Health inspection·April 8, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide adequate assistance to perform the activities of daily living for one of 13 sampled residents (Resident 17) when two staff assistance was not provided to assist Resident 17 during repositioning. Residents Affected - Few This failure had the potential to harm the resident who had impaired mobility. Findings: Review of the medical record for Resident 17 indicated he had brain injury, impaired mobility and multiple facility acquired pressure ulcers. The MDS (Minimum Data Set - an assessment tool used to direct care) for activities of daily living (ADL), dated February 24, 2022, indicated Resident 17 was dependent on two or more staff to turn him side to side in the bed. During an observation on 4/4/22 at 10:00 a.m., CNA 1 was observed from the hallway, alone, providing care for Resident 17. During an interview on 4/4/22 at 10:30 a.m., CNA 1 stated she cleaned up Resident 17 During an observation on 4/6/22 at 9:45 a.m. during a bed bath for Resident 17, CNA 1 strained to roll and push Resident 17. Resident 17 was unassisted on his left side while CNA 1 washed his back. CNA 1 did not ask for any help from staff. Resident 17 was awake, non-verbal, and unable to hold himself for support. CNA 1 left Resident 17 on his left side unattended when she walked to the sink to pour the dirty water from the basin. During an interview on 04/07/22 at 9:34 a.m., CNA 1 stated Resident 17 was heavy, hard to turn when by herself. CNA 1 stated Resident 17 cannot move on his own. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 2 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm During an observation, interview and medical record review, the facility failed to provide wound treatment for one of one sample residents (Resident 17) when Resident 17's pressure injury to the right lateral thigh was not covered with dressing as ordered by the physician. Residents Affected - Few This failure had the potential to delay healing and worsen the wound condition. Findings: During an observation on 04/06/22 at 9:45 a.m., CNA 1 positioned Resident 17 on his left side exposing his back side for the nurse (ICN) to clean and change a wound dressing on the buttock. On the right lateral thigh, there was a round indentation with an open wound bed that was exposed. During an observation and concurrent interview on 04/06/22 at 10:20 a.m., the Infection Control Nurse (ICN) prepared Resident 17's supplies at the treatment cart for the dressing change of the buttock wound. ICN set up her supplies at the bedside and completed the dressing change on the buttock. Then, the ICN identified the indentation to the right lateral thigh. ICN described the indentation as a lesion and superficial. ICN could not explain why it did not have a dressing and stated it needed to be covered. The ICN then gathered her supplies, measured the wound to be 1 cm wide by 1 cm length. The depth was not measured. The ICN then cleansed the area, applied antibiotic and placed a dressing. Review of the physician order dated 03/30/22 indicated Right lateral thigh lesion-cleanse with normal saline, pat dry, then apply triple antibiotic ointment and dry dressing one time a day until resolved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 3 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and document review, for three (Residents 14,9, and 18) of eight residents prescribed with psychotropic medication (capable of affecting the mind, emotions, and behavior), the facility failed to: 1. For Residents 14, the target behavior for Olanzapine (antipsychotic medication that is used to treat psychotic conditions) use was not monitored 2. For Resident 18, the target behavior for Divalproex Sodium (medication used to treat seizure disorders and certain psychiatric conditions), Melatonin Tablet (supplement for sleep aid) and Quetiapine Fumarate medication used to used to treat certain mental/mood disorders) use was not monitored. 3. For Resident 9, the target behavior for Lexapro (medication used to treat depression and anxiety) use was not monitored. These failures had the potential to delay identification of serious or even life-threatening adverse effects of psychotropic medications and prolonged unnecessary medication use. Findings: 1. During a review of the medical record for Resident 14, his diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of the physician order dated 2/12/22 indicated an order for Olanzapine tablet 5 milligrams at bedtime related to dementia in other diseases classified elsewhere without behavioral disturbance. Review of the Care Plan revised 3/12/22 indicated to monitor/record occurrence of target behavior symptoms by grabbing staff while providing ADL (activities of daily living) care. Further review indicated there was no record that indicated target behaviors were monitored. During an interview and concurrent medical record review on 04/07/22 at 12:03 PM, the Director of Nursing (DON) stated Resident 14's target behavior grabbing staff should be documented in the Medication Administration Record (MAR). The DON stated she expects nurses to monitor these behaviors. 2. During a concurrent interview and record review, on 4/5/22, at 2:05 p.m. with DON, Resident 18's Order Summary Report, dated 4/5/22 was reviewed. Order Summary Report indicated that Resident 18 had the following orders for psychotropic medications: Divalproex Sodium ER Tablet Extended Release 24-hour 500 mg give four tablets by mouth at bedtime for mood stabilizer, Melatonin Tablet 5 mg one tablet by mouth at bedtime for sleep aid and Quetiapine Fumarate tablet 200 mg give one tablet by mouth at bedtime related to schizoaffective disorder-bipolar type. The DON stated that behavior for the psychotropic medication should be monitored in the MAR to determine if a resident still needs the medication or if it needs to be tapered. DON stated that when there were no behavior monitoring, they could not determine if the medication was effective. DON stated that behavior monitoring for the three psychotropic medications were not on the chart and in the MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 4 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 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 0758 Level of Harm - Minimal harm or potential for actual harm 3. During a concurrent interview and record review, on 4/5/22 at 2:34 p.m., with the DON, Resident 9's Order Summary Report, dated 4/5/22 was reviewed. The Order Summary Report indicated that Resident 9 was on Lexapro Tablet 10 mg one tablet by mouth at bedtime for Depression manifested by crying. The Order Summary Report did not include an order for monitoring of behavior for Lexapro use. The DON stated that monitoring behaviors for psychotropic use would determine if medication were effective. Residents Affected - Some During a review of Resident 9's Care Plan, (undated), the Care Plan indicated, Resident 9 uses antidepressant (type of psychotropic) medication Lexapro tablet 10 mg. The goal of the care plan includes The resident will show decreased episodes of s/sx [signs/symptoms] of depression m/b [manifested by] crying. The interventions in the care plan included to monitor and document side effects and effectiveness every shift. During a review of the facility P&P titled, Antipsychotic Medication Use, dated December 2016, the P&P indicated, The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 5 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of 13 sample residents (Resident 3), was free from significant medication error when higher dose than the physician ordered was administered to Resident 3 for Seroquel (medication used to treat certain mental/mood disorders) Residents Affected - Some This failure placed Resident 3 at risk for adverse effect associated with the medication. Findings: Review of the medical record for Resident 3 indicated a diagnoses that included an altered mental status. Review of the physician order with a start date of 12/23/20 indicated an order for Seroquel 100 milligrams, give 1.5 tablet (total of 150 mg) by mouth at bedtime for delusions and hallucinations. During an interview on 4/8/22 at 10:25 a.m., Certified Nursing Assistant (CNA) 4 stated Resident 3 used be combative, attack and pull off CNA 4's mask during care a long time ago. CNA 4 stated Resident 3 was much calmer now. Review of the Medication Regimen Review (MRR, an evaluation of the medication regimen of a resident, with the goal of promoting outcomes and minimizing adverse consequences and potential risk associated with medication) dated 2/1/22 indicated the pharmacist evaluated the order dated 12/23/20 for Seroquel 150 mg. The pharmacist recommended to the physician to evaluate the current dose and to attempt a dose reduction of the Seroquel. Further review of the MRR indicated the physician responded to the recommendation with Condition stable: Attempt dose reduction to Seroquel 100 mg, oral, during hours of sleep. Review of the March and April MAR showed Resident 3's order was Seroquel tablet/100 mg/give 1.5 tablet by mouth at bedtime for delusions and hallucinations. Further review of the MAR indicated the licensed nurses were administering 150 mg of Seroquel for the month of March and April. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 6 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 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 - Many 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. Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately when: 1. Expired medications were stored in the medication cart and medication refrigerator. 2. Expired emergency kit (e-kit, a kit that contain a small quantity of medications that can be dispensed when pharmacy services are not available) were not replaced. 3. Temperature logs for the medication refrigerator were incomplete and there was no thermometer and temperature log for the medication room and the storage shed. 4. A bottle of Acidophilus (supplement to help restore the normal balance of intestinal bacteria) and a bottle of Lorazepam (a psychotropic medicine used to treat anxiety) was not stored in the refrigerator. 5. Food items were stored in the medication refrigerator. 6. A Humalog pen (medication used to treat diabetes) had no name and date opened on it. This failure had the potential for expired medications and less potent medication to be administered to all the residents in the facility. Findings: 1. During a concurrent observation and interview on 4/6/22, at 10:25 a.m., Director of Staff Development (DSD), the medication refrigerator was checked and there were two syringes of Energix B vaccine (Vaccine against infection caused by all known subtypes of hepatitis B virus) that were expired. DSD stated that the expiration date was 11/12/21 and it should have been discarded. During an observation on 4/6/22, at 2:28 p.m., the medication cart was observed to have the following expired medications: a. a bottle of anti-diarrheal 2 milligram (mg, a unit of measurement) expired on 9/21 b. a bottle of Robitussin DM 100 mg/5mL, expired on 2/22 c. Microdot glucose gel, expired on 11/21 During an interview on 4/6/22, at 2:28 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that the expired medications should not be in the cart. During a review of the facility's P&P titled, Medication Storage: Storage of Medication, dated 9/18, the P&P indicated, All outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures of medication disposal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 7 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 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 2. During a concurrent observation and interview on 4/6/22, at 11:11 a.m., with DON, the Intravenous (IV) supply e-kit was expired on 6/31/21 and the Schedule III drugs (CIII- drugs, substances, or chemicals are defined as drugs with a moderate to low potential for physical and psychological dependence) e-kit was expired on 4/1/21. The CIII e-kit contained the following expired medications: Residents Affected - Many a. Four Tylenol # 3 (pain medicine) 300/30 mg, expired on 2/22 b. Eight Klonopin (medicine used to treat the symptoms of seizures and panic disorder) 0.5 mg, expired on 4/21 c. Four Restoril (used to treat insomnia) 7.5 mg, expired on 5/21 d. Eight Ultram (pain medicine) 50 mg, expired on 5/21 e. Four Ambien (used to treat insomnia symptoms) 5 mg, expired on 5/21 DON stated that the e-kits should not be expired and that they should call the pharmacy when they need the e-kits to be replaced. During a review of the facility's P&P titled, Storage of Medications, dated April 2017, the P&P indicated, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 3. During a concurrent observation and interview on 4/6/22, at 9:53 a.m., with the DON, the medication room (med room) was observed to not have a thermometer inside. DON stated that there should be a thermometer inside the med room. DON also stated that they were not logging the temperatures for the med room. During an observation on 4/6/22, at 10:00 a.m., in the storage shed at the back parking lot, it was observed that shed did not have any thermometer inside. The following medications were stored inside the shed: Clearlax, Oyster Calcium with vitamin D, Melatonin and Sodium Bicarbonate. During an observation on 4/6/22, at 10:25 a.m., the temperature logs for the medication refrigerator was incomplete for January 2022, February 2022, and March 2022. During an interview on 4/7/22, at 7:32 a.m., with the DON, DON stated that it is important to monitor temperature in medication storage areas because most medicine bottle would indicate 'keep in room temperature'. DON stated that if not stored in room temperature it would decrease the potency of the medications. During a review of the facility's P&P titled, Medication Storage: Storage of Medication, dated 9/18, the P&P indicated, Medications requiring storage at room temperature are kept at temperatures ranging from 15°C (59°F) to 30°C (86°F). A daily recorded temperature should be documented and signed off. 4. During a concurrent observation and interview on 4/6/22, at 2:28 p.m., with LVN 1, it was observed that a bottle of Acidophilus was stored on the top drawer of the medication cart. Review of the manufacturer label indicated Refrigerate after opening to help maximize potency. LVN 1 stated that the bottle should be stored in the refrigerator. It was also observed that an opened bottle of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 8 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 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 Lorazepam 2 mg/ml liquid was stored in the narcotic box. Blue sticker instruction by the pharmacy on the plastic container indicated Keep refrigerated. During an interview on 4/6/22, at 2:35 p.m., with DON, DON stated, if the medication was not refrigerated it would make the medication less potent. Residents Affected - Many During a review of the facility's P&P titled, Medication Storage: Storage of Medication, dated 9/18, the P&P indicated, Medication requiring refrigeration are kept in a refrigerator with a thermometer to allow temperature monitoring. A daily recorded temperature should be documented and signed off. 5. During a concurrent observation and interview on 4/6/22, at 10:25 a.m., with the DSD, it was observed that two pink pitchers were stored on the door of the medication refrigerator. DSD stated that one pitcher had orange juice and one pitcher had milk. DSD stated that they were for the resident in case they would request for it at nighttime. During a review of the facility's P&P titled, Storage of Medications, the P&P indicated, Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medication must be stored separately from food and must be labeled accordingly. 6. During a concurrent observation and interview on 4/6/22, at 2:28 p.m., with LVN 1, one Humalog pen with no name and date when it was opened was stored on the top drawer of the med cart. LVN 1 stated that there should be a name on the pen and the date opened should written on it. During a review of the facility's P&P titled, Medication Storage: Storage of Medication, dated 9/18, the P&P indicated, Note the date on the label for insulin vials and pens when first used. During a review of the facility's P&P titled, Labeling of Medication Containers, dated April 2007, the P&P indicated, Labels for individual drug containers shall include all necessary information, such as: a. Resident's name. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 9 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interviews, and review the facility failed to ensure that open dates were indicated on food items in the kitchen. Residents Affected - Some This failure placed the 13 of 13 sampled residents at risk for food borne illnesses. Findings: During an observation of the kitchen on 4/4/22, at 9:09 a.m., the following food items were observed opened and did not have an open date: 1. A bag of cabbage and a bag of carrot in the fresh fruit and vegetables refrigerator. 2. Two boxes of thickened juice, a box of almond milk, a box of soy milk and a box of cranberry juice in Refrigerator 2. 3. Seven slices of bread in a bag in Refrigerator 1. 4. five burger patties in a bag in freezer 2. 5. a bag of elbow macaroni, a bag of egg noodles and eight cookies in a container in the dry storage shelf. During an interview on 4/4/22, at 11:35 a.m., with Dietary Supervisor (DS) stated, it is important to put an open date to determine if a food item was still good or it needs to be discarded or expired. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2020, the P&P indicated, Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. P&P also indicated, Newly opened food items will need to be closed and labeled with an open date and used by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 10 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and document review the facility failed to ensure infection control procedures were followed for handling of clean and dirty laundry and the manufacturer's guideline for using a disinfectant wipe for medical equipment was not followed. Residents Affected - Some These failures had the potential to transmit microorganisms and spread possible infection among the residents. Findings: 1. During an observation and concurrent interviews on 04/06/22 at 2:00 p.m., Certified Nursing Assistant (CNA) 2 entered the laundry room (Door 2). There was an adjacent door (Door 1) with a sign of Soiled. CNA 2 placed a bag full of laundry on the floor around a taped border in front of the washer. CNA 2 stated she normally entered Door 2 to deposit dirty laundry. Further inspection through Door 2 showed one clothes dryer and one washer with a taped border. In front of the washer, inside of the taped border were two bags (large and small). Laundry Personnel (LP) stated the large bag of laundry were wet and clean. LP stated she was waiting to put them in after clothes in dryer finished its cycle. The LP identified the small plastic bag as the dirty laundry. During an observation and concurrent interview on date 04/06/22 at 2:07 p.m., CNA 3 entered Door 2 and placed a bag full of laundry in between the large (clean) and small (dirty) bags of laundry. The bags touched each other. CNA 3 stated she usually entered Door 2 to place dirty laundry inside the taped border. CNA 3 stated she does not enter Door 1, the one labeled Soiled. CNA 3 stated all the bags on the floor were dirty because it was inside the outline on the floor, in front of the washing machine. During an interview on date 04/06/22 at 2:12 P.M., Infection Control Nurse (ICN) stated she was unaware staff entered Door 2 to bring in dirty laundry. ICN stated this practice was not appropriate. ICN stated staff should enter Door 1, labeled Soiled to place dirty laundry in bins to prevent cross contamination and the spread of infection. ICN stated the clothes in the large bag (washed) should be placed on a cart. Review of the undated policy and procedure titled, Laundry Department, it indicated soiled linen must not come into contact with the floor, not come into contact with clean linen at anytime, shall transfer linen as soon as the wash process is completed and cleaned/disinfected carts shall be used to move linen from the washer to the dryer. 2. During an observation on 4/6/22, at 8:10 a.m., LVN 1 did not disinfect the medication tray after use. During an observation on 4/6/22, at 8:30 a.m., LVN 1 disinfected the blood pressure (BP) cuff (instrument measuring blood pressure) for 20 seconds and disinfected the medicine tray for 17 seconds after being used. During an observation on 4/6/22, at 8:45 a.m., LVN 1 disinfected the BP cuff for 23 seconds, disinfected the medication tray for 19 seconds and did not disinfect the stethoscope that was used to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 11 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some check the patency of a gastrostomy tube (GT, a surgically placed device used to give direct access to stomach for supplemental feeding, hydration, or medication.) for Resident 10. During an observation on 4/6/22, at 11:43 a.m., LVN 1 did not disinfect the glucometer (small portable machine that's used to measure how much glucose [a type of sugar] in in the blood) that was used to check the blood sugar of one resident. The glucometer was placed in a plastic container. LVN 1 did not disinfect the plastic container after being brought in the resident's room. During an observation on 4/6/22, at 11:56 a.m., LVN 1 entered an isolation room to check the blood sugar of Resident 12 and brought in the plastic container containing the blood glucose monitoring supplies. LVN 1 disinfected the glucometer for 34 seconds and disinfected the plastic container for 46 seconds. During a concurrent interview and record review on 4/8/22, at 8:05 a.m., with Infection Control Nurse (ICN), the manufacturer's guideline for the germicidal medicinal disinfectant wipes was reviewed, the manufacturer's guideline indicated, contact time: Allow to remain wet two (2) minutes, let air dry. ICN stated that the wet time should be followed for the wipes to clean items adequately. ICN stated that if a resident care equipment was not disinfected it could cause cross contamination. During a review of the manufacturer's guideline in cleaning the glucometer, manufacturer's guideline indicated, cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. Manufacturer's guideline also indicated, to use a wipe remove from container and follow product label instructions to disinfect the meter. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated December 2021, the P&P indicated, Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During a review of the facility's P&P titled, Isolation-Categories of Transmission Based Precautions, dated January 2012, the P&P indicated, Resident-Care Equipment: when possible, dedicate the use of non-critical resident-care equipment items such as a stethoscope, sphygmomanometer, bedside commode, or electronic rectal thermometer to a single resident (or cohort of residents) to avoid sharing between residents. P&P also indicated that if use of common items is unavoidable for Resident-Care Equipment, the equipment shall be cleaned and disinfected before use for another resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 12 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and document review, the facility failed to provide Resident 19 a functioning call light. Residents Affected - Few This failure resulted in Resident 19 to receive delayed care. Findings: During the resident council meeting on 04/05/22 at 10:30 a.m., a resident stated the call light did not work in her/his room. The resident stated staff did not come when the call light was pressed. During an observation and concurrent interviews, on 04/06/22 at 9:40 A.M., Resident 19 sat in a wheelchair in her room. The call light outside the room was not illuminated. Resident 19 stated she pressed her call light, was waiting for help however, staff took a long time to respond. Resident 19 stated she wanted help from the nurse to give her Ensure (nutritional supplement drink) before she left for a family visit. The DON was called to demonstrate the use of Resident 19's call light. The DON discovered the call light did not work when she pressed the button. The assigned CNA 1 stated she was not aware the call light did not work. During an interview on 04/06/22 at 12:30 P.M. the Maintenance Supervisor (MS) stated he did not know about Resident 19's broken call light until he was told to fix it today. During an interview and concurrent document review on 04/06/22 at 12:40 P.M., the Facility Manager (FM) stated she was not aware of the broken call light for Resident 19. FM stated if anything needed repairs, it should be written in the Communication Binder. Review of the Communication Binder did not indicate a broken call light. The FM stated the MS would then review the concerns and input an electronic work order (in TELS) requesting service. FM directed the MS to follow this process from now on. Review of the policy, titled Work Orders, Maintenance, dated April 2010, indicated maintenance work orders shall be completed in order to establish a priority, filled out and forwarded to the Maintenance Director. The supply orders is maintained at each nurse's station and requests placed in the appropriate file basket, picked up daily. Emergency requests will be given priority in making necessary repairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 13 of 14 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 555842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jones Convalescent Hospital 524 Callan Avenue San Leandro, CA 94577 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide a safe and functional environment for one of 13 sampled residents (Resident 1) when the sink used by Resident 1 in her bathroom had a water leak and water spilled on to the floor. This failure had the potential for Resident 1, who had a risk for falls, to slip and cause injury. Findings: During an observation on 04/04/22 at 10:07 a.m., a pink bath basin, filled halfway with water was underneath the leaky sink in room [ROOM NUMBER]. During an observation on 04/04/22 at 11:00 a.m., Resident 1 was in the room, stood alone at the sink washing her face. During an observation on 04/06/22 at 12:03 p.m., there were wet paper towels underneath the sink in room [ROOM NUMBER], no basin. During an interview on 04/04/22 at 11:10 a.m., Resident 1 stated the sink always leaked. Resident 1 stated she fell on the floor coming out of the bathroom over a week ago at night when it was dark. The resident stated she now has back pain from that fall. Review of the medical record indicated Resident 1 had an unwitnessed fall on 3/26/22 and 07/24/21. The care plan indicated Resident 1 was a high risk for fall related to unsteady gait. During an interview on 04/08/22 at 10:25 a.m., Certified Nursing Assistant (CNA) 4 stated the the sink in room [ROOM NUMBER] always leaked and becomes more wet when Resident 1 used it because the water splashed everywhere. CNA 4 stated maintenance was aware of the leak. During an interview on 04/06/22 at 12:30 p.m., Maintenance Supervisor (MS) stated he was not aware of the leaky sink in room [ROOM NUMBER]. MS stated he could repair the leaky sink if someone told him and no one did. During an interview and concurrent document review on 04/06/22 at 12:40 p.m., the Facility Manager (FM) stated she was not aware of the leaky sink in room [ROOM NUMBER]. FM stated if anything needed repairs, it should be written in the Communication Binder. Review of the Communication Binder did not indicate a problem in room [ROOM NUMBER]. The FM stated the MS would then review the concerns and input an electronic work order (in TELS) requesting service. FM directed the MS to follow this process from now on. Review of the policy, titled Work Orders, Maintenance, dated April 2010, indicated maintenance work orders shall be completed in order to establish a priority, filled out and forwarded to the Maintenance Director. The supply orders is maintained at each nurse's station and requests placed in the appropriate file basket, picked up daily. Emergency requests will be given priority in making necessary repairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 14 of 14