Health inspection·January 25, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Resident Rights, dated 2001, indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with kindness, and dignity; Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 2 of 16 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 01/25/2024 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview with facility Nursing and Administrative staff, the facility failed to ensure that 1 sampled resident (10) out of 19 sampled residents had her needs accommodated while using her own wheelchair. This failure resulted in this resident not having a wheelchair which did not accommodate this resident's needs and preferences, which had the potential to result in decline and resident harm. Residents Affected - Few Findings: During a medication pass observation on 1/23/2024 at 9:30 am, Resident 10 was observed being administered her morning medications while sitting in her wheelchair. The who has multiple contractures (validated by facility administrative staff interview), had been sitting in her wheelchair with her neck, head and back not supported in any way. The resident's wheelchair had been made to tilt backwards, but the resident's back, neck, and head were not touching the wheelchair's back, and this appeared to be very uncomfortable for the resident who had been using her own strength to hold her body up in this wheelchair. The resident's wheelchair had been missing a head rest support which had originally come with this wheelchair (according to the DON). In addition, the resident's feet and legs had been dangling in an awkward position and this wheelchair's feet rests had been removed from the wheelchair making it difficult for the resident to adjust herself in the wheelchair so that she could sit comfortably in this wheelchair. Interview with the facility's Administrator and the DON on 1/23/2024 at 9:55 am revealed that neither of them knew where the back/neck support for this wheelchair had gone and neither of them knew what had happened to the resident's feet rests were. During the interview with the facility's DON, the DON confirmed that this resident's current wheelchair had not been accommodating this resident's needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 3 of 16 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 01/25/2024 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review for 2 (Resident 11 and 22,) of 19 sampled residents, the facility failed to ensure that Resident 11 and 22 had received Restorative Nursing Assistance (RNA) treatments as ordered by the resident's physician. Residents Affected - Few This failure had the potential to result in this resident's decline, which could result in the resident's decrease in muscle strength, decreased range of motion, contractures, and possible decline in function. Findings 1: Review of Resident 22's medical record on 1/25/2024 at 8:50 am revealed that this resident had a physician's order for Restorative Nursing Assistance (RNA). The physician order which had been written on 12/15/2023 read: RNA program every day (QD) 3 times per week for 90 days for (bilateral upper extremities) BUE (active assisted range of motion) AAROM as tolerated to maintain current level of function (CLOF). Further review of Resident 22's medical record revealed that this resident had not received treatment from the RNA program between 12/15/2023 and 1/23/2024, which resulted in this resident not receiving RNA services for 39 days, despite the physician's order. Interview with the facility's DON on 1/25/2024 at 8:55 am revealed that the reason why RNA services had not been provided to this resident for almost 40 days straight, was because the facility had been short on CNA staff during this time. She further stated that the facility's only RNA had been asked to cover CNA shifts making her unable to cover her RNA duties. Interview with Resident 22 on 1/22/2024 at 12:45 pm revealed that this resident had been having anxiety because she had not been assisted with increasing/strengthening her mobility since her Physical Therapy had ended on 12/19/2023. This resident also indicated during the interview, that she had been becoming depressed because the facility had not been assisting her with her mobility/strength training along with her inability to have the facility assist her with getting out of bed. The resident had expressed some concern about potential skin breakdown because she had not been assisted with getting out of her bed. Findings 2: During a review of Resident 11's admission Record, dated 1/23/24, the record indicated Resident 11 was admitted 4/2023 with multiple diagnosis that included acute and chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), chronic pain syndrome (pain that lasts for over three months) and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). During a review of Resident 11's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 1/5/24, the MDS indicated Resident 11's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information), was 15 (a BIMS score of fifteen is an indication of intact cognitive status). During an interview on 1/22/24, at 11:11 a.m., with Resident 11, Resident 11 stated that they have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 4 of 16 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 01/25/2024 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not received any rehab or exercise and as a result their range of motion has not improved. Resident 11 stated they were really upset about it. During a concurrent interview and record review on 1/24/24, at 11:33 a.m., with RNA 1, Resident 11's Doctor's Orders and Progress notes were reviewed. Resident 11's Doctor's Orders indicated, an active order, dated 8/31/23, RNA program QD 3xwkx90days (every day three times a week for 90 days) for maintaining AROM (assistive range of motion) of BLE (bilateral lower extremities), sit to stand transfers, and stand pivot transfers to maintain current functional mobility level. Resident 11's progress notes indicated Resident 11 did not participate in the RNA program from 12/7/23 to 1/23/24. RNA 1 stated residents remained on the RNA program unless there was a change in the resident's range of motion or level of mobility and if a change occurs Resident's would have been referred to Rehab for reevaluation. RNA 1 stated Resident 11 did not have any changes in range of motion or mobility and should have continued in the RNA program. RNA 1 stated that they didn't do the RNA program with Resident 11 from 12/7/23 to 1/23/24 because she was busy working as a CNA (Certified Nursing Assistant) on the floor. During a concurrent interview and record review on 1/24/24, at 12:46 p.m., with Rehab Director of Rehab (DOR), Residents 11's Doctor's Orders were reviewed. DOR stated RNA orders should have continued with no end date unless there was a decline or improvement, and Rehab would have assessed the resident at that time. DOR stated, based on Resident 11's Doctor's Orders, Resident 11 should have been on the RNA program from 12/7/23 to 1/23/24. During an interview on 1/25/24, at 12:05 p.m., with RNA 1, RNA 1 stated the RNA program was important for residents to keep their level of functioning. During an interview on 1/25/24, at 1:53 p.m., with Director of Nursing (DON), DON stated when residents missed their RNA program they were at risk for decreased mobility. DON stated the RNA program was important because it helped prevent falls, injuries, and contractures. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, revised July 2017, the P&P indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. The P&P indicated, Restorative goals may include, but are not limited to supporting and assisting the resident in: a. Adjusting to changing abilities; b. Developing, maintaining or strengthening his/her physiological and psychological resources; c. Maintaining his/her dignity, independence and self-esteem; and d. Participating in the development and implementation of his/her plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 5 of 16 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's policies and procedures, the facility failed to: Residents Affected - Some 1) Ensure that all expired or outdated medications were available for administration to 2 sampled residents (2 and 3) of the facility's 19 sampled residents. 2) Ensure that medications which had been discontinued by the resident's physicians, were no longer available for administration to 1 sampled resident (19) and 1 unsampled resident 1, of the facility's 19 sampled residents. 3) Ensure that medications were available for all residents, as needed, including medications which had been prescribed for unsampled resident 2. 4) Ensure that all medications had been administered as ordered by each resident's physician (Resident 3 and 22). These failures had the potential to put the residents who may have received these medications at risk for medication errors and the potential for harm. Findings: 1) Inspection of the hospital's medication cart on [DATE] at 12:00 pm with the facility's Director of Nurses (DON), revealed two vials of insulin (Novolog, which is used to lower blood sugar in diabetic residents) with open dates of [DATE] which were still currently in use. Review of the facility's policy and procedure entitled: Injectable vials and Ampules, dated 12/2012, reads: Discard multi-dose vials when empty .Expiration dating not specifically referenced in the manufacturer's package insert should not exceed 28 days once the vial has been opened. Concurrent interview with the facility's DON on [DATE] confirmed that these insulin vials had been opened for more than 32 days, which was outside of the facility's drug storage policy above for insulin vials. The DON confirmed during the interview that these vials of insulin should have been discarded prior to our inspection of this medication cart. Review of the facility's policy and procedure entitled: Storage of Medication, dated 9/2018, reads: Outdated, contaminated, discontinued, or deteriorated medications and those in containers are immediately removed from stock, disposed of according to procedures for medication disposal . 2) On [DATE] at 12:09 pm, continued inspection of the facility's medication cart revealed one bubble package of Digoxin 125 micrograms (mcg). Digoxin is used to treat atrial fibrillation [irregular heartbeat and heart failure]. There were 5 tablets left in this bubble pack for unsampled Resident 1. Review of this unsampled resident's physician orders for this resident on [DATE] at 12:15 pm revealed that this medication had been discontinued on [DATE]. The discontinuation of this medication was verified by RN 1 and the DON on [DATE] at 12:15 pm. On [DATE] at 12:30 pm, continued inspection of the facility's medication cart revealed one bubble package of Hydroxyzine HCL (an antihistamine, which is often used to treat allergies, itching, rash, nausea, etc.) 25mg. This bubble pack of Hydroxyzine contained 8 tablets and this medication had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 6 of 16 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm ordered and administered to Resident 19. On [DATE], this medication had been discontinued by this resident's physician, yet this medication remained in the facility's medication cart and available for facility staff to administer this medication even though there was no longer a physician's order for this resident to receive this medication. The discontinuation of this medication was verified by RN 1 and the DON on [DATE] at 12:45 pm. Residents Affected - Some 3) On [DATE] at 8:17 am LVN 1 was observed passing medications to the facility's residents. During the medication pass observation, this Nurse was passing medications to unsampled resident 2. The Nurse mentioned that resident 2, was to receive Atovaqueone oral suspension 750mg/5ml (an antimicrobial used to treat infection) at 7:30 am that morning. LVN 1 indicated that she could not find the Antovaqueone and that she would contact the facility's Pharmacy regarding obtaining this medication. On [DATE], I went back to unsampled resident #2's medical record (Medication Administration Record [MAR]), which confirmed that unsampled resident 2 had not received this medication on [DATE], as ordered by the resident's physician. On [DATE] at 2:42 pm during an interview with RN 2, RN 2 confirmed that LVN 1 had not given unsampled resident 2's Atovaqueone on [DATE] as ordered by the resident's physician. Further review of unsampled resident 2's medical record revealed that on [DATE] with the facility's DON, unsampled resident 2 had not received this same medication on [DATE] and again on [DATE] even though RN 2 had confirmed, in an interview, that Atovaqueone had been brought into the facility by the facility's Pharmacy on [DATE], indicating that this medication was in the facility and could have been given for each of the missed administrations above. Review of the facility's policy and procedure entitled: Medication Administration General Guidelines, dated 9/2018, reads: .Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of scheduled time .The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given .If a dose. 4) Review of the clinical record for Resident 22 and concurrent interview with the facility's DON on [DATE] at 11:01 am revealed that this resident had a physician's order to receive Gabapentin (Neurontin) 100mg three times a day for leg pain. Record review and interview with the facility's DON confirmed that Resident 22 had not received her 2:00 pm dose of Gabapentin on [DATE]. The resident's clinical record did not any explanation as to why this 2:00 pm dose of Gabapentin had not been administered to this resident as ordered, by the resident's physician. Review of the clinical record for Resident 3 and concurrent interview with the facility's DON on [DATE] at 11:10 am revealed that this resident had a physician's order to receive Allopurinol 100mg one time a day for Gout (a type of inflammatory arthritis that causes pain and swelling in your joints). Record review and interview with the facility's DON confirmed that Resident 3 had not received her 9:00 am dose of Allopurinol on [DATE]. The resident's clinical record did not any explanation as to why this 9:00 am dose of Allopurinol had not been administered to this resident as ordered, by the resident's physician. Review of the clinical record for Resident 3 and concurrent interview with the facility's DON on [DATE] at 11:10 am revealed that this resident had a physician's order to receive Aspirin 81mg chewable tablet one time a day for Stroke. Record review and interview with the facility's DON confirmed that Resident 3 had not received her 9:00 am dose of Aspirin on [DATE]. The resident's clinical record did not any explanation as to why this 9:00 am dose of Aspirin had not been administered to this resident as ordered, by the resident's physician. Review of the clinical record for Resident 3 and concurrent interview with the facility's DON on [DATE] at 11:10 am revealed that this resident had a physician's order to receive Benztropine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 7 of 16 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Mesylate (Cogentin) 2mg tablet one time a day for bipolar disorder. Record review and interview with the facility's DON confirmed that Resident 3 had not received her 9:00 am dose of Benztropine Mesylate on [DATE]. The resident's clinical record did not any explanation as to why this 9:00 am dose of Benztropine Mesylate had not been administered to this resident as ordered, by the resident's physician. Review of the clinical record for Resident 3 and concurrent interview with the facility's DON on [DATE] at 11:10 am revealed that this resident had a physician's order to receive Depakote Sprinkle capsule (Valproic Acid) 125 mg 2 capsules one time a day for Dementia, Bipolar Disorder, and Anxiety. Record review and interview with the facility's DON confirmed that Resident 3 had not received her 9:00 am dose of Depakote Sprinkles on [DATE]. The resident's clinical record did not any explanation as to why this 9:00 am dose of Benztropine Mesylate had not been administered to this resident as ordered, by the resident's physician. Review of the clinical record for Resident 3 and concurrent interview with the facility's DON on [DATE] at 11:10 am revealed that this resident had a physician's order to receive Oyster Calcium with Vitamin D3 (Calcium Carbonate Cholecalciferol) 1 tablet one time a day for Calcium Supplement. Record review and interview with the facility's DON confirmed that Resident 3 had not received her 9:00 am dose of Calcium with Vitamin D3 on [DATE]. The resident's clinical record did not any explanation as to why this 9:00 am dose of Calcium with Vitamin D3 had not been administered to this resident as ordered, by the resident's physician. Review of the clinical record for Resident 3 and concurrent interview with the facility's DON on [DATE] at 11:10 am revealed that this resident had a physician's order to receive Risperdal (Risperidone) 1mg two times a day for bipolar disorder. Record review and interview with the facility's DON confirmed that Resident 3 had not received her 9:00 am dose of Risperdal on [DATE]. The resident's clinical record did not any explanation as to why this 9:00 am dose of Risperdal had not been administered to this resident as ordered, by the resident's physician. Review of the clinical record for Resident 3 and concurrent interview with the facility's DON on [DATE] at 11:10 am revealed that this resident had a physician's order to receive Artificial Tears 0.2% solution 1 drop in both eyes three times a day for dry eyes. Record review and interview with the facility's DON confirmed that Resident 3 had not received her 2:00 pm dose of Artificial Tears 0.2% solution on [DATE]. The resident's clinical record did not any explanation as to why this 2:00 pm dose of Artificial Tears 0.2% solution had not been administered to this resident as ordered, by the resident's physician. Review of the clinical record for Resident 3 and concurrent interview with the facility's DON on [DATE] at 11:10 am revealed that this resident had a physician's order to receive Ipratropium-Albuterol (breathing treatment) Solution 3 MG/ 3ML 1 dose every 6 hours for Chronic Obstructive Pulmonary Disease with Acute Exacerbation. Record review and interview with the facility's DON confirmed that Resident 3 had not received her noon dose of Ipratropium-Albuterol Solution 3 MG/ 3ML on [DATE]. The resident's clinical record did not any explanation as to why this noon dose of Ipratropium-Albuterol Solution 3 MG/ 3ML had not been administered to this resident as ordered, by the resident's physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 8 of 16 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 01/25/2024 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 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 observation, interview, and record review, the facility failed to comply with the Federal regulations related to the oversight of food service operations when: Residents Affected - Many a. the facility did not have a full-time dietitian or a full-time dietetic service supervisor. b. dietary staff did not have competencies and training to carry out to carry out Food and Nutrition Services in a safe and sanitary manner. The lack of a full-time, competent supervisor resulted in Food and Nutrition Services staff not having adequate training and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner placed 23 residents who received food from the kitchen at risk for food borne illnesses (illnesses caused by food contaminated with bacteria, viruses, parasites, and toxins) and/or malnutrition. Findings: a. During the initial kitchen observation and interview on 1/22/24 at 10:13 a.m., accompanied by [NAME] (CK) 1 and CK 2, CK 2 stated, Food and Nutrition Services Director (FNSD) works three days per week. CK 2 also stated, there was no manager to check kitchen when FNSD was not working. CK 1 added, Registered Dietician (RD) comes to work in the facility once per month. During an interview on 1/22/24 at 12:43 p.m. with the FNSD, FNSD confirmed he worked three days per week at the facility. FNSD also stated, no one to oversee the kitchen when he was not around. During an interview on 1/25/24 at 9:20 a.m. with the Administrator (ADM), ADM confirmed FNSD and RD were both part-time employees. ADM also stated, FNSD worked Tuesday, Wednesday and Thursdays while RD worked as consultant and comes in once per month. ADM further added, hours worked 30 hours or less per week was considered part-time. During a concurrent interview and document review on 1/25/24 at 10:52 a.m., RD confirmed she worked 3.5 hours for month of November 2023, 6.5 hours for month of December 2023, and 5.5 hours in January 2024. RD also stated, she was employed as a consultant and worked part-time. RD further added, she comes in once per month and spent less than seven hours in a day at the facility. According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a qualified full-time dietetic services supervisor to supervise dietetic service operations. b. During a concurrent observation and interview on 1/22/24 at 10:50 a.m. with DA 1, DA 1 ran the low temperature dish machine through a wash and rinse cycle. When asked to demonstrate use of chemical test strip, DA 1 placed the test strip inside water draining from the machine. DA 1 then stated, she does not use test strip to check for sanitizing level of the dish machine because she did not know how to do it. DA 1 also added, she was not trained how to use chemical test strip to test for sanitizing level. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 9 of 16 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 01/25/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview and document review on 1/22/24 at 1:05 p.m. with DA 1, DA 1 confirmed her entry on the Dish Machine Temperature Log, for two months (12/2023 and 1/2024), were not accurate. DA 1 stated, she did not know how to use chemical test strip because she was not trained. DA 1 further added, she copied what was already written on the log. During a concurrent interview and document review on 1/23/24 at 11:48 a.m. with FNSD, FNSD stated it was his responsibility to ensure kitchen staff have competency skills check upon hire. FNSD did not provide competency training related to DA 1's duties and responsibilities. FNSD further stated, I don't have it, I forgot to do it. During a review of DA 1's employee record titled, Employee Orientation Check List, revealed, DA 1's Date of Hire was 4/24/23. According to the facility's Policy and Procedure (P&P) titled, Job Description, Position: FNS (Food and Nutrition Services) Director, dated 2018, it indicated under duties and responsibilities: .2. Schedule and supervise the Food & Nutrition Service Staff providing in-service training. Assure all food & nutrition service staff are oriented . During a review of the facility's P&P titled, Job Description Position: Dietary Aide, (undated), it indicated Dietary Aide's duties and responsibilities included . 2.f. Dishwshing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 10 of 16 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 01/25/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to follow the correct serving size to one Resident for a census of 23 (Resident 13). Residents Affected - Few This deficient practice resulted in Resident 13 not receiving the appropriate diet portions to meet each individual needs. Findings: During a concurrent tray line observation and interview on 1/22/24, at 12:15 p.m., with [NAME] (CK) 1, CK 1 used a number 8 scoop to a tray of regular texture beef enchiladas, black beans, and cilantro lime rice to serve Resident 13. CK 1 stated, she was aware Resident 13 required small portion servings but did not follow what was on Resident 13's diet card. During a concurrent interview and record review on 1/22/24, at 3:42 p.m., with Food and Nutrition Services Director (FNSD), FNSD was asked why it was the important for CK 1 to follow small portion servings for Resident 13. FNSD stated, I don't know why it's important, do I have to know that . During a concurrent interview and document review on 1/25/24 at 11:01 a.m. with Registered Dietician (RD), RD confirmed Resident 13's diet card servings should be small portions. RD described facility's color-coded portion control chart CK 1 should have used when serving Residents. RD confirmed CK 1 did not follow scoop size as indicated on the chart which showed green scoop number 12 is regular portion equivalent to 2.66 fl oz (fluid ounce - unit of measurement) and blue scoop number 16 is small portion equivalent to 2.00 fl oz. RD further added, Resident 13 should have received small portions of starch and protein because of kidney disease. RD also stated, when dietary recommendations are not met, it can lead to worsening of Resident 13's condition. During a review of Resident 13's face sheet dated, 1/24/24, showed Resident 13 was admitted to the facility in December 2020 with multiple diagnoses that included Chronic Kidney Disease, Stage 4 (Severe), Diabetes Mellitus (DM - a disease in which blood sugar levels are too high) with Diabetic Chronic Kidney Disease and was dependent on renal dialysis (treatment that helps the body remove extra fluid and waste products from the blood when kidneys are not able to). During a review of Resident 13's order summary, dated 1/24/24, revealed a CCHO diet (Consistent, Constant or Controlled Carbohydrate Diet), Renal Diet, regular texture, thin liquid consistency, SMALL PORTION. During a review of the facility's policy and procedure (P&P) titled, Portion Sizes, dated, 2018, it indicated under Policy: Various portion sizes of the food served will be available to better meet the needs of the residents. During a review of the facility's P&P titled, Kitchen Weights and Measures, dated 4/2007, it indicated, .7. The Food Service Supervisor will ensure cooks prepare the appropriate amount of food for the number of servings required. During a review of the facility's P&P titled, JOB DESCRIPTION, dated 2018, the FNS Director's qualifications included, .6. Ability to follow prepared medues and portion control guides.9. Maintain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 11 of 16 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 01/25/2024 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 0805 resident diet card -cardex in order and current . Check trays to ensure diets are served as order. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 12 of 16 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 01/25/2024 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, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: Residents Affected - Many - stainless steel waste can was dirty; - kitchen floor tiles were dirty; - staff did not adequately check for chemical sanitation of dishwashing machine; - plate warmer was dirty; - plates inside plate warmer was dirty; - pair of thermal gloves was dirty; - moldy and unusable foods were not discarded; - food items stored in the refrigerator was unlabeled; - mounted can opener was dirty; - multiple dented cans were stored; - staff did not follow hand hygiene practices; - ice machine was dirty. These failures placed the facility's 23 residents who received food from the kitchen at risk of foodborne illness. Findings: During initial observation of the kitchen on 1/22/23 at 10:13 a.m. accompanied by [NAME] (CK) 1 and CK 2, showed the following: (a) Stainless-steel waste can next to refrigerator was dirty, half-filled and had no plastic lining to hold kitchen waste materials; (b) kitchen floor tiles had multiple thick-sticky black spots; (c) staff did not adequately check for chemical sanitation of low temperature dishwashing machine; (d) inside bottom of plate warmer had grease and multiple black and brown sticky substance; (e) five plates inside plate warmer had black sticky substance, dry food particles, and oil stains; (f) pair of thermal gloves use for hot pans and plates was covered in white dry debris and grease; (g) moldy and unusable foods were stored in the refrigerator (h) food items stored in the refrigerator was unlabeled; (i) mounted can opener had brown and tan matter on its' blade and black accumulation on surrounding parts; (j) multiple dented cans were stored with remaining stock in dry storage room; (k) staff did not perform hand hygiene upon entry to the kitchen; (l) ice machine had black wet spots inside ice compartment and white build up residue inside door opening. During a concurrent interview and observation on 1/22/23 at 10:14 a.m., with CK 2, CK 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 13 of 16 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 01/25/2024 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 Residents Affected - Many acknowledged the dirty waste can and removed from the kitchen. CK 2 added, Dietary Aide (DA) 1 was responsible for ensuring all waste can was clean and emptied daily. During an interview on 1/22/24 at 10:50 a.m. with DA 1, DA 1 stated, she was responsible for cleaning and emptying waste bins in the kitchen but does not include the stainless-steel waste can when cleaning. DA 1, also stated she was responsible for cleaning and mopping the floor daily. When asked regarding multiple black thick-sticky spots on floor tiles near the dish washing areas, DA 1 stated, I don't mop that area, it was too dirty, I feel like if I mop it the mop is gonna get dirty. During a concurrent observation and interview on 1/22/24 at 10:50 a.m., with DA 1, DA 1 ran the low temperature dish machine through a wash and rinse cycle. When asked to demonstrate use of chemical test strip, DA 1 placed the test strip inside water draining from the machine. DA 1 then stated, she does not use test strip to check for sanitizing level of the dish machine because she did not know how to do it. DA 1 also added, she was not trained how to use chemical test strip to test for sanitizing level. During an interview on 1/22/24 at 10:27 a.m. with CK 1, CK 1 confirmed the inside bottom of plate warmer was dirty and stated it does not get cleaned every day. CK 1 further added, it has been a long time since it was cleaned and foil lining has not been replaced for a while. CK 1 acknowledged the five plates inside plate warmer were dirty. CK 1 removed the five plates from the pile of clean plates to be re-washed. During a concurrent observation and interview on 1/22/24 at 10:27 a.m. with CK 1, CK 1 used a pair of dirty thermal gloves, picked up clean hot plates from plate warmer. When asked regarding white debris and grease, CK 1 stated I know it's dirty. CK 1 also stated, the thermal gloves do not get washed often. During a concurrent observation and interview on 1/22/24 at 10:46 a.m. with CK 1, CK 1 removed five of one pound (lbs-unit of measurement) each, containers of molded strawberries, half-used wilted celery placed directly on shelf of refrigerator without protection and without label, open bag of 5 lbs shredded cabbage not labeled. CK 1, acknowledged there were molded strawberries and unlabeled vegetables in refrigerator #3. CK 1 also stated, she does not recall when the vegetable were placed in the refrigerator but it was some time last week. CK 1 further added, all opened food items should be labeled when it was opened so they cannot be used beyond use by. During a concurrent observation and interview on 1/22/23 at 11:13 a.m. with CK 2, 1 can of 6 ounce (oz unit of measurement) diced carrots, 2 cans of 6 oz white beans, 2 cans of 6 lbs diced pears, 2 cans 1 lbs pimento rojo (red peppers) were dented and stored with the remaining stocked supplies. CK 2 stated, dented cans were supposed to be removed and separated from supply but there was no designated dented cans area. During an interview on 1/22/23 at 11:50 a.m. with CK 1, CK 1 agreed the mounted can opener was dirty. CK 1 further added, the mounted can opener does not get fully clean because it requires to be disassembled to be cleaned and washed. During a concurrent interview and try line observation on 1/22/24 at 12:30 p.m. Food and Nutrition Services Director (FNSD) entered, kitchen from outside through side door, FNSD then went inside dry storage room/office, came out of dry storage room while donning on hair covering. FNSD did not wash his hands, then walked towards the tray line production. When asked what the procedure for all staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 14 of 16 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 01/25/2024 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 upon entry to the kitchen was, FNSD reluctantly walked to the sink and washed his hands. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 1/22/24 at 1:28 p.m., with FNSD, the ice machine located in the staff breakroom had white build up residue inside door opening that house ice cubes, wet large black spot on left side and multiple small black spots on right side of ice compartment. FNSD, stated it was not his responsibility to ensure ice machine was clean. Residents Affected - Many During a review of the facility's policy and procedures (P&P) titled, Job Description Position: Dietary Aide, (undated), it indicated Dietary Aide's duties and responsibilities included . 2.e. Cleaning as assigned on cleaning schedule. f. Dishwashing. 3. Keep work area clean. 4. All other duties assigned by the Dietary Service Supervisor. During a review of the facility's P&P titled, Sanitation, dated 10/2008, it indicated, .13. Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers . During a review of the facility's P&P titled, Sanitation, dated 10/2008, it indicated under policy statement, The food service area shall be maintained in a clean and sanitary manner. Under policy interpretation and implementation 1. All kitchens, kitchen areas and dining areas shall be kept clean free from litter and rubbish . 2. All utensils, counters, shelves, and equipment shall be kept clean . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water . During a review of the facility's P&P titled, FOOD STORAGE-DENTED CANS, dated 2018, it indicated under policy, food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used by the facility. Under procedures, All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return . During a review of facility's P&P titled, ICE MACHINE CLEANING PROCEDURES, dated, 2018, the P&P indicated, .5. Be sure special attention is paid to cleaning the door molding and the lid of the machine. During review of facility's P&P titled, Job Description, Position: FNS Director, dated 2018, indicated under qualifications, .7. Ability to schedule, supervise, and control a food & nutrition staff.11. Ability to train staff how to properly prepare and serve food and how to keep kitchen clean and sanitary. Under duties and responsibilities: 2. Schedule and supervise the Food & Nutrition Service Staff providing in-service training. Assure all food and nutrition service staff are oriented per policy form.6. Is responsible for maintaining cleanliness of kitchen equipment, and follows all department of health regulations. During a review of facility's Job Description and Performance Evaluation (JDPE) for Director of Food Services, dated, 8/5/20, it indicated under Purpose of Position: .to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner. The JDPE also revealed, the qualifications of Director of Food Services encompass many functions that included, maintain the care and use of supplies, equipment, etc., as well as perform regular inspections of dietary service areas for sanitation, order, safety, and proper performance of assigned duties. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 15 of 16 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 01/25/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure garbage and refuse were properly stored in dumpster when the left lid cover of one dumpster was left open. Residents Affected - Some This failure had the potential for pest infestations and spread of diseases in the facility. Findings: During a concurrent observation and interview on 1/23/24 at 2:35 p.m. with Environmental Services Director (ESD), accompanied by the Facility Manager (FM), one large garbage dumpster in the rear building was left open. ESD attempted to close the open lid. However, the lid was damaged on the side and did not securely cover the dumpster. ESD acknowledged this was broken and had potential to attract rodents and pests. FM stated, she will contact waste management for lid replacement. During a review of the facility's policy and procedure (P&P) titled, Waste Disposal dated, January 2012, indicated under policy statement, All infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555842 If continuation sheet Page 16 of 16