Health inspection·March 25, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (a document that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) for four of six sampled residents (Residents 11, 12, 15, and 31), when Residents 11, 12, 15, and 31 did not have a care plan to address their antibiotic-resistant infection called Carbapenemase-Producing Organisms (CPO, are bacteria that are resistant to a class of antibiotics called carbapenems which are typically used as a of last-line treatment for serious infections) specific to enzyme New Delhi [NAME]-ß-lactamase (NDM, an enzyme that makes bacteria resistant to a broad range of antibiotics including the carbapenem family). This failure had the potential for Residents 11,12, 15. And 31 to not receive person-centered appropriate care, monitoring, and treatment. Findings: During a review of Resident 11 ' s admission Record, printed on 3/14/25, the AR indicated Resident 11 was admitted to Facility 2 in January 2025 with diagnoses to include anoxic brain damage (a condition where the brain is deprived of oxygen for a prolonged period, leading to damage or death of brain cells), acute respiratory failure (ARF), and cardiac arrest (when the heart stops beating suddenly). During a review of Resident 1 ' s Laboratory Report, dated 2/20/25, the Laboratory Report showed, NDM detected, indicating Resident 11 tested positive for NDM organism infection. During a review of Resident 12 ' s AR, printed on 3/14/25, the AR indicated Resident 12 was admitted to Facility 2 in February 2025 with diagnoses to critical illness myopathy (a form of generalized weakness involving the muscles of the extremities, trunk, and respiration that frequently occurs in conjunction with severe illness), chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow making breathing difficult), and tracheostomy status. During a review of Resident 12 ' s Laboratory Report, dated 2/20/25, the Laboratory Report showed, NDM detected, indicating Resident 12 tested positive for NDM organism infection. During a review of Resident 15 ' s AR, printed on 3/14/25, the AR indicated Resident 15 was admitted to Facility 2 in September 2024 with diagnoses to include cervical spine fusion (a surgical procedure that connect two or more bones in the spine), tracheostomy status and dependence in ventilator Page 1 of 12 555809 555809 03/25/2025 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0656 status. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 15 ' s Laboratory Report, dated 2/20/25, the Laboratory Report showed, NDM detected, indicating Resident 15 tested positive for NDM organism infection. Residents Affected - Some During a review of Resident 31 ' s AR, printed on 3/14/25, the AR indicated Resident 31 was admitted to Facility 2 in April 2023 with diagnoses to include ARF, COPD with exacerbation, and dependence on ventilator. During a review of Resident 31 ' s Laboratory Report, dated 2/20/25, the Laboratory Report showed, NDM detected, indicating Resident 31 tested positive for NDM organism infection. During a review of Residents 11, 12, 3, 15, and 31 ' s Care Plan, Residents 11, 12, 3, 15, and 31 did not have a comprehensive care plan to address their NDM infection. During an interview on 3/19/25 at 1:58 p.m. with Director of Nursing (DON), DON stated the facility should have developed the care plans for all residents who had infections especially during the outbreak (usually caused by an infection, transmitted through person-to-person contact, animal-to-person contact, or from the environment or other media) in the facility. DON stated he did not think about implementing and creating an individualized care plans for infected residents. DON stated they were only focused on the type of isolation each resident needed and not the specific infection each resident had. DON stated the facility should have had a person-centered or individualized care plan for all the residents who became infected. DON stated a comprehensive care plan should have been created to provide quality of care because each resident had different medical conditions and situations. During a review of the facility ' s policy and procedure (P&P), titled, Care Plans – Comprehensive, revised in September 2010, indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident ' s medical, nursing mental, and psychological needs is developed for each resident .3. Each resident ' s comprehensive care plan is designed to .a. Incorporate identified problem areas .b. Incorporate risk factors associated with identified problems .8. Assessments of residents are ongoing, and care plans are revised as information about the resident ' s condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .a. where there has been a significant change in the resident ' s condition. 555809 Page 2 of 12 555809 03/25/2025 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, Facility 2 failed to follow infection control practices to prevent the spread of infection in Facility 2 when the following were identified: Residents Affected - Many 1. Facility 2 did not follow the recommendations to stop the spread of infection as outlined by the local public health department (LPHD). The recommendations were as follows: a.Close Facility 2 to new admissions and halt movement of residents from other buildings to the facility . b.Submission of adherence monitoring logs for hand hygiene, PPE (personal protective equipment, any piece of clothing or equipment that ' s worn by the employees to minimize exposure to biological, chemical, or any physical hazards on work site) use, and environmental cleaning at weekly intervals and contact precaution (infection control measures used to prevent the spread of infectious diseases that are transmitted through direct contact with an infected person or their contaminated environment) and hand hygiene observations of staff to 50 per shift . c.Implement infection control committee meetings if not currently in place, including lead staff from all disciplines. Provide meeting cadence and participant list to LPHD . d.Provide documentation of outbreak notification and education provided to residents and families . e.Notify licensing California Department of Public Health about infection outbreak . 2. Certified Nursing Assistant (CNA) 1 and CNA 2 entered Resident 1 and Resident 2 ' s room without performing hand hygiene. 3. Facility 2 failed to separate direct care staff (assists with tasks such as bathing, dressing, personal hygiene, and medication management) for residents who were infected with MDRO (multi-drug resistant organism, are bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria) from non-infected residents. These failures resulted in an increase of Carbapanemase-Resistant Organism (CRO, bacteria that are resistant to a class of antibiotics called carbapenems which are typically used a last-line treatments for serious infections) infections in Facility 2. The cross-contamination resulted in non-infected residents becoming infected, including: -Residents 10, 49, 50, 52, 53, 54, and 56 were infected with Carbapenem-Resistant Pseudomonas aeruginosa (CRPA, bacteria that can cause pneumonia, bloodstream infections, urinary tract infections, and surgical site infections, and they are particularly dangerous for patients with chronic lung diseases). -Residents 1, 6, 7, 8, 9, 39, 40, 41, 42, 43, 44, 45, 46, 47, and 48 were infected with MDRO -Residents 4, 5, 11, 12, 13, 14, 15, 16, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, and 38 were infected with Carbapenem-resistant Acinetobacter baumannii (CRAB, a bacteria that can 555809 Page 3 of 12 555809 03/25/2025 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many cause human infections of the blood, urinary tract, lungs, wounds, and other body sites. CRAB is a multidrug-resistant, making infections very difficult to treat) and/or with New Delhi [NAME]-ß-lactamase (NDM, an enzyme that makes bacteria resistant to a broad range of antibiotics including the carbapenem family). An Immediate Jeopardy situation (IJ, a situation in which a facility's actions places one or more residents/patients in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) was identified and called due to the failure of Facility 2 to follow infection control practices to prevent the spread of infection among Facility 2 ' s 63 residents. The Administrator (ADM) was verbally notified of the IJ situation on 3/13/25 at 7:45 p.m. During a visit to Facility 2 on 3/25/25, Facility 2 provided an acceptable plan of action and the IJ was removed at 2:50 p.m. Findings: Upon entrance to Facility 2 on 3/13/25 at 12:30 p.m. with Infection Preventionist (IP), a request was made to provide a line list (a table that contains key information about each case in an outbreak) for Facility 2. During a record review of Facility 2 ' s document, titled, CRO Line List, dated March 2025, CRO Line List did not contain laboratory test dates for the residents who tested positive for CROs. During an interview on 3/14/25 at 3:31 p.m. with IP, IP was requested to provide an updated line list for Facility 2 with laboratory test dates for the residents who tested positive for CRO infections. During a phone interview on 3/20/25 at 8:04 a.m. with IP, IP was requested to provide another updated line list for Facility 2 with the laboratory test dates included. During a review of a document titled, CRO List, dated March 2025, sent via email by Medical Record Director (MRD) on 3/20/25 at 10:09 a.m., the CRO List included Facility 2 ' s updated line list but was missing test dates for Residents 42 and 56. Furthermore, Facility 2 did not provide laboratory results for Resident 42 and Resident 56 to confirm the dates the infection was identified. During a review of Resident 1 ' s admission Record (AR), printed on 3/14/25, the AR indicated Resident 1 was admitted to Facility 2 in February 2025 with diagnoses that included quadriplegia (a severe medical condition that causes partial or total loss of sensation and movement of all four limbs) and acute respiratory failure (ARF, results from inadequate gas exchange by the respiratory system). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 1 tested positive for an MDRO on 2/18/25. During a review of Resident 4 ' s AR, printed on 3/14/25, the AR indicated Resident 4 was admitted to Facility 2 in April 2016 with a diagnosis of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 4 tested positive for CRAB and NDM infections on unknown test date. 555809 Page 4 of 12 555809 03/25/2025 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0880 Level of Harm - Immediate jeopardy to resident health or safety During a review of Resident 5 ' s AR, printed on 3/14/25, the AR indicated Resident 5 was admitted to Facility 2 in May 2018 with a diagnosis of nontraumatic intracerebral hemorrhage (a type of stroke or bleeding within the brain tissue). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 5 tested positive for CRAB and NDM infections on unknown test date. Residents Affected - Many During a review of Resident 6 ' s AR, printed on 3/14/25, the AR indicated Resident 6 was admitted to Facility 2 in February 2025 with diagnoses of ARF and dependence in ventilator (a machine that helps an individual breathe) status. The AR showed Resident 6 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 6 tested positive for an MDRO on 2/2/25. During a review of Resident 7 ' s AR, printed on 3/14/25, the AR indicated Resident 7 was admitted to Facility 2 in November 2024 with a diagnosis of amyotrophic lateral sclerosis (ALS, a nervous system disease that affects nerve cells in the brain and spinal cord that can cause loss of muscle control). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 7 tested positive for an MDRO on 2/15/25. During a review of Resident 8 ' s AR, printed on 3/14/25, the AR indicated Resident 8 was admitted to Facility 2 in February 2025 with diagnoses of quadriplegia and chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis). The AR showed Resident 8 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 8 tested positive for an MDRO on 2/2/25. During a review of Resident 9 ' s AR, printed on 3/14/25, the AR indicated Resident 9 was admitted to Facility 2 in January 2025 with diagnoses of cerebral infarction (stroke), hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body), affecting right dominant side, and tracheostomy status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 9 tested positive for an MDRO on 2/15/25. During a review of Resident 10 ' s AR, printed on 3/14/25, the AR indicated Resident 10 was admitted to Facility 2 in February 2025 with diagnoses of nontraumatic intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside) and dependence on ventilator status. The AR showed Resident 10 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 10 tested positive for CRPA on 2/23/25. During a review of Resident 11 ' s AR, printed on 3/14/25, the AR indicated Resident 11 was 555809 Page 5 of 12 555809 03/25/2025 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0880 Level of Harm - Immediate jeopardy to resident health or safety admitted to Facility 2 in January 2025 with diagnoses of anoxic brain damage (a condition where the brain is deprived of oxygen for a prolonged period, leading to damage or death of brain cells), ARF, and cardiac arrest (when the heart stops beating suddenly). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 11 tested positive for CRAB on 2/15/25. Residents Affected - Many During a review of Resident 12 ' s AR, printed on 3/14/25, the AR indicated Resident 12 was admitted to Facility 2 in February 2025 with diagnoses of critical illness myopathy (is a form of generalized weakness involving the muscles of the extremities, trunk, and respiration that frequently occurs in conjunction with severe illness), COPD, and tracheostomy status. The AR showed Resident 12 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 12 tested positive for CRAB on 2/15/25. During a review of Resident 13 ' s AR, printed on 3/14/25, the AR indicated Resident 13 was admitted to Facility 2 in January 2025 with diagnoses of quadriplegia, ARF, and ventilator dependence status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 13 tested positive for CRAB and NDM infections in February 2025. During a review of Resident 14 ' s AR, printed on 3/14/25, the AR indicated Resident 14 was admitted to Facility 2 in January 2024 with diagnoses of cardiac arrest, secondary malignant neoplasm (cancer) of left lung, tracheostomy status and dependence in ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 14 tested positive for CRAB in August 2024. During a review of Resident 15 ' s AR, printed on 3/14/25, the AR indicated Resident 15 was admitted to Facility 2 in September 2024 with diagnoses of cervical spine fusion (a surgical procedure that connect two or more bones in the spine), tracheostomy status and dependence in ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 15 tested positive for CRAB on 2/15/25. During a review of Resident 16 ' s AR, printed on 3/14/25, the AR indicated Resident 16 was admitted to Facility 2 in September 2024 with diagnoses of chronic respiratory failure, tracheostomy status, and unspecified pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) of sacral region. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 16 tested positive for NDM on 10/23/24. During a review of Resident 24 ' s AR, printed on 3/14/25, the AR indicated Resident 24 was admitted to Facility 2 in January 2024 with diagnoses of acute and chronic respiratory failure, encephalopathy (a brain disease that alters functions or structure), COPD, tracheotomy status and severe sepsis (an infection in the blood). 555809 Page 6 of 12 555809 03/25/2025 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0880 Level of Harm - Immediate jeopardy to resident health or safety During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 24 tested positive for CRAB on 12/29/24. During a review of Resident 25 ' s AR, printed on 3/14/25, the AR indicated Resident 25 was admitted to Facility 2 in September 2024 with diagnoses of nontraumatic intracerebral hemorrhage, chronic respiratory failure, quadriplegia, and resistance to multiple antibiotics. Residents Affected - Many During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 25 tested positive for CRAB on unknown test date. During a review of Resident 26 ' s AR, printed on 3/14/25, the AR indicated Resident 26 was admitted to Facility 2 in November 2023 with diagnoses of sepsis, cerebral infarction, and tracheostomy status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 26 tested positive for CRAB in December 2023. During a review of Resident 27 ' s AR, printed on 3/14/25, the AR indicated Resident 27 was admitted to Facility 2 in October 2023 with diagnoses of paraplegia (the inability to voluntarily move the lower parts of the body), severe sepsis, and ventilator associated pneumonia. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 27 tested positive for CRAB in November 2023. During a review of Resident 28 ' s AR, printed on 3/14/25, the AR indicated Resident 28 was admitted to Facility 2 in March 2023 with diagnoses of ARF, sepsis, pressure ulcer of right and left hip stage 4, attention to tracheostomy, and dependence on ventilator. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 28 tested positive for CRAB on unknown test date. During a review of Resident 29 ' s AR, printed on 3/14/25, the AR indicated Resident 29 was admitted to Facility 2 in March 2024 with pneumonia, ARF, nontraumatic intracerebral hemorrhage, and tracheostomy status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 29 tested positive for CRAB in October 2024. During a review of Resident 30 ' s AR, printed on 3/14/25, the AR indicated Resident 30 was admitted to Facility 2 in September 2024 with diagnoses of cerebral infarction, ARF, tracheostomy status, and resistance to multiple antimicrobial drugs. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 30 tested positive for CRAB on 11/23/24. During a review of Resident 31 ' s AR, printed on 3/14/25, the AR indicated Resident 31 was admitted to Facility 2 in April 2023 with diagnoses of ARF, COPD with exacerbation, and dependence on ventilator. 555809 Page 7 of 12 555809 03/25/2025 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0880 Level of Harm - Immediate jeopardy to resident health or safety During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 31 tested positive for CRAB on 2/15/25. During a review of Resident 32 ' s AR, printed on 3/14/25, the AR indicated Resident 32 was admitted to Facility 2 in October 2024 with diagnoses of chronic respiratory failure, enterocolitis due to clostridium difficile (inflammation in your intestinal lining and colon), and dependence on ventilator. Residents Affected - Many During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 32 tested positive for CRAB on 11/23/24. During a review of Resident 33 ' s AR, printed on 3/14/25, the AR indicated Resident 33 was admitted to Facility 2 in May 2023 with diagnoses of ARF, cerebral palsy (a group of conditions that affect movement and posture), tracheostomy status, and dependence on ventilator. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 33 tested positive for CRAB on 11/23/24. During a review of Resident 34 ' s AR, printed on 3/14/25, the AR indicated Resident 34 was admitted to Facility 2 in August 2024 with diagnoses of ARF, severe sepsis with septic shock, tracheostomy status, and pressure ulcer of sacral region (stage 4). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 34 tested positive for CRAB on 11/23/24. During a review of Resident 35 ' s AR, printed on 3/14/25, the AR indicated Resident 35 was admitted to Facility 2 in December 2022 with diagnoses of quadriplegia, cerebral infarction, attention to tracheostomy, and dependence on ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 35 tested positive for CRAB on 11/23/24. During a review of Resident 36 ' s AR, printed on 3/14/25, the AR indicated Resident 36 was admitted to Facility 2 in October 2024 with diagnoses of nontraumatic subarachnoid hemorrhage (a type of stroke, bleeding in the space between the brain and the tissues that cover the brain), tracheostomy status, and dependence on ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 36 tested positive for CRAB on 11/23/24. During a review of Resident 37 ' s AR, printed on 3/14/25, the AR indicated Resident 37 was admitted to Facility 2 in November 2024 with diagnoses of ARF, anoxic brain damage (occurs when oxygen is cut off completely from the brain), tracheostomy status, paraplegia, carrier of CRE, and resistance to multiple antimicrobial drugs. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 37 tested positive for CRAB in December 2024. During a review of Resident 38 ' s AR, printed on 3/14/25, the AR indicated Resident 38 was 555809 Page 8 of 12 555809 03/25/2025 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many admitted to Facility 2 in June 2024 with diagnoses of ALS, severe sepsis with septic shock, tracheostomy status, and dependence on ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 38 tested positive for CRAB in July 2024. During a review of Resident 39 ' s AR, printed on 3/14/25, the AR indicated Resident 39 was admitted to Facility 2 in November 2024 with diagnoses of Diabetes Mellitus Type 2, Essential Hypertension, and Malignant Neoplasm of Kidney. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 39 tested positive for an MDRO on 2/4/25. During a review of Resident 40 ' s AR, printed on 3/14/25, the AR indicated Resident 40 was admitted to Facility 2 in November 2023 with diagnoses of Tracheostomy, Ventilator Dependence, Diabetes Mellitus Type 2, and Essential Hypertension. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 40 tested positive for an MDRO on 2/15/25. During a review of Resident 41 ' s AR, printed on 3/14/25, the AR indicated Resident 41 was admitted to Facility 2 in October 2024 with diagnoses of Tracheostomy, Ventilator Dependence, Diabetes Mellitus Type 2, Malignant Neoplasm of Unspecified Breast, and Deep Tissue Damage of the Sacral Region. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 41 tested positive for an MDRO on 2/18/25. During a review of Resident 42 ' s AR, printed on 3/14/25, the AR indicated Resident 42 was admitted to Facility 2 in January 2024 with diagnoses of Tracheostomy, Ventilator Dependence and Diabetes Mellitus type 2. During a review of Facility 2 ' s CRO Line List, dated March 2025, received on 3/14/25, showedResident 42 ' s positive test result for MDRO was hand written in as January 2024. An updated CRO Line List, dated March 2025, received on 3/20/25 no longer showed the date Resident 42 tested positive for an MDRO. During a review of Resident 43 ' s AR, printed on 3/14/25, the AR indicated Resident 43 was admitted to Facility 2 in December 2016 with diagnoses of Resistance to Multiple Antibiotics, Diabetes Mellitus type 1, and Essential Hypertension. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 43 tested positive for an MDRO on 12/29/22. The CRO Line List also showed Resident 43 refused to be tested again. During a review of Resident 44 ' s AR, printed on 3/14/25, the AR indicated Resident 44 was admitted to Facility 2 in October 2018 with diagnoses of Hemiplegia of both Right and Left Sides, Diabetes Mellitus type 2, and Essential Hypertension. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed 555809 Page 9 of 12 555809 03/25/2025 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0880 Resident 44 tested positive for an MDRO on 2/18/25. Level of Harm - Immediate jeopardy to resident health or safety During a review of Resident 45 ' s AR, printed on 3/14/25, the AR indicated Resident 45 was admitted to Facility 2 in April 2023 with diagnoses of Tracheostomy, Ventilator Dependence, Gastrotomy, Diabetes Mellitus type 2, and Essential Hypertension. Residents Affected - Many During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 45 tested positive for an MDRO in November 2023. The CRO Line List also showed Resident 45 refused to be tested again. During a review of Resident 46 ' s AR, printed on 3/14/25, the AR indicated Resident 46 was admitted to Facility 2 in April 2023 with diagnoses of Tracheostomy and Essential Hypertension. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 46 tested positive for an MDRO on 2/18/25. During a review of Resident 47 ' s AR, printed on 3/14/25, the AR indicated Resident 47 was admitted to Facility 2 in October 2024 with diagnoses of Tracheostomy, Ventilator Dependence, Diabetes Mellitus type 2, Essential Hypertension, Latent Tuberculosis, and Unstageable Pressure Injuries of the Right Heel and Sacral Region. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 47 tested positive for an MDRO on 2/15/25. During a review of Resident 48 ' s AR, printed on 3/14/25, the AR indicated Resident 48 was admitted to Facility 2 in August 2024 with diagnoses of Tracheostomy, Ventilator Dependence, Essential Hypertension, and Myotonic Muscular Dystrophy. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 48 tested positive for an MDRO on 10/22/24. During a review of Resident 49 ' s AR, printed on 3/14/25, the AR indicated Resident 49 was admitted to Facility 2 in January 2025 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that cause long-term breathing problem) and Pneumonia (lung infection often cause by virus, bacteria or fungi), and tracheostomy status, dependence on ventilator status, and atelectasis (lung collapse). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 49 tested positive for CRPA on 1/27/25. During a review of Resident 51 ' s AR, printed on 3/14/25, the AR indicated Resident 51 was admitted to Facility 2 in October 2023 with diagnoses of Traumatic subdural hemorrhage (bleeding near the brain) and acute respiratory failure (low blood oxygen levels). During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 51 tested positive for CRPA on 2/15/25. During a review of Resident 52 ' s AR, printed on 3/14/25, the AR indicated Resident 52 was admitted to Facility 2 in February 2018 with diagnoses of Chronic Respiratory Failure, dependence on 555809 Page 10 of 12 555809 03/25/2025 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many ventilator status, encounter for attention to tracheostomy, sepsis due to MRSA, severe sepsis with septic shock and personal history of traumatic brain injury. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 52 tested positive for CRPA with an unknown test date. During a review of Resident 53 ' s AR, printed on 3/14/25, the AR indicated Resident 53 was admitted to facility in June 2023 with diagnoses of acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), tracheostomy status and dependence on ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 53 tested positive for CRPA on 10/18/23. During a review of Resident 54 ' s AR, printed on 3/14/25, the AR indicated Resident 54 was admitted to Facility 2 in July 2024 with diagnoses of diffuse traumatic brain injury (severe type of brain injury), sepsis (life-threatening infection of the bloodstream) due to other specified staphylococcus (bacteria), bacteremia (condition where bacteria enter the bloodstream), resistance to multiple antibiotics, tracheostomy status and dependence of ventilator status. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 54 tested positive for CRPA on 1/27/25. During a review of Resident 55 ' s AR, printed on 3/14/25, the AR indicated Resident 55 was admitted to the Transitional Care Unit (TCU) in December 2024 with diagnoses of acute respiratory failure with hypercapnia, acute respiratory failure with hypoxia, tracheostomy status, dependence on ventilator status, atelectasis and pneumonia. During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 55 tested positive for CRPA with an unknown test date. During a review of Resident 56 ' s AR, printed on 3/14/25, the AR indicated Resident 56 was admitted to the TCU in November 2022 with diagnoses of chronic respiratory failure with hypoxia, respiratory failure unspecified with hypoxia and pseudomonas (a group bacterial infection commonly found in the environment, like soil and water that can affect skin, blood, lungs, and other parts of the body.) During a review of Facility 2 ' s CRO Line List, dated March 2025, the CRO Line List showed Resident 56 ' s positive test result for CRPA was hand written in as October 2022. An updated CRO Line List, dated March 2025, received 3/20/25, no longer showed the date Resident 56 tested positive for CRPA. 1.(a.1) During a review of a letter from the LPHD, dated 1/8/25, the letter indicated On 11/15/2024, LPHD provided recommendations to mitigate transmission of these organisms .including closure of Facility 2 .This includes halting resident movement from Facility 1 to Facility 2 .We do not recommend any movement of residents into Facility 2 at this time . During a review of Facility 2 ' s Admission/Discharge To/From Report, printed on 3/14/25, the Admission/Discharge To/From Report indicated Residents 1, 6, 7, 8, 9, 10, 11, 12, 13, and 14 were discharged from Facility 1 and admitted to Facility 2 between 12/1/24 to 3/14/25. 555809 Page 11 of 12 555809 03/25/2025 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many During an interview on 3/13/25 at 12:46 p.m. with IP, IP confirmed and stated the LPDH recommended Facility 2 not admit new residents to Facility 2 since November 2024. IP stated despite the recommendations from LPHD, Facility 2 still moved residents from Facility 1 to Facility 2 because of their insurance ' s last day of coverage. IP stated when they moved the residents from Facility 1 to Facility 2, it was considered a new admission because Facility 1 and Facility 2 operated under two different licenses. 1.(a.2) During a review of Resident 2 ' s AR, printed on 3/14/25, the AR indicated Resident 2 was originally admitted to Facility 2 in August 2023 with multiple diagnoses that included COPD and pneumonia (lung infection often cause by virus, bacteria or fungi), and tracheostomy status. During a review of Resident 2 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/6/25, indicated Resident 2 had a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 15, indicating Resident 2 had intact cognition. During a concurrent observation and interview on 3/13/25 at 2:50 p.m. with CNA 2, CNA 2 entered Resident 2 ' s room without performing hand hygiene or donning PPE. The room had a contact precaution (an infection control measures used to prevent the spread of diseases that are transmitted through direct or indirect contact with an infected person or environment) sign posted on the door. CNA 2 then embraced Resident 2. CNA 2 then stated, she established good rapport with Resident 2 when Resident 2 was in Facility 2 where CNA 2 worked. CNA 2 added, Resident 2 was transferred to the TCU from Facility 2 one month ago and wanted to give Resident 2 a hug. CNA 2 then exited from the TCU building and into the parking lot. 1.(a.3) During a review of Resident 3 ' s AR, printed on 3/14/25, the AR indicated Resident 3 was recently re-admitted to Facility 2 in March 2025 with multiple diagnoses that included, acute respiratory failure with hypoxia and atelectasis (collapsed lungs). During a concurrent interview and record review on 3/19/25 at 3:35 p.m. with Social Worker (SW), Facility 2 ' s resident census (the number of residents currently under care at Facility 2 at that time), dated 3/19/25, indicated the following: a. Resident 2 was transferred to the TCU building in Facility 2 from Subacute building in Facility 2 on 1/4/25. b. Resident 3 was originally admitted to Facility 1 on 12/6/24. Resident 3 was discharged from Facility 1 on 3/11/25 and then admitted to the TCU building in Facility 2 on 3/11/25. During an interview on 3/14/25 at 11:36 a.m. with IP, IP stated Resident 2 was transferred to the TCU building in Facility 2 from 555809 Page 12 of 12