Health inspection·August 22, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete at 1:12 p.m. with LVN 3, LVN 3 stated Resident 8 randomly chew on his blanket otherwise Resident 8 had no behaviors. LVN 3 stated Resident 8 stayed in bed. During a review of Resident 8's Preadmission Screening and Resident Review (PASRR), dated 5/28/25, the PASRR indicated Resident 8 has no diagnoses or suspected serious mental illness.(PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care). During a concurrent interview and record review on 8/21/25 at 1:20 p.m. with Director of Nursing (DON), Resident 8's medical records, physician orders, progress notes, interdisciplinary notes and care plans were reviewed. There was no documentation that non-pharmacological approaches have been attempted. DON stated facility process was to review use of psychotropic medication for appropriate diagnosis or indication if appropriate for use of psychotropic medication, reach out to psychiatrist as needed. DON stated her expectation was that nursing staff implement nonpharmacological intervention with documentation. DON could not provide documentation that staff provided Resident 8 non-pharmacological interventions with use of antipsychotic medication.According to the Seroquel manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular (e.g. heart failure, sudden death). {Reference: https://[NAME].com/seroquel} During a review of facility's policy and procedure (P&P) titled, Antipsychotic Medication Management revised August 2022, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. Antipsychotic medications will not be used if only symptoms are one or more of the following: wandering, restlessness, impaired memory, inattention or indifference to surroundings, fidgeting, nervousness, uncooperativeness . Event ID: Facility ID: 555809 If continuation sheet Page 2 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), accurately reflect the assessment status for two (Resident 8 and 53) of four sampled residents when Resident 8's MDS section B vision did not reflect limited vision. Resident 53's MDS section L oral/dental status did not reflect missing and cracked teeth. This failure had the potential for residents to not receive appropriate care and services. During a review of Resident 8's admission Record (AR), AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included Glaucoma (a group of eye conditions that can cause blindness) and vision loss. During a review of Resident 8's visual impairment care plan, dated 11/12/18, the care plan indicated Resident 8 had impaired visual related to diagnosis of glaucoma. During a review of Resident 8's Annual Minimum Data Set (MDS), Resident Assessment and Care Screening tool used to guide care, dated June 20, 2025. MDS section B indicated Resident 8 had adequate vision, sees fine details such as regular prints in newspapers/books. During a concurrent interview and record review on 8/20/2025 at 1:54 p.m. with Director of Nursing (DON), MDS coordinator (MDSC) and Social Services Director (SSD), Resident 8's MDS section B was reviewed. MDSC stated Resident 8's section B vision was completed by SSD. SSD stated she was assigned to complete Resident's 8 MDS section B. SSD stated she thought Resident 8 liked to close his eyes. SSD stated she did not know Resident 8 had vision problems. SSD stated she did not interview Resident 8's care givers. MDSC stated Resident 8's section B was not coded accurately for vision. During a review of Resident 53's admission Record (AR), AR indicated Resident 53 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing). During an observation on 8/18/2025 at 12:15 p.m. in the dining area, Resident 53 had lunch of salad in the dining area and suddenly coughed and cried. Licensed Vocational Nurse (LVN 2) and CNA 3 at Resident 53's dining table side encouraged Resident 53 to cough out.During an interview on 8/18/25 at 12:20 p.m. with Certified Nursing Assistant (CNA3), CNA 3 stated Resident 53 had missing and cracked teeth. CNA 3 stated that it was the first time for Resident 53 had this episode of coughing while eating. CNA 3 stated it will be beneficial for Resident 53 to have dentures for Resident 53 to chew better.During an observation and concurrent interview on 8/18/25 at 12:20 p.m. in the dining area Resident 53 had missing and cracked teeth in the front and side of mouth. Resident 53 stated she was doing ok.During a review of Resident 53's Oral Health Care patient notes, dated March 21, 2025, indicated Resident 53 was unable to eat with existing dentition. During a review of Resident 53's MDS, dated [DATE], MDS section L for oral/dental status indicated Resident 53 had no chipped, cracked, broken, loose teeth or difficulty with chewing. During a concurrent interview and record review on 8/19/2025 at 11:24 a.m. with MDS coordinator (MDSC), Resident 53's MDS section L dental/oral status dated 1/29/25 was reviewed. MDS section L indicated Resident 53 had no dental problems. MDSC stated MDS section L was not coded accurately.During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, dated October 2023, the P&P indicated Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 3 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure necessary treatment and care services in accordance with professional standards of practice, comprehensive assessment, and care plan for three of 23 sampled residents (Residents 6, 45 and 58) when:Facility did not provide proper oral care for Resident 45 and 58Facility did not provide timely incontinent care for Resident 6These failures had the potential for Resident 45 and Resident 58 to suffer from oral infections, discomfort and an increased risk for pneumonia, and for Resident 6 to not received the necessary care and services to maintain skin integrity. Residents Affected - Some 1.During a record review of Resident 45's admission Record (AR), printed on 8/20/25, the AR indicated Resident 45 was admitted to the facility on [DATE] with diagnoses of diffuse traumatic brain injury (widespread damage occurs to the brain, often resulting in prolonged loss of consciousness and potential long-term disability), dependence on ventilator status (a type of breathing apparatus that provides mechanical ventilation to a patient who is physically unable to breathe), and gastrostomy status (state of having a surgically created opening in the stomach for the purpose of feeding). During a record review of Resident 58's AR, printed on 8/20/25, the 'AR indicated Resident 58 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) following cerebral infraction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain ), dependence on ventilator status, and gastrostomy status. During an interview and record review on 8/20/25 at 11:30 a.m., with Minimum Data Set Coordinator (MDSC), Residents 45's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized carte plan) dated 6/21/25 and Resident 58's MDS assessment dated [DATE] were reviewed. The MDSC stated Residents 45 and 58 were totally dependent on the staff for oral hygiene. During an observation on 8/18/25 at 9:34 a.m., Resident 45 was lying in bed with eyes closed and mouth open. Dried, light, tan-colored matter was noted on Resident 45's lips and brown-colored, dry matter at the corners of the mouth. When Resident 45 was smacking their lips, sticky, creamy matter was observed between the lips and inside the mouth. During an observation on 8/18/25 at 9:40 a.m., Resident 58 was lying in bed with eyes open and non-verbal. Resident 58's upper lip was dry and coated with off white, thick, peeling layer of skin. During an observation and interview on 8/19/25 at 8:17 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 45 and 58's shared room, LVN 1 stated Resident 58's mouth was dry, peeling and needed oral care. LVN 1 stated both Resident 45 and 58 tended to bite their lips and teeth to cause bleeding, and maybe the brown dry matter around Resident 58's mouth was dried blood. LVN 1 further stated the night shift Respirator Therapist (RT) should have performed oral care for Residents 45 and 58 during the night shift. During an interview on 8/20/25 at 9:01 a.m., with Director of Nursing (DON), the DON stated poor oral care could lead to bacteria growth in the mouth, cause tooth decay, and increase risk for aspiration pneumonia (when food, liquid, saliva, or vomit accidentally goes down into the lungs instead of the stomach and cause an infection in the lungs). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 4 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 8/20/25 10:34 a.m., with RT Manager (RTM), reviewed Resident 45 and 58's oral care performed by RT records, printed on 8/20/25. The records indicated Resident 45 and 58's oral care was performed by RT on 8/17/25 at 02:21 a.m. and 8/17/25 at 02:22 a.m. RTM stated that RT staff were supposed to perform oral care with Chlorohexidine solutions (a special liquid often used in medical setting to clean the skin, mouth or medical equipment to prevent infection by killing germs) every shift and as needed for each resident. RTM stated it usually took a day or two to build up thicken, creamy matter in their mouths. RTM stated poor oral care could cause oral odors, dental problems and make residents feel unwell. Review of facility's policy (P&P) titled Oral Care for the Residents with Special Needs released July 2025, indicated The facility will provide oral care to residents with special needs every shift and as needed. 2.During a review of Resident 6's Annual-Minimum Data Set (MDS, Resident Assessment and care guide tool), dated 7/23/25, the MDS indicated Resident 6 was comatose (a state of coma meaning in a deep, prolonged and unarousable state of unconsciousness, unresponsive to stimuli). MDS indicated Resident 6 used external urinary condom catheter (is a urine collection device fits like a condom over penis). MDS indicated Resident 6 was always incontinent of bowel. MDS indicated Resident 6 was dependent for toileting hygiene, care givers do all the effort to complete the activity, or the assistance of two or more helpers is required to complete activity. MDS indicated Resident 6's diagnoses included Traumatic Brain Injury (Brain dysfunction caused by an outside force, usually a violent blow to the head). During a telephone interview on 8/20/25 at 8:59 a.m. with Family Member (FM 1), FM1 stated she visited Resident 6 on 8/14/25 in the morning around 10:00 a.m. and found Resident 6 laid on a draw sheet saturated with dry urine up to his shoulders and upper body. FM1 stated nursing staff did not reposition and changed Resident 6's soiled linen. FM 1 stated she reported incident to the facility staff. During a concurrent observation and interview 8/20/25 at 9:20 a.m. with Licensed Vocational Nurse (LVN 5) in Resident 6's room, Resident 6 laid in bed unconscious with tracheostomy (a surgical procedure that creates an opening in the neck to help the patient breathe) and on ventilator (breathing machine). LVN 5 stated Resident 6 used a condom catheter and was cleaned, repositioned and provided incontinent care. LVN 5 stated Resident 6 condom catheter was changed every shift and as needed. During a telephone interview on 8/20/25 at 3:41 p.m. with Certified Nursing Assistant (CNA 4), CNA 4 stated he was assigned to care for Resident 6 on 8/14/25 night shift ending 7:30 am. CNA 4 stated Resident 6's condom catheter sometimes came off and it took time for licensed nurse to replace condom catheter. CNA 4 stated he provided Resident 6 incontinent care and repositioned Resident 6 every two hours. CNA 4 stated he did not observe Resident 6's draw sheet with urine stained. During a concurrent observation and interview on 8/20/25 at 9:02 a.m. with CNA 5, Resident 6 laid in bed. CNA 5 stated she was assigned to care for Resident 6 on 8/14/25 morning shift start time 7a.m. CNA 5 stated she checked on Resident 6 at around 8a.m. CNA 5 stated Resident 6 was clean and reposition. CNA 5 stated she does walk rounds with night shift CNA to check residents and make sure residents were cleaned and repositioned. CNA 5 stated she returned to Resident 6 around 10 a.m. for care because she has other residents to attend and was busy. CNA 5 said she did not see that Resident 6's draw sheet was stained with urine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 5 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 8/20/25 at 10:18 a.m. with Director of Staff Development (DSD), DSD stated he was informed that Resident 6's FM1 complained that Resident 6's draw sheet was saturated with urine stain and not changed overnight. DSD stated CNA 5 was interviewed and stated Resident 6's condom catheter was loose and may be leaking. DSD stated he was shown a picture of Resident 6 wet bed with saturated urine-stained draw sheet underneath Resident 6. DSD stated he followed up with night shift nurse CNA 4 and reminded CNA 4 and CNA 5 to check, clean and reposition Resident 6 every two hours and stress the importance of checking residents' incontinence episodes. During an interview on 8/21/25 at 11:21 a.m. with Administrator (Admin), Admin stated facility was aware of a complaint on 8/14/25 that Resident 6 laid on a draw sheet that was saturated and stained with urine and had started investigation. During a concurrent interview and record review on 8/22/25 at 10:15 a.m. with Director of Nursing (DON), Resident 6's bladder and bowel continence records, safety checks every 2 hours including positioning and assistance in bowel and bladder records were reviewed. The safety checks every 2 hours records indicated on 8/14/25, Resident 6 was checked at 12:06 a.m. and next check was at 6:44 a.m. DON stated her expectation was for nursing staff to follow the safety protocol, and check residents every 2 hours for positioning, incontinence care so residents are comfortable, clean and prevent wounds. During a review of the facility's policy and procedure (P&P) titled, Repositioning, dated 2001, the P&P indicated, Residents who are in bed should be on at least an every-two-hour (q2hour) repositioning schedule. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting dated 2001, the P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 6 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all 59 residents who lived in the subacute building were free from environmental hazards when:1. A free-standing propane (flammable gas used for cooking or heating) tank and a propane tank attached to a gas grill were stored indoors in the subacute building in a hallway next to the kitchen and where a year's supply of emergency supplies were stored.2. Four ceiling mounted televisions (TV) were found partially detached from the ceiling and dangling over four of the 59 current residents (Resident 3, 7, 33 and 69) who were unable to move or protect themselves.These failures placed:1. All residents at risk of fire and explosion potentially causing serious harm and death and had the potential to disrupt kitchen services for any residents who depended on meals from the kitchen.2. Residents 3, 7, 33 and 69 under falling equipment hazards which had the potential to cause injuries and dislodge critical life sustaining medical equipment potentially causing death.The failures to ensure all 59 residents who lived in the subacute building were free from environmental hazards resulted in an Immediate Jeopardy situation (IJ, a situation which facility noncompliance has place the health and safety of residents at risk for serious harm, injury, serious impairment or death). The Administrator (ADM) and Director of Nursing (DON) were notified of the IJ on 8/20/25, at 2:23 p.m. The facility submitted an acceptable Plan of Action on 8/22/25, at 2:40 p.m. and based on observation, staff interviews and record review, the IJ was lifted onsite during the recertification survey exit conference on 8/22/25, at 5:20 p.m.1. During an observation on 8/20/25, at 9:49 a.m., in the hallway on the first floor of the subacute building, two propane tanks, one freestanding and another connected to a gas grill were observed. There were no staff in the area. At the other end of the hallway was the staff break room which had an exit that provided a clear and direct line of sight to the gas grill and propane tanks. The kitchen was located across the hall from where the propane tanks and gas grill were observed. The markings on the propane tanks indicated a 47 lb. (pounds, unit of weight measurement) tank weight.A review of the facility map titled [Facility Name] North Top Floor, printed 8/18/25, indicated resident rooms were located on the second floor of the two-floor subacute building, directly above where the gas grill and the two propane tanks were being stored. The second floor also included 17 Residents who were on ventilators (medical equipment that supports or replaces a person's breathing when they cannot breathe adequately on their own).During a second observation in the first-floor hallway of the subacute building on 8/20/25, at 12:17 p.m., the gas grill and the two propane tanks were in the same location. There were no staff in the area.During a concurrent observation and interview on 8/20/25, at 3:55 p.m., with Registered Dietitian (RD), RD was in their office in the same hallway as the gas grill and the propane tanks. The RD stated they were responsible for oversight of kitchen equipment and didn't know who put the gas grill and propane tanks in the hallway. The RD stated the gas grill and propane tanks had been in the hallway for at least a week.During a concurrent observation and interview on 8/20/25, at 4:29 p.m., with Maintenance Supervisor (MS) and RD, MS stated the kitchen was behind the wall across from where the gas grill and propane tanks were located, and the room behind the gas grill and propane tanks was the emergency supply room. RD stated paper products and emergency water were stored in the emergency supply room. The emergency supply room was adjacent to the gas water boiler room. MS stated there were two water boilers which were heated by gas.During an interview on 8/21/25, at 11:40 a.m, with MS, MS stated the propane tanks and gas grill were moved from an outdoor shed into the hallway about a year ago. MS stated they didn't know it was unsafe to store propane tanks indoors.During an interview on 8/22/25, at 11:25 a.m., with DON, DON stated propane tanks (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 7 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many stored indoors were a fire hazard. The DON stated the staff lounge on the first floor was used by staff during breaks and lunchtime. The DON stated they expected all staff to report hazardous conditions to the fire safety coordinator.During an interview on 8/22/25, at 11:51 a.m., with ADM, ADM stated MS was the fire safety coordinator for the facility. ADM stated MS was responsible for ensuring the facility was free of fire hazards.During a review of the facility's policy and procedure (P&P) titled, Fire Safety and Prevention, undated, the P&P indicated flammable items should be stored in separate areas away from resident living areas or store outside.During a review of National Fire Protection Association (NFPA) code titled, 2024 NFPA-58 Liquefied Petroleum Gas Code, dated 2024, the code indicated on Table 8.3.1 a maximum of 2 lbs. of propane stored in 1 lb. containers was allowed to be stored indoors in a health care setting. 2. A review of Resident 7's admission Record indicated Resident 7 was admitted on [DATE], with a diagnosis of anoxic brain damage (brain damage due to lack of oxygen), acute respiratory failure, cognitive communication deficit, gastrostomy (tube surgically placed in the abdomen to provide nutrition and medications) and tracheostomy (tube surgically placed in the neck to provide a hole for breathing).During a record review of Resident 7's minimum data set (MDS, an assessment tool to guide resident care), dated 7/28/25, the MDS indicated Resident 7 was dependent on staff to transfer out of bed and for all aspects of care. The MDS indicated Resident 7 was unable to understand others and could not make themselves understood.During a record review of Resident 7's weekly nursing summary titled, Nursing - Weekly Summary - V3.0, dated 8/15/25, the summary indicated Resident 7 was dependent on staff for transfers and bed mobility.A review of Resident 33's admission Record indicated Resident 33 was admitted on [DATE], with a diagnosis of chronic respiratory failure, tracheostomy, gastrostomy, muscle wasting, muscle weakness and dependence on respirator [ventilator] status.During a record review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 7 was dependent on staff to transfer out of bed and for all aspects of care. The MDS indicated Resident 7 was unable to understand others and could not make themselves understood.A review of Resident 3's admission Record indicated Resident 3 was admitted on [DATE], with a diagnosis of quadriplegia (loss of function of all limbs), long term use of anti-coagulants (medications used to prevent blood clots and increases risk of bleeding), gastrostomy, tracheostomy, respiratory failure, and cerebral infarction (occlusion of a blood vessel in the brain).During a record review of Resident 3's minimum data set (MDS, an assessment tool to guide resident care), dated 7/29/25, the MDS indicated Resident 3 was dependent on staff to transfer out of bed and for all aspects of care. The MDS indicated Resident 3 was to understand others but could not make themselves understood.A review of Resident 69's admission Record indicated Resident 69 was admitted on [DATE] with a diagnosis of acute respiratory failure, gastrostomy, tracheostomy, anoxic brain damage and long-term use of anti-coagulants.During a record review of Resident 69's nursing assessment titled, Nursing - Daily Skilled Charting Form - [Facility], dated 8/20/25, the assessment indicated Resident 7 was dependent on staff for transfers and bed mobility.During a concurrent observation and interview on 8/20/25, at 10:09 a.m., with Registered Nurse 1 (RN 1), the television ceiling mount over an unoccupied bed in room [ROOM NUMBER] was observed. RN 1 stated the condition of the mount was loose and dangerous to potential occupants of the bed. The ceiling mount had a visible gap between the mount base and the ceiling and upon manual manipulation, the mount could be swung back and forth at the base of the mount.During an observation on 8/20/25, at 10:14 a.m., Resident 3, 7 and 33's TV ceiling mounts in their shared room were inspected. All three mounts were over the resident beds with Resident 3, 7 and 33 in their respective beds. A family member was present with Resident 7. All three TV ceiling mounts had a visible gap between the mount base and the ceiling and could be manually swung back and forth at the base (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 8 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete of the mount. All three residents were non-interactive.During a concurrent observation and interview on 8/20/25, at 12:40 p.m., with Resident 3's resident representative (RP), RP stated Resident 3's TV mount had been wobbly because the ceiling mount was loose. RP stated RP kept hitting their head on the TV because it was too low. RP stated the facility attempted to fix the ceiling mount, but the TV mount was still wobbly. RP stated they were scared the TV was going to fall on top of Resident 3. RP stated they were concerned if staff moved the curtain to where the TV was it could potentially make the TV fall.During a concurrent observation and interview on 8/20/25, at 4:40 p.m., with MS and ADM, the TV ceiling mount in Resident 69's room was inspected. Resident 69 was in bed below the TV mount. MS was able to swing the TV mount manually and stated the mount was loose. MS stated for the loose mounts found in Resident 3, 7 and 33's room, the mounting hardware was not installed into a secure structure and repeated contact by Hoyer Lifts (machine used to lift and transfer residents out of bed) caused fasteners to become detached from the ceiling. MS stated some of the loose mounts were held up by only one fastener.During an interview on 8/22/25, at 11:25 a.m., with DON, DON stated Residents 3, 7, 33 and 69 could not protect themselves from environmental hazards and were dependent on staff for safety.During a review of the facility's P&P titled, Maintenance Service, dated 2001, the P&P indicated the maintenance department is responsible for maintaining .equipment in a safe and operable manner at all times.functions of maintenance personnel include.maintaining the building in good repair and free from hazards. Event ID: Facility ID: 555809 If continuation sheet Page 9 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to provide the appropriate foley catheter (a flexible tube used to empty the bladder and collect urine) care and services for one of one sampled resident (Resident 4) when Resident 4's indwelling urinary catheter bag and tube were touching the floor. This failure had the potential for Resident 4 to develop a urinary tract infection (UTI, an infection in any part of the kidneys, bladder, or urethra (the tube which empties urine from the bladder). During a record review of Resident 4's admission Record (AR) printed on 8/19/25, the AR indicated Resident 4 was admitted to the facility in June 2025 with diagnoses of cardiac arrest (when the heart suddenly stops breathing) and pseudomonas (a type of bacteria that can cause serious infections), and pressure ulcer (develops when one or more layers of skin and tissue are damaged from continuous pressure to the area) of sacral region stage four (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). During a record review of Resident 4's Order Summary Report (OSR) dated 8/19/25, the OSR indicated, .foley catheter 16#French (Fr, a unit used to measure the size of catheter and tubes) . Indication of use: wound management. During a concurrent observation and interview on 8/19/25 at 11:10 a.m. with Certified Nurse Assistant (CNA) 2, Resident 4's foley catheter bag was not properly secured to the bed and was found completely resting on the floor. CNA 2 stated whoever lowered the bed must have forgotten to check the foley catheter bag. CNA 2 stated the foley catheter bag should have been completely off the floor because it had the risk of contamination and infection. CNA 2 further stated if she had the foley catheter, she would not want her foley catheter bag on the floor. During an interview on 8/20/25 at 10:51 a.m. with Infection Preventionist (IP), IP stated it was unacceptable for the foley catheter bag to be on the floor. IP stated Resident 4 was at risk for catheter-associated urinary tract infection (CAUTI, happens when a bacteria enters the bladder or urinary tract though a urinary catheter which can lead to complications like bladder infections, kidney infections, and even sepsis or an extreme reaction to an infection).During a record review of the facility's policy and procedure (P&P), titled, Catheter Care, Urinary, revised in August 2022, the P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including UTI.Infection Control.2. Be sure the catheter tubing and drainage bag are kept off the floor. Event ID: Facility ID: 555809 If continuation sheet Page 10 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to provide appropriate care and services related to enteral feeding (also referred to as tube feeding, is the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) for six of eight sampled residents (Residents 1, 2, 4, 5, 23 and 55) when:1. Residents 1, 2, 4, 23 and 55 enteral feeding items were unlabeled. 2. Resident 5's enteral feeding formula was unlabeled and the water flush (the process of gently pushing water through the feeding tube to prevent it from becoming clogged and to help with hydration) bag was not administered per physician's order.These failures had the potential to cause Residents 1, 2, 4, 5, 23, and 55 to receive incorrect administration of feeding formulas and water flush, potentially causing serious harm, including but not limited to respiratory aspiration (occurs when stomach contents or feeding formula enters the lungs), foodborne illness (illnesses caused by consuming contaminated food or beverages), dehydration (absence of enough water in the body) or discomfort. 1.During an observation on 8/18/25 at 9:20 a.m., Resident 55's feeding formula, water flush, and syringe were not labeled with residents' identifying information, date, or time the formular, water flush and syringe were initiated. During an observation on 8/18/25 at 10:33 a.m., in Resident 23 and 2's shared room, Resident 23's feeding formula, Resident 2's feeding formula and water flush were not labeled with residents' identifying information, date, or time the formular, water flush and syringe were initiated. During an observation on 8/18/25 at10:51 a.m., in Resident 1 and 4's shared room, Resident 4's feeding formula, and Resident 1's feeding formula and water flush were not labeled with residents' identifying information, date, or time the formular, water flush and syringe were initiated. During an interview on 8/20/25 at 9:01 a.m., Director of Nursing (DON) stated nurses should label the feeding formula, water flush and syringes with resident's name, date, and time to ensure residents receive the correct formula, the correct flow rate and the correct amount of water. DON stated that without proper labeling, residents were at risk of receiving expired food (formula), experiencing upset stomach and developing foodborne illness such as diarrhea. During a concurrent interview and record review on 08/21/2025 11:19 a.m., with Infection Control and preventionist (IP), in tube feeding supply storage, IP stated it was the nursing standard practice to label the formula, water flush and syringes. IP stated the nurses should label the formula, water and syringe when hanging new bags, to ensure syringes not being shared among residents in the same room and to track how long a syringe had been in use, since syringes should be disposed of after 24 hours. During a review of the facility's policy and procedure (P&P), titled, Enteral Feedings - Safety Precautions, dated November 2023, the P&P indicated, .2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.Preventing misconnection errors.1. Ensure that all enteral formula labels indicate Not for intravenous (IV, into the vein) Use .3. Regularly inspect tubing for proper and secure connections. 2. During a record review of Resident 5's admission Record (AR), printed on 8/19/25, the AR indicated Resident 5 was admitted to the facility in August 2024 with diagnoses including anoxic brain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 11 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0693 Level of Harm - Minimal harm or potential for actual harm damage (occurs when the brain receives no oxygen at all), dependence on ventilator status (a type of breathing apparatus that provides mechanical ventilation to a patient who is physically unable to breathe), gastrostomy status (state of having a surgically created opening in the stomach for the purpose of feeding) and type 2 diabetes mellitus (a long-term disease in which the body cannot regulate the amount of sugar in the blood) with unspecified complications. Residents Affected - Some During a record review of Resident 5's Order Summary Report (OSR), dated 8/19/25, the OSR indicated an order for Enteral feed every shift tube feeding formula: Diabetisource AC (is a specialized formula to meet the nutritional needs of individuals with diabetes) at 60 milliliters/hour (ml/hr) via gastrostomy tube via feeding pump continuous for 20 hours/day (off at 10:00 a.m. to 2:00 p.m. or until total 1200 ml is given) and Flush tube with water to run at 60 ml/hr via feeding pump continuous for 20 hrs/day for total 1200 ml free water per day. Hold at 10:00 a.m. and on at 2:00 p.m. During an observation on 8/18/25 at 9:53 a.m. with Resident 5, Resident 5 had an ongoing tube feeding administration of Diabetisource AC feeding formula. Resident 5's feeding formula and water flush bags were unlabeled and did not have Resident 5's information such as name, date and time the formula and water flush were started, and the physician's order for feeding and water flush rate. Resident 5 also had approximately 1000 ml remaining in the unlabeled water flush bag. During an observation and interview on 8/18/25 at 10:17 a.m. with Licensed Vocational Nurse (LVN 4), LVN 4 checked the enteral feeding and water flush bags and stated she did not know why the bags were unlabeled. LVN 4 stated Resident 5's feeding formula and water flush bag were started on the previous day, 8/17/25. LVN 4 stated she was unsure why the water flush bag remained full and why it was not administered. LVN 4 stated if the water flush had been properly administered to Resident 5, the volume in the water flush bag should have decreased accordingly. LVN 4 further stated the feeding formula and water flush bag should have been labeled correctly including Resident 5's name and the date and time the feeding started. LVN 4 stated not labeling the feeding formula and water flush bag, Resident 5 had the risk of receiving the wrong formula and/or volume amount that could have caused Resident 5 complications of diabetes such as high or low blood sugar. During an interview on 8/22/25 at 10:45 a.m. with the DON, the DON stated licensed nurses were expected to provide monitoring for the residents who had enteral feeding and make sure the feeding formulas and water flush bags had complete and accurate labels. The DON further stated licensed nurses should have verified if the feeding pump (a medical device that delivers liquid nutrition, fluid, and medications directly into a person's gastrointestinal tract through a feeding tube when they cannot consume food or liquids orally) was working properly. The DON stated administering the water flush as ordered by the physician was important to ensure residents maintain proper hydration. During a review of the facility's policy and procedure (P&P), titled, Enteral Feedings - Safety Precautions, dated November 2023, the P&P indicated, Promoting feeding tolerance.3. Feeding pumps must be calibrated periodically to ensure that the pump delivers the prescribed volume within 10 percent accuracy .Preventing errors in administration .1. Check the enteral nutrition label against the order before administration . 2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.Preventing misconnection errors.1. Ensure that all enteral formula labels indicate Not for intravenous (IV, into the vein) Use .3. Regularly inspect tubing for proper and secure connections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 12 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 5), received proper infection control measures for tracheostomy (surgically created hole in the trachea or windpipe that provides an alternative airway for breathing) care when Resident 5's two Ambu bags or manual resuscitator bag (is a hand-held device used in emergencies to provide manual, positive pressure ventilation to patients who are not breathing adequately) were left exposed in the room without any protective coverings. This failure resulted in Resident 5 being at risk of acquiring life-threatening infections including but not limited to ventilator (a type of breathing apparatus that provides mechanical ventilation to a patient who is physically unable to breathe) associated pneumonia (an infection that inflames the air sacs in one or both lungs) that can also lead to sepsis (the body's extreme and harmful reaction to an infection) if the contaminated Ambu bags were used. During a record review of Resident 5's admission Record (AR), printed on 8/19/25, the AR indicated Resident 5 was admitted to the facility in August 2024 with diagnoses of anoxic brain damage (occurs when the brain receives no oxygen at all), dependence on ventilator status, gastrostomy status (state of having a surgically created opening in the stomach for the purpose of feeding) and chronic respiratory failure (a gradual-onset condition where the lungs can't get enough oxygen into the blood to meet the body's needs).During a record review of Resident 5's Order Summary Report (OSR), dated on 8/19/25, the OSR indicated Resident 5 had a physician order dated 1/15/25 for continuous ventilator setting. The Order Summary record also indicated Resident 5 had a physician order, dated 5/19/25, for a full code (a medical status indicating if the person's heart and breathing stop, all resuscitative measures are to be performed, including chest compressions, Ambu bag ventilation, electric shocks, etc.) status.During an observation on 8/19/25 at 10:16 p.m. in Resident 5's room, Resident 5 was sleeping while the tracheostomy was connected to a ventilator. An Ambu bag without any protective covering was on top of a bedside table, tucked between the wall and a medium-sized fan. Another Ambu bag was also found inside the basket of a rolling stand, left exposed without any protective covering. During an interview on 8/19/25 at 10:22 p.m. with Respiratory Therapist (RT) 1, RT 1 confirmed there were two uncovered Ambu bags without protective coverings in Resident 5's room and were likely left exposed when Resident 5 had a shower. RT 1 stated Ambu the two Ambu bags should have been stored inside a sealed plastic bag to prevent contamination. RT 1 further the improper storage of the Ambu bags placed Resident 5 at risk for contracting infections, including pneumonia, particularly if the exposed Ambu bags were used on Resident 5's respiratory care.During an interview on 8/20/25 at 10:47 a.m. with Infection Preventionist (IP), IP stated any respiratory equipment including an Ambu bag should have been properly inside a protective bag after use to prevent contamination. IP stated the two Ambu bags left exposed were considered contaminated. IP stated the Ambu bags could have been picked up from the floor or may have belonged to another resident. IP stated Resident 5 was at increased risk for developing hard-to-treat bacterial infections. During a record review of facility's policy & procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated September 2022, the P&P indicated, Residentcare equipment, including reusable items and durable medical equipment will be cleaned and disinfected.b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g. respiratory therapy equipment). Such devices should be free from all microorganisms. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 13 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview, and record review, the facility failed to ensure sufficient staffing when the weekend staffing levels were excessively low across four fiscal year (FY) quarters, and the minimum requirement of 2.4 Direct Hours Per Patient Day (DHPPD - refers to the minimum number of direct care service hours a facility is required to provide to each resident per day) of direct nurse aide coverage was not met on 15 audited days. This failure had the potential to result insufficient nursing staff and inadequate nursing care for the facility residents. During a record review of a document, titled, Payroll Based Journal (PBJ) Staffing Data Report (a system where nursing homes submit auditable information about the hours worked each day by different types of staff), the PBJ Staffing Data Report showed the following quarters were triggered for excessively low weekend staffing:FY Quarter 4 2024 (July 1 - September 30)FY Quarter 3 2024 (April 1 - June 30)FY Quarter 2 2025 (January 1 - March 31)FY Quarter 1 2025 (October 1 - December 31) During an interview on 8/21/25 at 11:20 a.m. with the Administrator (ADM), the ADM stated the facility did not have a staffing waiver (an official permission granted by a state agency to allow a skilled nursing facility to operate below the state's minimum staffing requirements for a temporary period, usually due to a demonstrated workforce shortage) from 7/1/24 to 6/30/25. During an interview on 8/21/25 at 1:45 p.m. with the Staffing Coordinator (SC), the SC stated she determined the daily staffing levels needed to care for residents based on the calculated DHPPD. SC stated DHPPD result below 2.4 for CNAs indicated short staffing, which could have negatively impacted the facility's ability to provide necessary care and services to residents. During a concurrent interview and record review on 8/22/25 at 9:06 a.m. with Staffing Coordinator (SC), the facility's records, titled, Census and DHPPD on various dates between 1/1/25 through 6/30/25 were reviewed. The Census and DPHPPD data were as follows: 1/18/25 CNA DHPPD was 2.201/21/25 CNA DHPPD was 2.301/27/25 CNA DHPPD was 2.312/9/25 CNA DHPPD was 2.362/11/25 CNA DHPPD was 2.302/12/25 CNA DHPPD was 2.362/13/25 CNA DHPPD was 2.362/14/25 CNA DHPPD was 2.322/16/25 CNA DHPPD was 2.352/17/25 CNA DHPPD was 2.302/19/25 CNA DHPPD was 2.302/21/25 CNA DHPPD was 2.135/12/25 CNA DHPPD was 2.285/19/25 CNA DHPPD was 2.386/23/25 CNA DHPPD was 2.32 During an interview on 8/22/25 at 10:45 a.m. with the Director of Nursing (DON) the DON stated the CNA DHPPD below 2.4 was risk for staffing burnout and could have affected the resident care. During a record review of the facility's undated policy and procedure (P&P), titled, Nursing Hours Per Patient Day (NHPPD) Licensed Nurse (LN) and CNA, the P&P indicated, The facility shall ensure that all residents receive safe, effective, and timely nursing care by maintaining at least 3.5 DHPPD, of which a minimum of 2.4 hours shall be provided by the CNAs. Event ID: Facility ID: 555809 If continuation sheet Page 14 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when: The ice machine had black and brown particles on the inside parts. The resident refrigerator-freezer temperature was not monitored.Unlabeled and undated food items were stored in the resident refrigerator-freezer.Beyond use by and best by date food items were stored in the resident refrigerator-freezer.Food items were stored less than six inches above the floor.These failures had the potential for contamination of food resulting in food borne illness for the 59 residents who lived at the facility. During an observation on 8/18/25, at 9:51 a.m., the ice machine was observed with black and brown particles on the inside parts. During an observation on 8/18/25, at 11:20 a.m., the resident refrigerator-freezer was observed with a sign posted on the refrigerator-freezer's front door that indicated Please be aware that opened food/drinks can only last 3 days. During an observation on 8/18/25, at 11:37 a.m., the resident refrigerator-freezer was observed. The freezer had one plastic container of orange slices undated and not labeled with resident name and one opened soda bottle with an expiration date of 7/21/25 and not labeled with resident name. The refrigerator had one half and half carton with a best buy date by date of 8/6/25 and not labeled with resident name, one salad dressing bottle with a best buy date of 7/26/25 and not labeled with resident name and one jar of an unknown food item not labeled with date or resident name. During a review of the Resident's Refrigerator Temperature Log, dated August 2025, the Log indicated the temperature was not recorded 8/1/25 through 8/12/25 and on 8/15/25 through 8/17/25. During an observation 8/18/25, at 3:09 p.m., central supply was observed with nutritional beverages and tube feeding formulas stored less than six inches above the floor. During an interview on 8/21/25, at 10:39 a.m., with Registered Dietician (RD), RD stated the ice machine should have been clean and an unclean ice machine could have had unsafe water and could have been a risk for infection. RD stated the resident refrigerator-freezer temperature should have been monitored and documented daily, otherwise they could have served food that was stored in the danger zone (the food danger zone is the temperature range between 40 Farenheit and 140 Farenheit, where bacteria grow rapidly, increasing the risk of foodborne illness). RD stated food in the resident refrigerator-freezer should have been labeled with resident name and date received. RD stated if food was not labeled with resident name, it could have caused residents to get the wrong diet, choking and cross contamination. RD stated if food was not labeled with date received, staff may not have known how old the food was and could have caused resident sickness. RD stated the resident refrigerator-freezer should not have had food that was beyond their use by date, beyond their best buy date or expired. RD stated beyond use by date, beyond best buy date and expired food items placed residents at risk for sickness, stomach aches, vomiting and diarrhea. RD stated resident food should have been stored at least six inches above the floor. RD stated food stored less than six inches above the floor was a risk for contamination from pests, could have altered the food temperature and had the potential to cause resident sickness. During an observation and interview on 8/21/25, at 11:32 a.m., with the Maintenance Director (MainD), the ice machine was observed. The inside parts of the ice machine did not have black and brown particles. MainD stated the ice machine was cleaned on 8/20/25. MainD stated it was clean and there was a big difference from before. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated 2001, the P&P indicated, Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and closing in the evening. During a review of the facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, revised March 2022, the P&P (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 15 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete indicated, Containers are labeled with the resident's name, the item and the use by date. The P&P indicated, The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example . past due package expiration dates). During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 2001, the P&P indicated, Foods and Snacks Kept on Nursing Units . All foods belonging to residents are labeled with the resident's name, the item and the use by date. The P&P indicated, Food in designated dry storage areas are kept at least six (6) inches off the floor. Event ID: Facility ID: 555809 If continuation sheet Page 16 of 17 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 555809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578 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 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Based on interview and record review, the facility failed to ensure the Medical Director (MD) perform duties and responsibilities when MD stated did not regularly attend quality assurance and performance improvement (QAPI) committee and did not participate in the development of the facility assessment or development and evaluation of policy and procedures for two years.This failure had the potential for all residents to have substandard quality of care due to lack of physician oversight of patient quality assurance and facility performance.During an interview on 8/22/25, at 3:48 p.m., with MD, MD stated they had been the medical director for two years. MD stated they had not regularly attended QAPI meetings. MD stated they had attended two QAPI meetings in recent memory and was not getting regular invites to meetings until recently. MD stated they did not review or update any facility policy and procedures (P&P). MD stated they were not involved in the development of the facility assessment (assessment used to determine what services the facility is capable of offering). MD stated they would be involved in assessing individual residents for admission, but did not provide input into the overall scope of services provided.A review of facility QAPI sign in sheets for 2025, indicated MD was present for three of seven QAPI meetings (January, June and July).A review of California Department of Public Health (CDPH) All facilities letter titled, Assembly [NAME] (AB) 48 - Nursing Facility Resident Informed Consent Protection Act of 2023, dated 2/28/24, indicated residents have the right to be free of psychotherapeutic drug (medication used to treat psychiatric disorders).AB 48 requires the facility to obtain written informed consent and specifies disclosure of material information for proper informed consent.must include: possible nonpharmacological approaches that could address the resident's needs. Whether the drug has a current boxed warning label.whether the drug is prescribed for a purpose that has or has not been approved by the United States Food and Drug Administration (FDA). Possible interactions with other drugs .facilities must review and revise their P&Ps to ensure compliance with the new law. The P&Ps must specifically consider and plan for how the facility will verify the resident provided informed consent or refused treatment or a procedure pertaining to the administration of psychotherapeutic drugs.A review of facility P&P titled, Antipsychotic Medication Management, dated August 2022, indicated the P&P was last revised in August 2022. The P&P indicated Residents (and/or resident representatives) will be informed of the recommendation, risk, benefits, purpose and potential adverse consequences of antipsychotic medication use. Residents.may refused medications of any kind. The P&P did not indicate antipsychotic medication use required written informed consent and did indicate the consent contained specific information pertaining to nonpharmacological approaches, medication warning label, medication use approval by FDA and possible interactions with other medications.During a record review of MD's contract titled, Medical Director Services Agreement, dated 1/1/23, the contract indicated the MD serve as a member of the facility's quality assurance committee.be involved in developing, reviewing and implementing policies and procedures regarding clinical care of residents to ensure clinical validity and consistency with current standards of care.provide input into the facility's: scope of services provided to residents .and review and updating of policies and procedures to reflect current standards of practice. Event ID: Facility ID: 555809 If continuation sheet Page 17 of 17