Health inspection·November 10, 2021

F 0689 that he keeps his own smoking paraphernalia. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 11's care plan titled, The resident is a smoker, [revised] 11/8/21, indicated, . The resident will not smoke without supervision . Instruct resident about the facility policy on smoking: . times: 9am-10am; 2pm-3pm; 6pm-7pm . Observe clothing and skin for signs of burns . resident can smoke UNSUPERVISED . facility to store lighter and cigarettes . resident requires a smoking apron while smoking . During a concurrent interview with LVN 1 on 11/9/21, at 10:29 AM, LVN 1 confirmed Resident 11 required supervision and smoking apron while smoking. LVN 1 stated, I don't know why it says here unsupervised . resident is high risk for fall and have a low blood pressure. LVN 1 added, she had not seen Resident 11 wearing a smoking apron when smoking. Residents Affected - Few Review of the facility's policy and procedure titled, Smoking Policy - Residents, revised July 2017, indicated, . 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: . d. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted to the care plan, and all personnel caring for the resident shall be alerted of these issues. 10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member . at all times while smoking. 14. Residents without independent smoking privileges may not have or keep any smoking articles . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 2 of 11 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 555813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Oaks Nursing Center 3635 Jefferson Avenue Redwood City, CA 94062 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility had an 8.57 % error rate when 3 medication errors out of 35 opportunities were observed during a medication pass for Resident 11 and Resident 13. Residents Affected - Some These deficient practice resulted in medications not given in accordance to the manufacturer's specification which may result in residents not receiving the full therapeutic effect of the medications. Findings: 1. During a medication pass observation, on 11/9/21 at 8:45 AM, Licensed Vocational Nurse (LVN)1, administered Olopatadine Hydrochloride Ophthalmic Solution (a solution indicated for the treatment of signs and symptoms of allergic conjunctivitis) one drop each eye to Resident 13. LVN 1 did not instruct resident to close eyes slowly after the drop and to keep eyes closed for 3 minutes. LVN wiped eyes with tissue, did not compress inner canthus for 1-2 minutes. During an interview on 11/9/21 at 11:40 AM, LVN 1 stated, I did not put pressure on the inner corner of the eye that long. Review of the clinical record for Resident 13 indicated, a physician order dated 6/8/21 for: Olopatadine HCI Solution 0.1% Instill 1 drop in both eyes two times a day for eye allergies. Review of the facility's Policy and Procedure (P&P), titled Medication Administration Eye Drops dated 5/16 indicated, . 9. Instruct resident to close eyes slowly to allow for even distribution over surface of the eye. The resident should refrain from blinking or squeezing eyes shut. 10. while eye is closed, use one finger to compress the tear duct in the inner corner (inner canthus) of the eye for 1-2 minutes. This reduces systemic absorption of the medication. Alternatively, the resident may keep eyes closed for approximately three minutes . According to Lexicomp, a nationally recognized drug reference, Olopatadine Hydrochloride Opthalmic solution, .After use, keep your eyes closed. Put pressure on the inside corner of the eye. Do this for 1 to 2 minutes. This keeps the drug in your eye . 2. During a medication pass observation, on 11/9/21 at 9 AM, LVN 1, administered to Resident 11, 1. Basaglar Kwikpen Solution Pen-Injector 100 Units/ml Insulin (indicated to improve blood sugar control)15 units Subcutaneously (SQ) on Right upper abdomen. 2. Novolog Solution 100 units/ml 12 units SQ on left upper abdomen. LVN 1 pulled the needle and did not apply firm pressure over site. During an interview on 11/9/21 at 11:45 AM, LVN 1 acknowledged that she did not apply pressure over the site and stated, I pulled off the needle right away. Review of the clinical record for Resident 11 indicated, a physician order dated 7/11/21 and 7/9/21 for: 1. Basaglar Kwikpen Solution Pen-Injector 100 Units/ML 15 units (Insulin Glargine) Inject 15 units subcutaneously every 12 hours for Type 1 Diabetes Mellitus. 2. Novolog Solution100 Unit/ML (Insulin Aspart) Inject 12 Units SQ with meals for Diabetes. Hold if NPO or BG <110. Review of the facility's P&P, titled Medication Administration Subcutaneous Insulin dated 5/16 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 3 of 11 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 555813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Oaks Nursing Center 3635 Jefferson Avenue Redwood City, CA 94062 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated, .17. Inject Insulin slowly. Leave needle in the skin for several seconds after injection with finger on the plunger or per manufacturer's recommendation. 18. Remove needle and apply firm pressure over site to prevent seepage of Insulin. Do not rub area . According to Manufacturer's Guide for Insulin Aspart (Injection) dated 11/19, indicated, . Instruct patients that when injecting Insulin Aspart, they must press and hold down the dose until the dose counter shows 0 and then keep the needle in the skin and count slowly to 6 as the prescribed dose is not completely delivered until 6 seconds later. If the needle is removed earlier, the full dose may not be delivered (a possible under-dose may occur by as much as 20%) . 3. During a medication pass observation on 11/10/21 at 9:38 AM on Resident 13, LVN 2 administered Olopatadine Hydrochloride Ophthalmic Solution (a solution indicated for the treatment of signs and symptoms of allergic conjunctivitis) one drop each eye to Resident 13. LVN 2 did not instruct resident to close eyes slowly after the drop and to keep eyes closed for 3 minutes. LVN 2 put thumb and forefinger to both inner canthus for short 30 seconds. During an interview on 11/10/21 at 10:30 AM, LVN 2 admitted she did not keep the pressure long enough, stated, I only held for not even a minute. Review of the facility's Policy and Procedure (P&P), titled Medication Administration Eye Drops dated 5/16 indicated, .9. Instruct resident to close eyes slowly to allow for even distribution over surface of the eye. The resident should refrain from blinking or squeezing eyes shut. 10. while eye is closed, use one finger to compress the tear duct in the inner corner (inner canthus) of the eye for 1-2 minutes. This reduces systemic absorption of the medication. Alternatively, the resident may keep eyes closed for approximately three minutes . According to Lexicomp, a nationally recognized drug reference, Olopatadine HCI, . After use, keep your eyes closed. Put pressure on the inside corner of the eye. Do this for 1 to 2 minutes. This keeps the drug in your eye . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 4 of 11 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 555813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Oaks Nursing Center 3635 Jefferson Avenue Redwood City, CA 94062 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure the competency of one kitchen staff (KS) when the standardized recipes were not followed during the noon meal on 11/9/21. Residents Affected - Few Findings: During an observation of food production activities on 11/9/21 beginning at 9:51 AM, Kitchen Staff (KS) did not consistently follow recipes (Cross Reference F804). In an interview on 11/10/21 at 9:46 AM with the Dietary Supervisor (DS), DS described guidance to dietary staff as informal discussions during food production activities if issues or concerns are observed. DS stated, I check everything what my staff do. Training documents were requested and review of training records revealed there was no documented in-service training related to preparing and following standardized recipes. DS said that in-service training will be given later that day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 5 of 11 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 555813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Oaks Nursing Center 3635 Jefferson Avenue Redwood City, CA 94062 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on food production observations, resident and dietary staff interview, and dietary document review, the facility failed to ensure meal palatability and menu meets nutritional requirement when: Residents Affected - Many 1. The noon meal on 11/9/21 lacked flavor; 2. The recipes were not followed for two lunch items per the planned menu on 11/9/21 for 23 residents. These deficient practices could negatively affect the caloric and nutrient intake needs of the residents. Findings: 1. During an initial tour interview on 11/8/21 at 10:05 AM, Resident 10 had concerns about food served. Resident 10 stated, Sometimes the food is salty, sometimes it doesn't have taste. I couldn't eat it it's not food appropriate for nursing home . Resident 10 said that staff were aware of the issues. During an initial tour interview on 11/8/21 at 10:12 AM, Resident 25 stated she had concerns regarding the food served. Resident 25 stated, I don't like the food . there's too much sauce on the meatballs . the food is salty . During a concurrent observation and interview with Resident 7 on 11/8/21 at 12:23 PM, in resident's room, Resident 7 was eating lunch consisted of pot roast, mashed potato, brussels sprouts, and corn salad. Resident 7 stated, The meat is tender but salty. Review of the Resident Council Meeting Minutes dated 8/31/21 indicated, .Food is cold when served . meat served with bone, hard to cut . During a tray line observation on 11/9/21 starting at 11:54 AM, five trays did not have sauce on the pasta. At around 12:18 PM, lunch cart #1 was brought out from the kitchen. While trays were being checked by Licensed Vocational Nurse 2 before distribution, it was noted that the lunch trays for Residents 25, 16, 7, 11 and 13 did not have sauce on their pasta. During a concurrent observation and interview on 11/9/21 at 12:29 PM, in resident's room, Certified Nursing Assistant (CNA) 2 was setting up the lunch tray for Resident 25 . The lunch tray consisted of pasta, baked chicken, and spinach. Resident 25 stated, I like a little bit of sauce. CNA 2 acknowledged the pasta served did not have sauce and stated, There's no sauce. During an interview on 11/9/21 at 12:35 PM with CNA 1, CNA 1 acknowledged that Resident 7's pasta did not have sauce and stated, No sauce. It's plain. During an observation on 11/9/21 at 12:38 PM, in resident's room, Resident 16 was eating lunch consisted of pasta, baked chicken, and spinach. The pasta served for Resident 16 did not have sauce on it. During a concurrent observation and interview on 11/9/21 at 12:41 PM, in the dining room, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 6 of 11 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 555813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Oaks Nursing Center 3635 Jefferson Avenue Redwood City, CA 94062 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 13 was eating lunch consisted of pasta, baked chicken, and spinach. CNA 1 acknowledged there was no sauce on Resident 13's pasta. During a test tray with the Dietary Supervisor (DS) on 11/9/21 at 12:41 PM, DS said the lunch menu for the day consisted of baked chicken, pasta with creamy italian sauce and spinach. Test tray for the regular diet consisted of baked chicken, pasta with creamy italian sauce and spinach. The test tray for the pureed diet consisted of pasta and spinach. The food served had a watered down flavor. During a concurrent interview, DS stated, It's bland. No taste. During an interview with the DS on 11/10/21 at 9:46 AM, DS stated, The problem is, when the recipe is not followed, the taste is compromised. Review of facility policy titled Meal Service dated 2018 indicated, .Procedure .8. Nursing personnel will serve the trays immediately upon checking the tray to be sure nothing is missing from the tray . 2. During food production observation on 11/9/21 beginning at 9:51 AM, it was noted kitchen staff (KS) was preparing creamy italian sauce in a large pot. KS placed the following ingredients into the pot without measuring: two slices of butter, flour, milk, ground oregano, basil leaves, black pepper, salt and garlic powder. During a concurrent interview, KS said that the butter was about three ounces. KS did not taste test the sauce. Review of standardized recipe for Creamy Italian Sauce listed ingredients as margarine, pepper, italian seasoning, salt, all-purpose flour and milk; with their corresponding measurements for 24 servings. During another food production observation on 11/9/21 starting at 10:08 AM, it was noted KS was preparing the marinade for brown sugar baked chicken. In a small stainless bowl, without measuring, KS placed and mixed the following ingredients : oil, fresh garlic, paprika, ground oregano, salt and black pepper. KS also put three tablespoons of dark brown sugar. Furthermore, using his gloved hand, KS scooped and added three handful of parsley flakes to the bowl. With a brush, KS coated 22 pieces of chicken thighs with the marinade mixture. During an interview on 11/9/21 at 10:24 AM, when asked how the ingredients for both recipes were measured, KS stated, I just eyeballed it. During a food production observation on 11/9/21 at 10:28 AM, without measuring the ingredients, KS prepared another marinade for brown sugar baked chicken by combining the following: oil, paprika, black pepper, garlic powder, parsley flakes. A tablespoon of brown sugar was added. With a brush, KS coated 4 pieces of chicken thighs with the marinade mixture. Review of standardized recipe for Brown Sugar Baked Chicken listed ingredients as chicken thighs, oil, brown sugar, paprika, dried oregano, garlic powder, salt and pepper; with their corresponding measurements for 24 servings. Review of the written menu for Week 2 Tuesday lunch for 11/9/21 indicated, .Brown Sugar Baked Chicken .Seasoned Pasta with Creamy Italian Sauce . During an interview with the DS on 11/9/21 at 11:27 AM, DS expected the staff to follow the recipe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 7 of 11 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 555813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Oaks Nursing Center 3635 Jefferson Avenue Redwood City, CA 94062 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 0804 and stated, Follow the measurements also .so that nutrients are there . Level of Harm - Minimal harm or potential for actual harm Review of facility document titled Job Description indicated, Position: [NAME] A .Qualifications: .3. Ability to accurately measure food ingredients and portions .Duties and Responsibilities: 1. Responsible for the preparation of food for .noon meals . Residents Affected - Many Review of facility policy titled Food Preparation dated 2018 indicated, Policy: Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Procedure: .2. Recipes are specific as to .amounts of ingredients .3. Prepared food will be sampled. The Food & Nutrition Services employee who prepares the food will sample it to be sure the food has a satisfactory flavor .4. Poorly prepared food will not be served. Such food is to either be improved, prepared again or replaced . The purpose of using standardized, tested recipes is for consistent food quality and to ensure the best possible food items are produced every time (National Food Service Management Institute, 2017). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 8 of 11 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 555813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Oaks Nursing Center 3635 Jefferson Avenue Redwood City, CA 94062 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on dietetic services observation, dietary staff interview, and dietary record review, the facility failed to ensure dietetic services were implemented in accordance with facility policy and acceptable standards of practice when: 1. A red bucket with chemical sanitizer was directly adjacent to single-use articles; 2. Scoop for uncooked regular rice was kept inside the bin. These deficient practices had the potential to subject residents to foodborne illnesses. Findings: 1. During the initial kitchen tour observation and concurrent interview on 11/8/21 at 10:00 AM with the Dietary Supervisor (DS), a red bucket containing chemical sanitizing solution with a soaked wiping cloth, was stored inside the cabinet together with clean single-use items such as cups and bowls. The DS acknowledged that the chemical solution in the bucket was used for cleaning surfaces and stated, It (the bucket) should not be kept here with the clean items. Review of facility policy titled Sanitation indicated, .Procedure .21. The FNS (Food & Nutrition Service) Director is responsible for instructing employees in the fundamentals of sanitation in food service . 2. During the initial kitchen tour observation in the dry storage room and concurrent interview on 11/8/21 at 10:09 AM with the DS, a scoop was kept inside a white plastic bin that contained uncooked rice. The DS stated, It should not be left inside the bin for infection control. Review of facility policy titled Storage of Food and Supplies indicated, .Policy: Food and supplies will be stored properly and in a safe manner .Procedures for Dry Storage: .6. Dry bulk foods .should be stored in .plastic containers with tight covers .Scoops should not be left in the containers . According to the FDA (Food & Drug Administration) Food Code 2017, .3-304.12 .During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .E. In a clean, protected location if the utensils .are used only with a food that is not time/temperature control for safety food .3-304.14 .E. Containers of chemical sanitizing solutions .in which wet wiping cloths are held between uses shall be stored off the floor and used in a manner that prevents contamination of .single-service or single-use articles . [fda.gov/food/fda-food-code/food-code-2017] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 9 of 11 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 555813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Oaks Nursing Center 3635 Jefferson Avenue Redwood City, CA 94062 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to implement its Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) Program when corrective actions were not developed to address issues about food preparation and food palatability (refers to the taste and/or flavor of the food). (Refer to F804) Failure to develop quality assurance plan and corrective actions had the potential to negatively affect the resident's nutrition and hydration status. Findings: Review of the facility's Resident Council Meeting Minutes dated 8/31/21, indicated, . food is cold when served every meal, served too much food, meat served with bone hard to cut . Review of the facility's Quality Assurance and Assessment/Quality Assurance & Performance Improvement, dated 7/15/21 and 10/27/21, indicated, no corrective actions were developed to address the issues/concerns about food being served to the residents. During an interview with the Administrator (ADM) and Director of Nursing (DON) on 11/10/21, at 1:38 PM, the ADM stated the residents' complaint about food palatability has been on-going and was discussed with the department heads during the stand-up meeting but was not aware there were issues on the standard recipes not being followed. The ADM acknowledged these issues were not discussed in the QAPI/QAA meeting and stated, we did not formally do a root cause analysis of the issue. Review of the facility's policy and procedure titled, Resident Council, dated 04/2017, indicated, .5. A Resident Council Response Form will be utilized to track issues and their resolution. the facility department related to any issues will be responsible for addressing the item(s) of concern. 6. The Quality Assurance and Performance Improvement (QAPI) Committee will review information and feedback from the Resident Council as part of their quality review. issues documented on council response forms may be referred to the QAPI Committee, if applicable (i.e. the issue is of serious nature or if there is a pattern, etc.). Review of the facility's policy and procedure titled, Quality Assurance and Performance Improvement (QAPI) Program, dated 04/2014, indicated, This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. 1. (c) It covers all systems of care and management practices, with priority given to quality of care, quality of life and resident choice. 3. Feedback, data systems and monitoring: a. Systems are in place to monitor care and services. 4. (a) Performance improvement projects (PIPs) are initiated when problems are identified. (b) PIPs involve systematically gathering information to clarify issues and to intervene for improvements. 5. (a) Root Cause Analysis (RCA) is used to determine whether identified issues are exacerbated by the way care and services are organized or delivered, and if so, how. (b) RCA serves as a highly structured approach to fully understanding the nature of an identified problem, its cause and the implications of making changes to improve the problem. QAPI Action Steps 9. Establishing a QAPI Plan that guides quality efforts and serves as the main document that supports the QAPI implementation. 10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 10 of 11 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 555813 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Oaks Nursing Center 3635 Jefferson Avenue Redwood City, CA 94062 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Communicating the QAPI plan and principles to all caregivers, including consultants, contractors and business associates. 13. Gathering and using QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include: . (b) Complaints from residents and families; . 17. Prioritizing identified quality issues based on risk of harm and frequency of occurrence, and determining which will become the focus of PIPs. 18. Planning, conducting, and documenting PIPs. 19. Conducting Root Cause Analysis to identify the underlying issues that contribute to recognized problems. 20. Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply do the right thing. Event ID: Facility ID: 555813 If continuation sheet Page 11 of 11