Health inspection·January 7, 2026

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure the facility front entry door would lock.This failure had the potential to result in a significant security and safety issue potentially endangering the residents, staff and visitors.During an observation on 9/18/25 at 9:57 a.m. the front door of the facility was ajar and unlocked. The survey team was able to access the facility without staff being aware. There was no audible alarm to signify that someone had entered the facility, and the reception area was unattended.During a phone interview with the facility Administrator and Maintenance Supervisor on 9/19/25 at 12:20 p.m. the Maintenance Supervisor and Administrator both stated they did not know the entry door did not lock.During a concurrent observation and interview on 9/19/25 at 12:30 p.m. with the Maintenance Supervisor, the facility front entry door was observed unlocked and ajar. The Maintenance Supervisor was observed from the outside pushing the front entry door close. The Maintenance Supervisor stated once the entry door was closed the locking mechanism did not activate to secure the entry door. The Maintenance Supervisor stated the door did not have an alarm when the door was open to notify staff someone had opened the front door and was walking in the building. The Maintenance Supervisor stated he did not know how long the door lock had been malfunctioning. During the observation the Maintenance Supervisor made the Administrator aware the front door locking mechanism did not work and the entry door did not have an alarm when opened. During an interview and record review with the Maintenance Supervisor on 9/19/25 at 12:45 p.m., the Maintenance Supervisor presented a quote dated 6/12/25 for a commercial door repair. review of the Maintenance logbook dated January 2025 through [DATE], the maintenance logbook did not indicate an entry or request to follow-up for the broken entry door lock. The Maintenance Supervisor stated he did not have access to the prior logbooks. Page 1 of 3 555819 555819 01/07/2026 Elmwood Care Center 2829 Shattuck Avenue Berkeley, CA 94705

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that during a facility COVID outbreak:All staff wore a facemask. This failure had the potential to result in transmission of the respiratory COVID virus.Staff actively monitored visitors entering the facility for hand hygiene, temperature checks, and assessment of respiratory infections(fever, cough, shortness of breath and sore throat). This failure had the potential to result in transmission of the COVID -19 virus.1.During an observation and interview on 9/19/25 at 10:45 a.m. Maintenance Worker (MW)1 was observed walking through the facility not wearing a mask and exited down the stairwell on station 2. With an interpreter MW 1 stated he was not wearing a face mask and did not stop when surveyor wanted to interview him. MW1 stated he knew the facility had a COVID outbreak and he did not have a mask.During an observation and interview on 9/19/25 at 10:45 a.m. a Laundry Aide exited the stairwell onto station 2 and walked over to the time clock. The Laundry aide was not wearing a face mask or name badge. The Laundry aide with an interpreter stated she was not wearing a face mask, and she had the facility COVID education training.During an interview with the Maintenance Supervisor (MS) on 9/19/25 at 11:23 a.m. the MS stated the staff should always wear a mask upon entry and exit from the build during a COVIS outbreak. MS stated the laundry aide and MW 1 names are not on the general in-service record, as he discussed COVID prevention during a staff meeting. He stated he does not keep minutes of his meeting.During an interview and record review on 9/19/25 at 12:00 p.m. with the Infection Preventionist (IP), IP stated a review of the COVID isolation and PPE in-service training sheets dated 9/9/25 and 9/12/25 indicated the Center for Disease Control : Infection control Guidance :SARS-CoV-2 dated June 24, 2024 and the Californian Department of Public Health, Health Associated Infectious Program Recommendations for the prevention and control of COVID-19 .In California Skilled Nursing Facilities 2024-2025 dated 11/2/2024, was reviewed with Certified Nursing Assistance, Registered Nurses and all departments. Review of the in-service training report does not include names or signature for the laundry aide and housekeeping staff. The IP stated staff not receiving in-service training and not wearing a face mask could cause transmission of the COVID outbreak to the residents, staff and visitors.During a review of the Center for Disease Control: Infection control Guidance: SARS-CoV-2 dated June 24, 2024, indicated source control is recommended more broadly by those working or residing on a unit or area of the facility experiencing a SARS-CoV2 or other outbreak of respiratory infection.During a review of the Californian Department of Public Health, Health Associated Infectious Program Recommendations for the prevention and control of COVID-19 .In California Skilled Nursing Facilities 2024-2025 dated 11/2/2024, the policy indicated in the setting of an outbreak, it's essential that the facility has instituted source control masking ( source control masking - the use of masks to cover a person's mouth and nose and to help reduce the spread of large respiratory droplets to others [NAME] the person talks, sneezes or coughs). 2. During observation on 9/18/25 at 9:57 a.m. and 9/19/25 at 9:59 a.m. the facility receptionist area at the door was unmanned with boxes of N95 face mask on the counter with signs indicating visitors are to wear a mask due to the COVID outbreak. There were no staff performing visitor screening or temperature monitoring. There was a book on the receptionist desk for visitors to sign in and answer questions related to symptoms. Observed a visitor entered the facility without putting on a mask or signing in the book.During an interview on 9/19/25 at 10:00 a.m. with the Director of Nursing (DON), The DON stated the receptionist, and several other staff were out due to COVID. DON stated the receptionist area was unmanned at this time, and visitors are to self-sign in. DON stated no one was monitoring visitor self-sign -in.During a review of California Department of Public Health Residents Affected - Few 555819 Page 2 of 3 555819 01/07/2026 Elmwood Care Center 2829 Shattuck Avenue Berkeley, CA 94705

F 0880 Level of Harm - Minimal harm or potential for actual harm Healthcare-Associated Infections Program dated 2024-2025, the document indicated during periods of increased community transmission of respiratory viruses and in the event of an outbreak: implement active screening of visitors for signs and symptoms of respiratory virus infections Residents Affected - Few 555819 Page 3 of 3