Health inspection·October 27, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation. interview, and record review, the facility failed to treat Resident 16, one of 14 sampled residents, with respect and dignity when the residents room door was found closed, and the resident, who was non-speaking, was observed in bed, wide awake, with one blanket, no sheets, or bed pillow, in a bare, two bed room, with minimal furniture, bare walls, with the residents nurse call light on the other side of the room, no drinking water or water pitcher, a bare over-bed table which was standing in the middle of the room and the bathroom door was blocked, from entering the bathroom, with a medium-sized nightstand. This failure had the potential to depress and isolate the resident resulting in mental distress and causing the resident to feel helpless, excluded and outcast from the facility. Findings: Resident 16 was admitted to the facility on [DATE] with diagnoses including dementia (impaired memory and judgement which interferes with daily functioning), kidney disease, depression (feeling of sadness and loss of interest), and high blood pressure. Resident's Minimal Data Set (MDS, an assessment tool) indicated difficulty with cognition (thinking ability), required assistance to eat, and substantial/maximal assistance to bathe, dress, required partial/moderate assistance to reposition in bed, and transfer to chair/bed. Resident spoke very little. In an observation during the initial tour on 10/23/23, at 9:45 AM, Resident 16's room door was closed. Resident's room doors on either side of the hall were open. After knocking on the door, identifying myself, and asking for entrance and no reply, I opened the door slightly. Peeking in the room and asking for permission to enter again. The Resident did not speak, she was in bed, eyes wide open and looking apprehensive, holding the edge of the one blanket on her bed up to her neck. The bed was situated at an angle in the room and not in it's bed space. There were no sheets on the bed, no pillow on the bed, no nurse call light within reaching distance. The call light was located hanging on the wall above the second bed's area. The resident's over-bed table was bare and raised to the highest height and standing in the middle of the room blocking the path into the room. There was no drinking water or water pitcher in the room. The room walls were bare. There was minimal furniture in the room. A medium-sized bed night stand had been placed in front of the door to the bathroom, blocking entrance into the bathroom. The resident never replied to any inquiries. In an interview on 10/23/23 at 10:00 AM, CNA (Certifed Nurse Aide) 1 was questioned why the resident had no drinking water, no reachable nurse call light, no bed pillow and why was the bathroom door blocked? The CNA did not respond to my questions and proceeded to move the resident's nurse call light hanging on the wall on the other side of the room to attach to Resident 16's bed side rails. He stated she did not use her call light but agreed the call light should be in reachable distance. CNA 1 went to bring resident drinking water, a bed pillow with pillowcase, and moved the night stand from blocking the residents bathroom door. In an observation on 10/23/23, starting at 12:45 PM, in the dining room, Resident 16 was observed dressed and sitting at dining table, with other residents, being fed by a staff member, and consuming her meal. She spoke little. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 2 of 21 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 10/27/2023 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 0557 Level of Harm - Minimal harm or potential for actual harm In an observation on 10/26/23 at 1:30 PM, Resident 16 was in her room in a patient gown and pacing in her room with door closed. She looked disheveled. In an observation on 10/27/23 at 11:20 AM, Resident 16 was in her room sitting on bed in patient gown with door closed. Her hair was uncombed and her face looked unwashed. She did not speak when spoken to. Residents Affected - Few In a consecutive interview , CNA 1 stated resident was sleepy and did not want to get up. In an interview with Director Of Nurses (DON) on 10/27/23 at 11:30 AM, when questioned why Resident 16 was not dressed and in activity room? DON stated she would be looking into the matter and addressing the problem today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 3 of 21 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 10/27/2023 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to accomodate resident needs for Resident 127, one of 14 sampled residents, when the resident, who is bed-bound, had an improperly functioning television since his admission, over ten days ago. Residents Affected - Few This failure had the potential to cause the resident feelings of depression (feeling of sadness and loss of interest), frustration, and resentment. Findings: Resident 127 was admitted to facility on 10/12/23 with diagnoses including cellulitis (serious bacterial skin infection), with draining wounds to both knees, arthritis, diabetes (elevated levels of sugar in the blood), and muscle weakness, due to medically complex conditions. Resident could not walk or stand and was restricted to bed. During an observation on the initial tour, 10/23/23 at 10:30 AM, Resident 127 was lying in bed, not moving, on his back, looking up at the television which he stated only receives one station. He stated he was annoyed that he could not view other stations. He stated he told the facility engineer about the problem before he went on vacation but the television was not fixed. During an interview on 10/23/23 at 2:35 PM, Director of Nurses (DON) stated the facility engineer had gone on vacation and would be back in a month. Review of the Maintenance Service policy, revised December, 2009, indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment .1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .i. Providing routinely scheduled maintenance service to all areas . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 4 of 21 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 10/27/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, environment when the women's bathroom, in the main hallway of the facility, was not working properly for four days and there was no maintenance personnel available to maintain equipment. This failure had the potential to cause frustration, impatience, and disappointment for staff, visitors, and residents who utilize and require facility services. Findings: In an observation on 10/23/23, at 10:35 AM, the facility women's bathroom located in the main hallway of the facility did not work properly. During an interview with the Director of Nurses (DON) on 10/23/23, at 11:15 AM, DON stated the facility Engineer went on vacation last Friday, 10/20/23, for one month. The DON stated another Engineer will be coming today. In an observation on 10/24/23, at 10:00 AM, the women's bathroom in the main hallway was not working properly. The Engineer did not arrive yesterday, 10/23/23. During a concurrent interview with the DON, DON stated the Engineer was expected today. In an observation on 10/24/23 at 3:00 PM, the Engineer did not arrive today. In an observation on 10/25/23 at 10:15 AM, the women's bathroom was not working properly. During a concurrent interview with the DON, she stated the Engineer was expected today. During an observation on 10/25/23, at 10:40 AM, a contractor arrived. He was asked to repair the women's bathroom. In an observation on 10/26/23 at 9:45 AM, the women's bathroom in the main hallway was not working properly. During an observation and interview with the DON, on 10/26/23 at 1:30 PM, an Engineer arrived. He was asked to fix the women's bathroom. Review of facility policy on Maintenance Service indicated, Maintenance Service shall be provided to all areas of the building, grounds and equipment. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 5 of 21 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 10/27/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to create a baseline care plan based on Admitting orders for one of three residents (Resident 3) reviewed when Resident 3 admitted [DATE] with Diagnosis of Cancer (abnormal cells) of the Breast, had no initial care plan. This failure could result in Resident 3 not getting the follow up care needed for Cancer treatment. Findings: A review of Resident 3's admission Record dated, 10/26/23, indicated, admitted to facility on 9/26/22 with diagnosis of Malignant Neoplasm of Unspecified site of Right Female Breast (Cancer of the Breast). A review of Nutrition/Dietary Note, Initial Assessment 9/27/22, indicated, admitted with Cancer of the Breast. On 12/2/22 , weight trending down since admit. On 9/29/23, RD indicated, weight loss continues. No care plan by RD to include Cancer of the Breast. A review of the facility Care Plan, initiated 10/2/22, no care plan found to address Diagnosis of Breast Cancer and its treatment plan and follow up visits. A review of Interdisciplinary (IDT, group of healthcare professionals working together towards their client's goals) Note, dated 2/20/23, indicated, Oncology recommendation for Palliative Care Consult. During an interview on 10/25/23 at 2:00 PM with the Medical Director (MD), MD stated, not aware of the recommendation from Oncologist, Resident has Breast Cancer as diagnosis. When patient has gradual loss, we monitor, we do bloodworks, recheck weights, dietician consult etc. Will consider Hospice at sometime .This gradual loss is Unavoidable, its probably the progression of the disease. During an interview and concurrent chart review on 10/25/23 at 2:29 PM, with the Director of Nursing (DON), DON stated, Care plan does not address Breast Cancer as diagnosis. I don't see one in the chart. During a review of facility document, titled, Care Plans- Baseline dated 12/2016, indicated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty eight (48) hours of admission. 2. The Interdisciplinary Team will review the healthcare practitioners' orders (e.g., dietary needs, medications, routine treatment, etc) and implement limited to : a. Initial goals based on admission orders; b. Physician's Orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 6 of 21 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 10/27/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview, and record review, the facility failed to revise the fall care plan for one of three sampled residents (Resident 9) after her fall incident on 7/29/23 and 8/3/23. Residents Affected - Few This failure had the potential not to prevent from another fall. Findings: Review of Resident 9's clinical record indicated, Resident 9 was admitted to the facility with diagnoses including dementia (memory loss), anxiety disorder (a mental health illness characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), restlessness and agitation (extreme motor activity or inner restlessness). Review of Resident 9's clinical record titled, SBAR (Situation, Background, Assessment, Recommendation) and Progress Note for COC (Change of Condition) dated 7/29/23 indicated, . unwitnessed fall . 07/29/2023 . At around 1930 (7:30 p.m.), resident found on the floor . unable to determined what happened. Denies pain, no skin discoloration noted . no change in LOC (Level of Consciousness, a resident's level of arousal and awareness) . Resident able to ambulate with assistant . Review of Resident 9's clinical record titled, SBAR (Situation, Background, Assessment, Recommendation) and Progress Note for COC (Change of Condition) dated 8/3/23 indicated, . Witnessed fall . 08/03/2023 . Resident had witnessed fall approximately 1300 (1:00 p.m.) Resident was in the dining room and got upset and punch staff on the chest when staff tried to help her. Resident knees buckled and fell . no injury noted no redness or swelling noted . resident was able to walk without c/o (complains of) pain . During a concurrent interview and record review on 10/26/23 at 11:56 a.m. with Infection Preventionist (IP), IP stated there was no care plans for Resident 9's fall after she fell on 7/29/23 and 8/3/23. IP acknowledged, Nothing . There is no updated care plan, when asked. IP stated, When the patient fell, do assessment then they should update the long-term care plan . They should have a care plan . when asked. IP stated, Resident 9 was often agitated. IP stated, Because of her behavior . She self-ambulates . when she is upset, she punches the staff, then falls . when asked. IP verified, Resident 9 did not have an injury due to her falls. During a concurrent interview and record review, on 10/26/23 at 1:35 p.m. with IP, Resident 9's MDS (Minimum Data Set, an assessment tool), dated 6/13/23 was reviewed. The MDS indicated, BIMS (Brief Interview for Mental Status, a tool used to screen and identify the cognitive condition of residents) Summary Score was 99. IP stated, 99 means she was not able to complete the interview because she is confused due to dementia, when asked. Review of the facility's P&P titled, Fall and Fall Risk, Managing, revised in March, 2018 indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . Review of the facility's P&P titled, Care plans, Comprehensive Person-Centered, revised in December (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 7 of 21 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 10/27/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 2016 indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met . Event ID: Facility ID: 555813 If continuation sheet Page 8 of 21 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 10/27/2023 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide discharge summaries for two (Resident 24, Resident 25) of three discharged patients reviewed when Residents 24 and 25 did not have discharge summaries in their clinical records. This failure had the potential for residents not to have follow up care in their homes and could lead to a lack of continuity of care in the community. Findings: 1. A review of Resident 25's facility document, admission Record, dated 10/26/23, indicated, Resident 25 was .admitted to facility on 6/8/23 with diagnoses including: Fracture of T11-T12 Vertebra (compression fracture of the bottom part of the thoracic spine), Dizziness (a sense of disorientation or lightheadedness), Osteoarthritis (a type of degenerative joint disease with symptoms of joint pain and stiffness) . discharge date : [DATE]. A review of Resident 25's facility document, Order Summary Report, order date range 6/8/23-9/1/23, indicated, RNA program 3x/week x 3 months (1). Ambulate pt using FWW with supervision as tolerated, (2). Perform BUE/BLE active range of motion exercises in all available planes as tolerated Start date 6/28/23, end date 9/28/23. A review of Resident 25's clinical documents, Progress Notes, undated, indicated, Resident picked up by caregiver and out on pass. There was no follow up documentation. Facility has no Social Services at this time to interview. An interview and concurrent chart review on 10/26/23 at 12:25 PM, with the Director of Nursing (DON), DON stated, Patient went out on pass on 8/30/23, picked up by caregiver. No further documentation, licensed nurse is not here anymore. No social services to interview. No discharge summary in the chart. A review of Resident 25's nursing weekly notes, dated 8/26/23, indicated, resident is independent with ADLs. Discharge Planning review on 6/11/23, indicated, 'Discharge to another LTC (long term care) center'. No discharge note found. 2. A review of Resident 24's facility document, admission Record, dated 10/26/23, indicated, Resident 24 was . admitted on [DATE] with admitting diagnoses including: Syncope and Collapse ( known as fainting or passing out, a loss of consciousness), Hypoglycemia (low blood sugar), Presence of Artificial Hip Joint, bilateral . discharge date : [DATE]. A review of Resident 24's facility document, Order Summary Report, date range 10/1/23-10/31/23, indicated, May discharge home 10/6/23 with HH RN/PT/OT with DME: wheelchair, walker. A review of Resident 24's Physical Therapy Discharge summary, dated [DATE], indicated, Bed mobility: Mod Independent, Transfer -sit to stand: Mod Independent, Gait: SBA with FWW, 80 ft. Patient progress: Patient made consistent progress with skilled interventions. Patient requested to DC home. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 9 of 21 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 10/27/2023 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 0661 Level of Harm - Minimal harm or potential for actual harm An interview and concurrent chart review on 10/26/23 at 11:30 AM, with the DON, DON stated, Patient admitted [DATE], I can't find discharge notes, when patient was discharged . No social services last month till now .Per PT notes on 10/5/23, patient is supervised for all ADLs, independent with toileting and dressing. Has a [family member] who lives with patient. PT recommends HH referral. No SS notes on discharge planning. There is no Discharge Summary in chart. Residents Affected - Some A review of facility document, Transfer or Discharge, Preparing a Resident for, dated 12/2016, indicated, A post-discharge plan is developed for each resident prior to his /her transfer. This plan will be reviewed with the resident, and family at least twenty four( 24) hours before the resident's discharge or transfer from the facility. Nursing Service will be responsible for: a. Obtaining orders for discharge or transfer, as well as the recommended discharge service and equipment; b. preparing the discharge summary and post-discharge plan; d. providing the resident or representative with required documents,(i.e. Discharge Summary and Plan ). h. completing discharge note in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 10 of 21 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 10/27/2023 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to post the daily Staffing Assignment Schedule, in a prominent place, at the beginning of each shift, in a clear and readable format, accessible to residents and visitors, when the schedule was kept stored in a binder, behind the nurses desk, on a shelf, instead of an easily located place for everyone, etc., to find and read. Residents Affected - Few This failure had the potential for visitors, family, staff, residents, etc., not to find the appropriate assigned staff who should provide needed care to a resident and could lead to inadequate care to residents. Findings: In an observation on 10/23/23 at 10:20 AM, there was no visible posting of the Staffing Assignment Schedule, in a prominent place, at the nurses station near the facility entrance. During a consecutive interview with the Director of Nurses (DON), she stated she would locate the Staffing Assignment Schedule and post it. In a consecutive observation of the DON, she found a binder located behind the nurses station filed on a shelf. She located the Staffing Assignment Schedule after looking through the pages of the binder. She posted it on the counter of the nurses station. Review of the facility policy on Postings Direct Care Daily Staffings Numbers, revised 7/2016, indicated, Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents . 1. Within two hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs), directly responsible for resident care will be posted in a prominent location(accessible to residents and visitors) and in a clear and readable format . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 11 of 21 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 10/27/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure medical supplies were not expired when review of stored medical supplies showed some supplies had an expired date. This failure would have resulted in questionable integrity of the medical supplies and deliver poor quality of care to the residents. Findings: During a review of stored medical supplies on [DATE], at 2:30 PM, accompanied by the Director of Nursing (DON) it was discovered that: One Tuberculin syringe had expired [DATE], 30 packets Veltassa oral suspension (treats high blood potassium) 8.4 gm (gram, a unit of measure) pack had expired October, 2023, Eleven (11) catheter stabilization devices (PICC Plus) had expired [DATE], Forty-three (43) specimen collection kit swabs (throat cultures) had expired [DATE], (300 + 6) Accuchek Fast Clix (lancing devices) had expired Nov. 2021, (100) 3 cc [NAME] syringe without needles had expired [DATE], Five [NAME] Control Solution for glucose test strips, 3 milliliters, 1 per box, had expired October, 2023. In a consecutive interview with the DON, she stated she would discard the expired medical supplies. Review of facility policy on Storage of Medications indicated: Outdated, contaminated, discontinued or deteriorated medications or cracked, soiled or insecure closures are immediately removed from stock . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 12 of 21 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 10/27/2023 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on dietetic staff observations, dietary staff interview and departmental document review the facility failed to ensure employment of a full-time qualified individual to manage and oversee dietary services. Residents Affected - Few Failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with physician's orders and standards of practice may jeopardize the health and well being of the 30 residents in the facility. Findings: During initial tour of dietetic services on 10/23/23, Dietary Staff 2 (DS 2) indicated the was the cook for the next meal as well as the supervisor for the kitchen staff. It was also noted on the door leading to the office the facility posted a county required food handler's certificate. In an interview with the Registered Dietitian on 10/24/23 beginning at 2:10 PM., the surveyor asked her to describe the qualification for Dietary Staff 2 (DS 2). The RD acknowledged she was aware DS 2 was not qualified to hold the position in accordance with regulatory requirements. The RD also stated while she had approached her to take the required educational/testing courses she had not done anything further. In an interview on 10/25/23 at 10:30 AM, Dietary Staff (DS) 2 stated she was a certified nursing assistant (CNA) by training and when initially hired was fulfilling that role. DS 2 further stated that she has worked in a local general acute care hospital as a diet aide. DS 2 indicated the facility used to have a qualified person for daily kitchen oversight, but at one point that person stopped coming to work at which point the facility Administrator, at the time, assigned her to the kitchen since she had some dietetic services working experience. DS 2 indicated her passion was working as a CNA but also felt if she wasn't there to work in the kitchen, residents wouldn't get fed. DS 2 indicated she has been working in this capacity since March 2023. Review of facility document titled Director of Food Services dated 2003 listed qualifications as .Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association and experience as a .minimum of five (5) years experience in a supervisory capacity in a hospital, nursing care facility, or other related medical facility . Review on 10/24/23 at 4:30 PM of DS 2's employee file revealed the employment application was listed as a CNA position. In addition, competencies that were included in the employee file were intended for the necessary skills required of a CNA. There was no Administrator employed by the facility during the survey timeframe of 10/23/23-10/27/23 as he resigned on 10/20/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 13 of 21 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 10/27/2023 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 Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on food production observations, dietary staff interview and dietary department document review the facility failed to ensure adequate staffing and staff competency when 1) dietary department staffing did not allow for adequate food production staff which resulted in the Director of Food Services routinely covering food production positions/duties and 2) Dietary Staff 1 was unable to demonstrate proper thermometer use and 3) Dietary Staff 1 did not prepare meals in accordance with standardized recipes. Failure to ensure adequate staff and staff competency may result in meals not prepared in accordance with resident preferences and acceptable standards of practice further compromising medical status. Findings: 1. During initial tour on 10/23/23 beginning at 9:30 AM, Dietary Staff 2 introduced herself as the Director of Food Services. DS 2 also indicated she was covering for the [NAME] as the person who was scheduled to cook was ill. DS 2 indicated for this morning it would be herself and one diet aid responsible for all food production activities for breakfast and lunch. DS 2 also indicated the evening cook would be coming at 11 a.m., to help out. Concurrent review of the posted weekly employee schedule revealed DS 2 was routinely scheduled with food production duties. In an interview on 10/24/23 beginning at 2:00 PM, DS 3 was observed coming to work. In a concurrent interview DS 3 stated she also worked in another licensed facility and was not readily available for any additional shifts. DS 3 stated she had limited availability to work at this facility. In an interview on 10/24/23 beginning at 2:10 PM, the Registered Dietitian (RD) indicated she was contracted for 15 hours per month. The RD indicated her primary duties were limited to the provision of clinical nutrition care and the monthly sanitation inspection. The RD indicated she would check with Dietary Staff 2 and do a brief walk through during weekly visits. The RD indicated while the facility may need additional RD hours, she has not asked the Administrator for increased contract hours. In an interview on 10/25/23 at 10:30 AM, DS 2 indicated she needed to cover the duties of the cook's helper today as that person was on leave. The surveyor asked DS 2 to describe the dietary department staffing schedule. DS 2 stated she has routinely asked the Administrator for additional staff, however, has not heard anything. DS 2 indicated there was no relief cook or relief diet aid positions which meant that either employees were working with limited or no days off or she would fill in for the position. Additionally, DS 2 stated she was often required to work as the cook or as the cook's helper since she knew if she didn't come residents would not get fed. DS 2 also stated there were no relief or per diem positions built in the schedule when staff were ill or on leave. DS 2 also expressed concern in a few months one staff member would be going out on leave and she would be the only available coverage. There was no Administrator onsite for interview during the survey as he resigned his position effective 10/20/23. Review of facility document titled Facility Assessment dated January 2022 under Component 1: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 14 of 21 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 10/27/2023 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 Resident Population Listed Dietary Services as a dietary services manager, registered dietitian and support staff. There was no indication the facility assessed the number and/or positions required to effectively run the department. Also, under Component 2: Center Resources failed to assess staffing needs to ensure delivered dietetic services were in accordance with the needs of the resident population as well as accepted standards of practice. Residents Affected - Some 2. The standard of practice would be to ensure thermometers are utilized in accordance with manufacturer's specification. For accurate temperature measurement, the probe of the bimetallic-coil thermometer must be inserted the full length of the sensing area (usually 2 to 3 inches). In contrast a digital thermometer has the semiconductor in the tip, and can measure temperature in thin foods, as well as thick foods (USDA Food Safety and Inspection Services). During general food distribution observations on 10/24/23 at 11:55 AM, Dietary Staff 1 (DS 1) was observed taking the temperature of a slice of pork, by inserting the thermometer vertically into the slice of meat, each piece measuring roughly 3/8 inch deep, using a bimetallic coil thermometer. In a concurrent observation there was a yellow digital thermometer lying on the counter. In a concurrent interview the surveyor asked DS 1 if he received training in the use of thermometers. DS 1 replied he received training on thermometer calibration, however, was not trained on the different types of thermometers. In a concurrent interview DS 2 confirmed staff received training on thermometer calibration. In an interview on 10/24/23 beginning at 2:10 PM, the Registered Dietitian (RD) indicated she relied on DS 2 to do in-service training of staff. The RD also stated if an issue is identified during the monthly sanitation rounds it was addressed at that time with staff and DS 2. Review of training documents beginning February 2023 revealed while staff received training there was no training or competency evaluation on the different types of thermometers present in the facility and the proper use of each type. 3. A standardized recipe is a set of written instructions used to consistently prepare a known quantity and quality of food for a specific location. A standardized recipe will produce a product that is close to identical in taste and yield every time it is made, no matter who follows the directions (University of Pennsylvania Press). During initial tour on 10/23/23 beginning at 9:20 AM, in the outdoor freezer there were four packages of unlabeled, frozen meat, which were flat, tan colored packages. In a follow up observation and interview on 10/24/23, beginning at 10:00 AM, it was noted two of four packages remained in the freezer. The other two were gone. DS 2 identified the remaining packages as pork belly. DS 2 also indicated the other two items are being used for the noon meal. During general meal production observation on 10/24/23 beginning at 10:15 AM, and concurrent review of the daily menu revealed the noon meal was listed as pacific rim pork roast, pacific rim gravy, red beans and rice, carrots with parsley, and apple bread pudding. During the observation DS 1 stated the pork for the meal was in the oven. The pork was sliced and in the oven with a small amount of clear liquid. In a concurrent interview DS 1 stated it was broth to keep the meat moist. It was also noted there were diced carrots on the portable steam table. DS 1 stated the carrots were completed at approximately 10 AM. DS 1 had also placed plain brown rice and in a separate steam pan of beans on the steam table. DS 1 confirmed the beans were a canned baked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 15 of 21 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 10/27/2023 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 Residents Affected - Some bean product. DS 1 also stated he completed the meals early since he was going to help DS 2 in putting away groceries. During meal plating observation on 10/24/23 beginning at 11:55 AM, DS 1 began serving the meal. It was noted the prepared meal was not consistent with the standardized recipe. The pork was heated with broth and plated with the pacific pork rim gravy on top. It was also noted the meat slices had a significant amount of fat running through them. It was also noted during meal plating DS 1 served an individual ½ cup of brown rice as well as an individual ½ cup of baked beans. In an interview on 10/24/23 beginning at 2:10 PM, the Registered Dietitian (RD) indicated her primary role was to complete the clinical nutrition care of residents. The RD stated she did a monthly sanitation check and would check in with DS 2 when she was in the building. The RD indicated she was in the building 15 hours per month. Review of the departmental document titled Pacific Rim Pork Roast guided staff to prepare a marinade, place the pork roast and cover and refrigerate for a minimum of two hours, preferably overnight. It was also noted the recipe called for a boneless pork roast, loin or leg. Review of departmental document titled Red Beans and Rice guided the staff to prepare the starch by sautéing onions, celery, brown rice as well as additional spices and green peppers, then adding chicken broth and red beans. Similarly, the recipe titled Carrots with Parsley guided staff to cook the carrots using salt for 10-20 minutes, then add melted margarine and parsley flakes. Review of departmental documents titled Consultant Dietitian Report dated 4/30, 5/31, 6/30, 8/31 and 9/30/23 failed to identify staff did not consistently use standardized recipes. Facility position description titled Cook guided cooks to .Prepare food in accordance with standardized recipes . Review on 10/25/23 at 4:15 PM, of Dietary 1's employee file revealed the facility could not demonstrate comprehensive training and/or orientation of DS 1 to the cook's position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 16 of 21 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 10/27/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on meal distribution observations, dietetic staff interview and departmental document review the facility failed to ensure meals were distributed in accordance with resident preferences and physician ordered diets when 1) staff did not follow a vegetarian menu/plan and 2) three residents with physician ordered mechanical soft received the same lettuce as those on regular diets in a feeding census of 29. Failure to ensure residents receive meals in accordance with approved menus may result in compromising nutritional and/or medical status. Findings: During meal distribution observation on 10/23/23 and 10/24/23 beginning at 12:00 PM, it was noted dietary staff were not following the menu written for physician ordered diets. On 10/23/23 there was one resident whose preference was a vegetarian diet. Dietary 3 plated the meal as ½ cup of pasta, 1 slice bread, ½ cup zucchini and 2 slices cheese. Similarly, during the noon meal on 10/24/23 the vegetarian diet's meal plate was limited to ½ cup brown rice, ½ cup beans and ½ cup carrots. It was also noted residents on physician ordered mechanical diets should have received a tossed salad where the lettuce was chopped. In a concurrent observation it was noted the lettuce was placed in bowls. The pieces of lettuce were not consistent in size, while some met the ½ inch size, as outlined on the menu, others were larger. In an interview on 10/24/23 at 1:00 PM, Dietary Staff 1 acknowledged he used a bag of pre-washed lettuce and placed it in bowls directly from the packaging. In an interview on 10/24/23 beginning at 2:10 PM, the Registered Dietitian described her typical duties as primarily completing the clinical nutrition care of residents. The RD stated she also briefly checks the kitchen at each visit and completes a monthly sanitation report. The RD stated she believed the facility had a vegetarian menu and would expect staff to follow it. The RD also stated with the exception of portion sizes she has not identified any issues related to accuracy of meal delivery. Review of undated departmental document titled Vegetarian Menus listed the intent of the menu was to make the vegetarian diet as close to the regular menu as possible. It also guided staff to select a vegetarian product from the selection of available vegetarian entrees. The departmental document titled Spreadsheet for Vegetarian guided staff to follow daily vegetarian alternatives by replacing the meat entree with a selected vegetarian entree following the provided recipe. Review of departmental training dated 2/22/23 indicated staff was trained on the preparation of .D. Mechanical Soft Diet . which indicated while the mechanical soft diet consists of nearly regular textures some foods must be chopped, ground or shredded to make them easier to chew of swallow. Departmental policy titled Meal Service Accuracy dated 1/6/20 indicated meal service accuracy refers to .b. The resident receives the consistency of the diet prescribed by the physician . Review of departmental document titled Diet Type Report printed 10/24/23 revealed there were 3 residents with physician ordered mechanical soft diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 17 of 21 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 10/27/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure hot food was served that is palatable, in proper temperature and appetizing texture, when test tray temperature was not in range per policy. Residents Affected - Some This practice had the potential to negatively impact the resident's dining experience which may result in poor dietary intake potentially compromising health and nutritional status of 30 residents. Definitions: 1. Food palatability - refers to the taste and/or flavor of the food acceptable to the taste. 2. Proper (safe and appetizing) temperature - both appetizing to the resident and minimizing the risk for scalding and burns. Findings: The guidance per the State Operations Manual (SOM) Appendix PP dated 2/3/23, from the Centers for Medicare and Medicaid Services (CMS) indicated, food should be palatable, attractive, and at a safe and appetizing temperature as determined by the type of food to ensure resident's satisfaction. Appendix PP also indicated, providing palatable, attractive and appetizing food and drink to residents helps encourage residents to increase the amount they eat and drink. During the resident council meeting on 10/23/23 at 2:14 PM, Resident 18, stated,food palatability has been ongoing issue for last 3 weeks since she has been here. Resident 8, stated, food palatability has been ongoing for last 3 months. During an observation and concurrent interview on 10/24/23 at 1:13 PM, with Dietary Staff 2, a test tray, reflecting a regular and pureed diet, was conducted near room [ROOM NUMBER] and 9. The test tray temperatures were taken by DS 2 using the facility's thermometer. Recorded temperatures were as follows: For regular tray: meat - 129 degrees Fahrenheit, rice- 131 degrees Fahrenheit, bean - 128 degrees Fahrenheit, carrot - 131 degrees Fahrenheit. For pureed: carrot - 100 degrees Fahrenheit, meat 102 degrees Fahrenheit, rice- 97 degrees Fahrenheit, beans - 126 degrees Fahrenheit. DS 2 stated, the facility's policy is that meal hot food temperature should be at goal at 150 degrees Fahrenheit. During the test tray on 10/24/23 at 1:13 PM, the pureed food was sticky, had no taste and was cold. The regular food, meat was salty, rice sticky and carrots were soggy. Review of the facility's document titled, Meal Service, dated 2018, 3. Hot food serving temperature must be at or above minimum holding temperature of 140 degrees Fahrenheit . 7. Temperature of the food when the residents receive it is based on palatability. The goal is to serve cold food cold and hot food hot. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 18 of 21 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 10/27/2023 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and, record review, the facility failed to ensure food safety standards of practice when 1) frozen meat was thawed using water with no system for time/temperature control monitoring; 2) use of sanitizer that was not in accordance with manufacturer's recommendations; 3) use of drying cloth on cleaned/sanitized food production equipment and utensils; 4) lack of an air gap in food production related equipment; 5) lack of overall kitchen cleanliness; 6) storage of unlabeled, undated and spoiled foods; and 7) presence of an open rodent bait station. Failure to implement and maintain food safety standards may put the facility census of 30 residents at risk for foodborne illness or contamination of food which may result in decreased intake and weight loss further compromising medical status. Findings: 1. The standard of practice when thawing meats is to ensure time/temperature control for food safety. There are several ways in which meat can be thawed, one of which would be to utilize running water as a method. When using running water, the food product cannot remain in the temperature danger zone (41 degrees to 140 degrees Fahrenheit) for more than four hours, which includes the time the food is thawed. Food safety also dictates when water is used as the thawing method the product must be used immediately. In the outdoor freezer there were four frozen tan-colored items resembling meat. Each piece measured approximately 12 (inches) long, 5 wide and 1-1/2 thick. During an observation and concurrent interview on 10/24/23 at 10:00 AM, it was noted two of the tan colored meats were gone. Dietary Staff (DS) 2, stated the remaining tan colored meat was pork belly. DS 2 further stated the other 2 pieces of meat are being used in the noon meal. During food production observation on 10/24/23 beginning at 10:30 AM, it was noted Dietary Staff (DS) 1 was preparing the noon meal which consisted of soy glazed pork. In a concurrent interview, DS 1 indicated the meat was fully thawed when he arrived. During an observation and concurrent interview on 10/24/23, at 3:00 PM, DS 4 indicated it takes 2 days to thaw frozen meats and to ensure meats are ready to use the following day she routinely thawed under running water. The surveyor asked whether during the process was there any time/temperature monitoring. DS 4 indicated there was no system for thawing under running water. DS 4 also stated as an example, she was the evening cook yesterday and the meat for the evening meal on 10/24/23 was frozen. DS 4 indicated she thawed the meat using water yesterday evening, and once it was thawed placed it in the refrigerator to use this evening. DS 4 confirmed there was no time/temperature monitoring for food safety during the thawing process when using water as the thawing method. Review of the facility document, titled, Food Preparation. Policy: Thawing of Meats indicated, 3. Submerge under running, potable water at a temperature of 70 degrees Fahrenheit or lower, with a pressure sufficient to flush away loose particles. The policy did not reflect the current standard of practice to monitor time/temperature. 2. During general kitchen observations and concurrent interview on 10/24/23 beginning at 10:30 AM, with DS 1, the surveyor inquired how he cleaned food production surfaces. DS 1 stated he used a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 19 of 21 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 10/27/2023 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 - Many sanitizer from the red bucket which was dispensed from a pump station located on the wall above the 2-compartment sink. DS 1 indicated he used the solution to wipe down counters and patient meal carts then allowing it to air dry. DS 2 indicated the chemical was placed by the facility's chemical vendor. Manufacturer's instructions from the chemical vendor received on 10/25/23 at 2:46 PM, listed conditions of use as To disinfect food service establishment or restaurant food contact surfaces .Apply solution with a cloth, sponge or hand pump trigger sprayer so as to wet all surfaces thoroughly. Allow the surface to remain visibly wet for 10 minutes, then remove excess liquid and rinse the surface with potable water. Do not use on utensils, dishes, glasses or cookware. 3. Food safety requires that cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils (Food Code, 2023). During dishwashing and pureed food preparation observation on 10/25/23 at 11:00 AM, DS 2, picked up the cleaned and sanitized blender and wiped it with a microfiber cloth. DS 2 was also observed using paper towels to wipe the inside of beverage cups. A review of facility document, Pot and Pan Washing, dated 2018, indicated, Policy: Pots and pans will be properly sanitized .Allow items to AIR DRY ONLY. Do not wipe dry. 4. The standard of practice is to ensure food production related equipment is installed in a manner that includes an air gap. Food production related equipment would include food production sinks and ice machines. An air gap is a physical separation between a potable and non-potable system. A rule-of-thumb dictates that air gaps should be not less than one inch. This method is both the simplest and most effective for preventing back siphonage and backflow (Food Code 2023). During a general kitchen observation and concurrent interview on 10/25/23, at 10:00 AM, it was noted there were no air gaps for ice machine or the food production sink. The food production sink was plumbed directly into the wastewater system. The ice machine condensation line was connected to a plastic pipe which went through the exterior wall and was connected directly to a grey water outlet. Greywater is wastewater from non-toilet plumbing systems such as hand basins, washing machines, showers, and baths. DS 2 stated, this is an old building, there are no air gaps in this building. 5. The standard of practice is that equipment, food-contact surfaces, nonfood-contact surfaces, and utensils are clean to both sight and touch. Non-food contact surfaces shall be kept free of an accumulation of dust, dirt, food residue, and other debris (Food Code, 2022). During kitchen observation on 10/25/23, at 10:00 AM, the interior of multiple drawers had unidentified dried on food particles and areas with a yellow sticky substance. In addition, the lower cabinet doors also had unidentified dried on food particles, an accumulation of dark grey material resembling dust and a grey grease-like substance on the handles and cabinet front protrusions. During an interview on 10/25/23 at 10:00 AM, DS 1 stated, After cooking I clean the countertops and equipment I used, no schedule for cleaning the drawers and cabinets. During a review of facility document, titled, Sanitation, dated, 2018, indicated, 9. All utensils, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 20 of 21 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 10/27/2023 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 - Many counters, shelves and equipment shall be kept clean, maintained, in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas . During a review of facility document, tilted, Cabinets and Drawers, dated 2018, indicated, Clean cabinets and drawers on a weekly basis. 1. Use mild detergent per manufacturer's instruction and water. Removable drawers should be removed and washed. Rinse shelves and drawers with a clean sponge and dry. 2. Do not use contact paper to line drawers or shelves. Drawers can be lined with plastic net liner. 6. During the initial tour observation on 10/23/23, beginning at 9:30 AM, the following was noted: a. In the outdoor freezer there were four frozen tan-colored items resembling meat. Each piece measured approximately 12 (inches) long, 5 wide and 1-1/2 thick. There were also four opened packages of meat, resembling cooked chicken, that were unlabeled/undated. Additionally, there were two packages of frozen beef, each weighing approximately five pounds that were unlabeled/undated. b. In refrigerator #1, spoiled cabbage in a grocery bag with black spots, resembling decaying product. There was also green and yellow peppers with black dots as well as celery in a sealed plastic bag with a slimy, milky fluid. During an observation and concurrent interview on 10/24/23 at 10:00 AM, Dietary Staff (DS) 2, stated, they are meat products, diced chicken and grilled chicken thigh It should be labeled and dated. It was also noted two of the tan colored meats were gone. DS 2 stated these items were pork belly which was used in the noon meal. It was also noted in the outdoor refrigerator there were two packages of beef, identified, by DS 2 as stew meat, which were fully thawed. DS 2 also stated our supply comes every Tuesday; we replace them when supplies come. During a review of facility document titled, Labeling and Dating of Foods, dated 2020, indicated, Policy: all food items in the storeroom, refrigerator, and freezer need to be labeled and dated Newly opened food items will need to be closed and labeled with an open date and used by date that follows guidelines Produce is to be dated with received dates. During a review of facility document, Procedure for Refrigerated Storage, dated 2019, indicated, 15. Produce will be delivered frequently and rotated in the order it is delivered to assure that a fresh produce is used, free of any wilting or spoilage. 7. The standard of practice is to ensure rodent bait stations shall be contained in a covered, tamper-resistant bait station (Food Code, 2022). During a general kitchen observation on 10/25/23, at 10:00 AM, there was an open mouse trap found behind the ice machine. In a concurrent interview, DS 2 stated she was unaware the bait station was there. DS 2 also indicated Ecolab puts those traps in the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555813 If continuation sheet Page 21 of 21