Health inspection·February 9, 2026

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Care of the Older Adult with Diabetes Mellitus, undated, revealed under Medication Management 1. Follow the provider orders for blood for blood glucose monitoring.7. Assist the resident with his or her specific medication regimen, as ordered and as needed.During a review of facility's P&P titled, Administering Medications, undated, under policy statement, Medications are administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation .4. Medications are administered in accordance with prescriber orders, including any required time frame.6. Medications are administered within one (1) hour their prescribed time, unless otherwise specified. Event ID: Facility ID: 555809 If continuation sheet Page 2 of 5 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 02/09/2026 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 0880 Provide and implement an infection prevention and control program. 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 observe infection control measures for two of six sampled residents (Resident 1 and Resident 2 ) when the following was observed: 1. House Keeper (HK) 1 was seen inside Resident 1's room who was on Contact Precaution (extra safety steps healthcare workers take to stop spread of germs) without Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and did not perform hand hygiene after exiting Resident 1's room.2. Registered Nurse (RN) 1 did not wear PPE or wash their hands after giving a subcutaneous (medication delivered through injection under the skin) injection to Resident 1.3. Certified Nursing Assistant (CNA) 1 emptied Resident 2's urinary drainage bag with gloved hands and exited Resident 2's room without removing gloves or performing hand hygiene. These failures had the potential to spread infections among residents at the facility.1. During a review of Resident 1's admission Record, dated 12/15/25, the admission Record indicated Resident 1 was admitted to the facility April 2023 with multiple diagnoses that included Type 2 Diabetes Mellitus with hyperglycemia (high blood sugar) and Gastrostomy Status (indicates a feeding tube (G-tube) placed directly into stomach through the abdominal wall used for long-term feeding, fluids, or medicine when a patient cannot eat enough by mouth). During a concurrent observation and interview on 12/15/25 at 1:15 a.m. in Resident 1's room, HK 1 was observed inside Resident 1's room not wearing PPE. HK 1 then exited Resident 1's room and did not perform hand hygiene. HK 1 explained, she just cleaned and emptied Resident 1's bathroom and trash bins. HK 1 then proceeded to fill up PPE supplies on Resident 1's supply rack. HK 1 stated, they knew they were supposed to wear PPE when cleaning Resident 1's room. HK 1 added, there was no supply of PPE this morning. During a review of Resident 1's Physician's Order Summary Report, dated 3/20/25, the Order Summary Report, indicated Resident 1 was on contact precaution as ordered by the physician. During a review of facility's infection control signage posted outside Resident 1's door, the infection control signage indicated CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. The signage also indicated PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. During a review of facility's infection control signage posted outside Resident 1's room titled Your 5 Moments for Hand Hygiene, undated, the infection control signage indicated .3. Clean your hands immediately after an exposure risk to body fluids (and after glove removal). To protect yourself and the health-care environment from harmful patient germs. 4. Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient's side. To protect yourself and the health-care environment from harmful patient germs. 5. Clean your hands after touching any object or furniture in the patient's immediate surroundings, when leaving - even if the patient has not been touched. To protect yourself and the health-care environment from harmful patient germs. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions undated, indicated, under Policy Interpretation and Implementation,.3.b. A resident .has a wound or indwelling medical device, and has secretions or excretions that cannot be covered or contained; .5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. 6. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen.8. Examples of high-contact resident care activities re [NAME] the use of gown and gloves for EBPs include: .h. prolonged, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 3 of 5 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 02/09/2026 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene undated, indicated, under Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene, .2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Under Indications for Hand Hygiene, 1. Hand hygiene is indicated: .c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; .g. immediately after glove removal. 2. During a review of Resident 2's admission Record, dated 12/15/25, the admission Record indicated Resident 2 was admitted to the facility in November 2024 with multiple diagnoses that included tracheostomy (surgical opening in the neck that allows a person to breathe through a tube) status, gastrostomy status and ventilator associated pneumonia (an infection/inflammation in the lungs). During a concurrent observation and interview on 12/15/25 at 1:35 p.m. with RN 1 in Resident 1's room, RN 1 was observed inside Resident 1's room not wearing PPE. RN 1 then exited Resident 1's room and did not perform hand hygiene. RN 1 stated, she did not wear PPE inside Resident 1's room because the PPE supply rack on Resident 1's door was empty. RN 1 further stated, PPE supply was kept at the nurse's station, not near Resident 1's room. RN 1 added, PPE was supposed to be worn because Resident 1 was on contact precaution. When asked if RN 1 had direct contact with Resident 1, RN 1 stated, yes because she had given medication to Resident 1 via G-tube, checked Resident 1's blood sugar check and gave insulin to Resident 1. RN 1 acknowledged she did not perform hand hygiene after direct contact with Resident 1. RN 1 added, there was increased risk of transmission of infection for not wearing PPE and not performing hand hygiene after giving direct care to Resident 1. During a review of Resident 2's Physician's Order Summary Report, dated 3/20/25, indicated Resident 2 was on contact precaution as ordered by the physician. During a review of Resident 2's care plan care plan (document that outline resident's care needs), dated 10/4/24, the care plan indicated Resident 2 was on contact precaution and one of the interventions were, staff will perform hand washing after completing care and leaving the room. The care plan also showed, use of personal protective equipment was required. During a review of facility's infection control signage posted outside Resident 2's room titled Your 5 Moments for Hand Hygiene, undated, the infection control signage indicated.3. Clean your hands immediately after an exposure risk to body fluids (and after glove removal). To protect yourself and the health-care environment from harmful patient germs. 4. Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient's side. To protect yourself and the health-care environment from harmful patient germs. 5. Clean your hands after touching any object or furniture in the patient's immediate surroundings, when leaving - even if the patient has not been touched. To protect yourself and the health-care environment from harmful patient germs. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions undated, indicated, under Policy Interpretation and Implementation,.3.b. A resident .has a wound or indwelling medical device, and has secretions or excretions that cannot be covered or contained; .5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. 6. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen.8. Examples of high-contact resident care activities re [NAME] the use of gown and gloves for EBPs include: .h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555809 If continuation sheet Page 4 of 5 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 02/09/2026 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete undated, indicated, under Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene, .2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Under Indications for Hand Hygiene, 1. Hand hygiene is indicated: .c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment;.g. immediately after glove removal. 3. During a concurrent observation and interview on 12/15/25 at 1:39 p.m. in Resident 2's room, CNA 1 was observed at Resident 2's bedside emptying their urinary drainage bag into a container, CNA 1 was wearing gown and gloves. CNA 1 exited Resident 2's room, removed and discarded the gown in the trash bin outside Resident 2's room. CNA 1 did not remove his dirty gloves. CNA 1 then walked towards the nurse's station while removing his gloves and then touched a clean pack of gowns that were located in the nurses' station. CNA 1 stated, he removed the dirty gown in the hallway because the garbage bin was outside Resident 2's room. CNA 1 also stated, he did not perform hand hygiene after emptying urinary bag because he did not think about it. CNA 1 added, the PPE supply rack on Resident 2's door was empty this morning so had to go to the nurse's station where PPE supplies are stored. During an interview on 12/15/25 at 3:38 a.m. with Director of Nursing (DON), DON stated, it was acceptable for CNA 1 to remove dirty gown in the hallway and discard the dirty gown in the garbage bin that was placed immediately outside Resident 2's room. DON also stated, RN 1 was expected to wear PPE when in direct contact with Resident 1 who was in contact precaution. DON added, CNA 1 was expected to disinfect hands with ABHR after removing dirty PPE and before donning new ones to prevent spread of infection. During a review of facility's infection control signage posted outside Resident 2's room titled Your 5 Moments for Hand Hygiene, undated, the infection control signage indicated, .3. Clean your hands immediately after an exposure risk to body fluids (and after glove removal). To protect yourself and the health-care environment from harmful patient germs. 4. Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient's side. To protect yourself and the health-care environment from harmful patient germs. 5. Clean your hands after touching any object or furniture in the patient's immediate surroundings, when leaving - even if the patient has not been touched. To protect yourself and the health-care environment from harmful patient germs. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions undated, indicated, under Policy Interpretation and Implementation,.3.b. A resident .has a wound or indwelling medical device, and has secretions or excretions that cannot be covered or contained; .5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. 6. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen.8. Examples of high-contact resident care activities re [NAME] the use of gown and gloves for EBPs include: .h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene undated, indicated, under Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene, .2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Under Indications for Hand Hygiene, 1. Hand hygiene is indicated: .c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; .g. immediately after glove removal. Event ID: Facility ID: 555809 If continuation sheet Page 5 of 5