use on multiple patients . During a concurrent observation and interview on 12/14/23 at 8:04 AM, with Licensed Vocational Nurse (LVN) 1, in nursing station 2 hallway, LVN 1 showed the surveyor the True Metrix blood glucose meter he uses, designated for multiple residents in nursing station 2. During a concurrent interview and record review on 12/14/23 at 9 AM, with the Director of Nursing (DON), DON stated he was not sure and had to check if the blood glucose meters used in the facility was used on multiple residents. DON confirmed after verification from staff that the True Metrix blood glucose meter used in nursing station 2 was used on multiple residents. A copy of the True Metrix Self Monitoring Blood Glucose System Owner's Manual was reviewed with the DON present. DON verified that the device was intended to be used by a single person and not to be shared. DON stated the facility's use of the True Metrix blood glucose meters was wrong. DON said, the device should be for single patient use. When asked how long he had known the issue of blood glucose meters used for multiple residents in the facility, DON responded, he just knew about it now. The surveyor requested the DON to provide a list of residents in the facility that had physician orders for blood glucose checks. Review of the facility's daily census list provided by the DON, dated, 12/13/23, indicated, 4 out of 59 residents (Resident 43, Resident 21, Resident 38 and Resident 47) were identified, and required blood glucose checks. 3 out of 4 residents (Resident 21, Resident 38, and Resident 47) used the same True Metrix blood glucose meter designated for nursing station 2 residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 15 of 19 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 12/14/2023 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 Review of Resident 21's Physician's Order, dated 12/1/23, indicated, Lantus Solution . (a type of insulin [used to manage blood sugar levels]) . inject at bedtime . hold for BS (Blood Sugar) below 100. Review of Resident 38's Physician's Order, dated 12/1/23, indicated, Basaglar . (a type of insulin) . inject at bedtime . hold for BS (Blood Sugar) below 100. Residents Affected - Some Review of Resident 47's Physician's Order, dated 12/1/23, indicated, .Check blood sugar BID [twice a day] two times a day for diabetes . Review of Centers for Disease Control and Prevention's (CDC) Injection Safety Summary, dated 3/2/11 (retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html) indicated, .Recommended Practices for Preventing Bloodborne Pathogen Transmission during Blood Glucose Monitoring and Insulin Administration in Healthcare Settings . Blood Glucose Meters - Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over blood and infectious agents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 16 of 19 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 12/14/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 pneumococcal immunizations for three of five sampled residents (Resident 61, Resident 60, and Resident 9) when the residents did not receive the pneumococcal immunization after it was offered. Residents Affected - Some This failure had the potential to not protect the residents against serious illnesses like pneumonia (lung infection). Findings: During a concurrent interview and record review on 12/13/23 at 2 PM, with the Infection Preventionist (IP), Resident 61's medical records were reviewed. IP stated Resident 61's admission date indicated 11/8/23. IP stated Resident 61 was given pneumococcal vaccine on 4/22/17 at a different facility. The facility's Pneumococcal Vaccine Consent, dated 11/9/23, indicated, Resident 61 signed and consented to receive the pneumococcal vaccination unless the physician indicated it is medically contraindicated. IP confirmed there was no record Resident 9 received the pneumococcal vaccination after the consent was signed on 11/9/23. IP stated the pneumococcal vaccination should be administered to the resident within a week after the consent was signed. During a concurrent interview and record review on 12/13/23 at 2:15 PM, with the IP, Resident 60's medical records were reviewed. IP stated Resident 60's admission date indicated 10/11/23. IP stated Resident 60 was given pneumococcal vaccine on 10/3/11 outside the facility at the doctor's office. The facility's Pneumococcal Vaccine Consent, dated and signed on 10/11/23, indicated, if she didn't have it she would like to have one. The IP stated the resident's decision maker was the resident's son. There was no additional record provided if Resident 60 received the pneumococcal vaccination. During a concurrent interview and record review on 12/13/23 at 2:20 PM, with the IP, Resident 9's medical records were reviewed. IP stated Resident 9's admission date indicated 12/8/23 after the resident was sent to the hospital. Ip stated Resident 9 was initially admitted to the facility on [DATE]. IP stated Resident 9 was given pneumococcal vaccine on 3/4/10. The facility's Pneumococcal Vaccine Consent, dated 4/4/23, indicated, Resident 9's responsible party signed and consented for the resident to receive the pneumococcal vaccination unless the physician indicated it is medically contraindicated. IP confirmed there was no record Resident 9 received the pneumococcal vaccination after the consent was signed on 4/4/23. During an interview on 12/13/23 at 2:22 PM, with the IP, IP stated she was not sure if residents who previously received a pneumococcal vaccination may receive another pneumococcal vaccination. During an interview on 12/14/23 at 12:38 PM, with the Pharmacist, the Pharmacist stated residents who previously received pneumococcal vaccines could receive another pneumococcal vaccination, with a minimum of 5 years since the last administration, and especially if the previous immunization was about 10 years ago. Review of the facility's Policy and Procedures (P&P), titled, Pneumococcal Vaccine, undated, the P&P indicated, Policy Statement - All residents will be offered pneumococcal vaccines to aid in preventing pneumococcal infections. Policy Interpretation and Implementation - 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 17 of 19 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 12/14/2023 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . Review of the Center for Disease Control and Prevention's (CDC) Vaccine Information Statement, dated 5/12/23, provided to the surveyor by the facility, indicated, Pneumococcal Conjugate Vaccine: What You Need to Know . Pneumococcal conjugate vaccine - Pneumococcal conjugate vaccine helps protect against bacteria that cause pneumococcal disease. There are three pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20). The different vaccines are recommended for different people based on age and medical status . Adults 65 years or older who have not previously received pneumococcal conjugate vaccine should receive pneumococcal conjugate vaccine. Some people with certain medical conditions are also recommended to receive pneumococcal polysaccharide vaccine (a different type of pneumococcal vaccine, known as PPSV23). Some adults who have previously received a pneumococcal conjugate vaccine may be recommended to receive another pneumococcal conjugate vaccine . Review of the Center for Disease Control and Prevention's (CDC) Vaccine Information Statement, dated 10/30/19, provided to the surveyor by the facility, indicated, Pneumococcal Polysaccharide Vaccine (PPSV23): What You Need to Know . PPSV23 is recommended for: All adults 65 or older . Most people need only one dose of PPSV23. A second dose of PPSV23, and another type of pneumococcal vaccine called PCV13, are recommended for certain high-risk groups. Your health care provider can give you more information. People 65 years or older should get a dose of PPSV23 even if they have already gotten one or more doses of the vaccine before they turned 65 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 18 of 19 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 12/14/2023 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer and provide COVID-19 immunizations for two of five sampled residents (Resident 61 and Resident 60). This failure could result in not protecting the residents against potential severe illness or post COVID-19 conditions that can be associated with COVID-19 infection. Findings: During a concurrent interview and record review on 12/13/23 at 2:30 PM, with the Infection Preventionist (IP), IP stated residents at the facility were offered and provided COVID-19 vaccinations and boosters. The surveyor requested the IP for COVID-19 immunization consents and administration records for 5 sampled residents (Resident 61, Resident 40, Resident 53, Resident 60, and Resident 9); however, the records were not available for review at the time. On 12/14/23, prior to the survey team's exit conference meeting at the facility, the Administrator provided the surveyor with documents related to COVID-19 immunization consents and administration records of the five sampled residents requested. Review of documents provided to the surveyor on 12/14/23, revealed there was no record a consent for COVID-19 vaccination was offered or filled out by Resident 61. Resident 61 was admitted to the facility on [DATE]. Further, review of Resident 60's COVID-19 vaccination consent, dated 10/11/23, and signed by the resident's responsible party or authorized representative, indicated a consent to receive the COVID-19 vaccination was completed; however, there was no information on Resident 60's COVID-19 vaccine administration record that the resident received the COVID-19 vaccine. Resident 60 was admitted to the facility on [DATE]. Review of the facility's Policy and Procedures (P&P), titled, Resident COVID-19 Vaccination and Testing, undated, the P&P indicated, Policy Statement - All residents are recommended to be vaccinated, and when eligible, boosted, which aids in preventing COVID-19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555767 If continuation sheet Page 19 of 19