Other·June 21, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the Recertification survey conducted 5/21/19 through 5/23/19. Representing the Department: Health Facilities Evaluator Nurses: 16684, 40050, 40849, 40968, 41658, 41796, 41898 The resident census at the start of the survey was 33.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 06/11/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 1 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop and implement a care plan for one (Resident 18) of one sampled resident with a hearing impairment when Resident 18 was assessed to have difficulty hearing and used hearing aids. This deficient practice resulted in Resident 18 not being able to hear well because she was not provided working hearing aids. Findings: A review of the Admission Minimum Data Set (MDS, an assessment tool used to guide resident care) dated 11/2/18, showed Resident 18 was able to understand others, and was understood. The MDS indicated Resident 18 had intact cognition (the ability to think and remember) with a Brief Interview of Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired.) score of 13. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 2 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE MDS also indicated Resident 18 had moderate hearing difficulty. A review of Resident 18's Quarterly MDS dated 4/16/19, showed Resident 18 used hearing aids with minimal difficulty hearing. A review of Resident 18's, "Inventory of Personal Effects," showed Resident 18 received three hearing aids on 3/31/19. During a record review and a concurrent interview with Director of Nursing (DON) on 5/21/19 at 11:12 a.m., DON stated she was responsible to complete assessments and enter data for the MDS. DON stated she had assessed Resident 18 as needing hearing aids for her hearing difficulty. DON was unable to provide documentation for a care plan for Resident 18's hearing impairment. A review of the facility's policy and procedure titled, "Care Plans, Comprehensive PersonCentered," revised December 2016, indicated, "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident."

F676 SS=D Activities Daily Living (ADLs)/Mntn Abilities CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii)

F676 06/11/2019 §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 3 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide necessary care and services to one (Resident 18) of one sampled resident with hearing difficulties when Resident 18 could not hear well without the use of her hearing aids. This deficient practice resulted in Resident 18 feeling isolated because she had difficulty hearing other people speak. Findings: A review of the Admission Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 4 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (MDS, an assessment tool used to guide resident care) dated 11/2/18, showed Resident 18 was able to understand others, and was understood. The MDS indicated Resident 18 had intact cognition (the ability to think and remember) with a Brief Interview of Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired.) score of 13. The MDS also indicated Resident 18 had moderate hearing difficulty. A review of Resident 18's Quarterly MDS dated 4/16/19, showed Resident 18 used hearing aids with minimal difficulty hearing. A review of Resident 18's, "Inventory of Personal Effects," showed Resident 18 received three hearing aids on 3/31/19. During an observation on 5/21/19 at 9:05 a.m., Certified Nursing Assistant 5 (CNA 5) talked loudly to Resident 18 while assisting her into bed. During a concurrent interview CNA 5 stated she talked loudly because Resident 18 could not hear well. CNA 5 stated she did not know if Resident 18 had hearing aids. During an observation and interview with Resident 18 on 5/21/19 at 9:06 a.m., Resident 18 put her left hand behind her left ear, and stated she could not hear well. She stated she had not used her hearing aids since they quit working two months ago. Resident 18 stated she had informed "a nurse" her hearing aids were not working, but nothing had been done to replace or fix them. Resident 18 stated she felt isolated because she had difficulty hearing other people speak. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 5/21/19 at 11:02 a.m., LVN 1 held a small, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 5 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE square box labeled with Resident 18's name; the box contained three hearing aids. LVN 1 stated she was aware Resident 18 had hearing difficulties, but stated she had not assisted Resident 18 with use of her hearing aids. A review of the facility's policy and procedure titled, "Hearing Impaired Resident, Care of," revised February 2018, indicated staff will assist hearing impaired residents to maintain effective communication and assist with care and maintenance of hearing devices.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/11/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide two staff members for supervision during use of a mechanical lift (an assistive device for lifting and transferring people from one surface to another) to prevent the fall of one (Resident 3) of two sampled residents at risk of falls. For Resident 3, the failure to provide two staff members during use of the mechanical lift resulted in a fall during transfer from bed to a shower chair, and caused a fracture of the left tibia (broken bone in the leg between the ankle and knee). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 6 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: A review of the Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 11/23/18, reflected a Brief Interview for Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired.) score of three, an indication of severe impairment. The MDS also indicated Resident 3 required total assistance from two or more staff members for transfer from bed to chair. A review of the care plan titled, "Activities of Daily Living," dated 11/21/16, showed Resident 3 was totally dependent on two staff members for transfer when using a mechanical lift. During a telephone interview with Certified Nursing Assistant 1 (CNA 1) on 5/22/19 at 8:53 a.m., CNA 1 stated her assignment on 12/28/18 included care of Resident 3. CNA 1 stated when she attempted to transfer Resident 3 from his bed to a shower chair using the [mechanical] lift, the sling (a cloth harness used to hold the resident during transfer) ripped, and Resident 3 fell to the floor. CNA 1 stated Resident 3's left foot had hit the floor first during his fall. CNA 1 stated she had not received training on use of the mechanical lift, so she had routinely transferred residents by herself until after Resident 3's accident on 12/28/18. A review of progress notes by Licensed Vocational Nurse 1 (LVN 1) dated 12/28/18 at 1:28 p.m., reflected, "Resident 3 had a fall incident while being transferred with the [mechanical] lift. This happened around 11:30 a.m. Noted to have a small abrasion on the right hip area." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 7 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the care plan, "The resident has had an actual fall," dated 12/28/19, indicated Resident 3 had a fall on 12/28/18. The care plan interventions included, "1) Will remind staff to always have two person assist on all [mechanical] lift patient [sic], 2) staff to check the sling strap at all times prior on using it for tear/worn out and will inform the charged [sic] nurse or SW (social worker) if it needed to replaced [sic] ..." A review of progress notes by LVN 1 dated 1/5/19 at 2:40 p.m., reflected, " ...the [physician] was notified of bruising and discoloration noted on the left lower leg and c/o (complained of) pain when the leg is being moved. An X-ray (X-ray, a noninvasive medical test which uses radiation to produce images of bones inside the body.) was ordered ...." A review of the X-Ray report dated 1/8/19, indicated Resident 3 received the X-ray on 1/8/19. The report indicated Resident 3 had a broken left lower leg near the knee, with the bone still in correct anatomical position. During an interview with the Assistant Administrator (AADM) on 5/21/19 at 2 p.m., AADM stated the facility hired CNA 1 on 12/10/18. AADM was unable to provide documentation the facility had trained CNA 1 on proper use of the mechanical lift before Resident 3's fall incident on 12/28/18. During an interview with the Director of Nursing (DON) on 5/21/19 at 11:16 a.m., DON confirmed Resident 3 fell and broke his leg when CNA 1 attempted a one person transfer with a mechanical lift on 12/28/18 at 11:30 a.m. DON stated the facility policy required a minimum of two staff members for use of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 8 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE mechanical lift to transfer residents. DON was unable to provide documentation CNA 1 received training on the use of the mechanical lift between CNA 1's date of hire on 12/10/18, and Resident 3's fall incident on 12/28/18. A review of the [mechanical] lift manufacturer's, "User Manual," copyright 2018, showed a manufacturer recommendation of, "two assistants be used for all lifting preparation, transferring from and transferring to procedures." A review of the facility policy and procedure titled, "Lifting Machine, Using Mechanical," revised July 2017, indicated: 1. At least two nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require ...b. Transferring a resident from bed to chair."

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 06/11/2019 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide pain relieving medication to one (Resident 8) of 13 sampled residents before a painful procedure. For Resident 8, the failure to provide pain relieving medication before a wound dressing change resulted in avoidable pain. See also tag F 578. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 9 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: A review of the Annual Minimum Data Set (MDS, an assessment tool used to guide patient care) dated 12/17/18, indicated Resident 8 had a Brief Interview for Mental Status (BIMS, an assessment tool for the abilities to think and remember, with a score of 15 an indication of intact abilities.) score of ten, an indication of moderate impairment. A review of a physician order dated 5/8/19 reflected Resident 8 had a left lower leg wound treatment and dressing change ordered for completion on a daily basis. A review of Resident 8's care plans showed a care plan for treatment of acute pain dated 3/22/19. The care plan interventions included: Resident 8 should receive pain medication onehalf hour before treatments, and to "anticipate the resident's need for pain and respond immediately to any complaint of pain." During an observation in Resident 8's room on 5/21/19 at 9:39 a.m., Resident 8 returned to her room in a wheeled chair after a shower, and stated she was in pain. In a concurrent interview with Resident 8, she stated her pain was at a level of ten [on a scale of zero to ten, with ten the highest pain]. Director of Nursing (ADON) entered the room, and started changing the wound dressing on Resident 8's left lower leg, while Resident 8 continued to complain of pain and pointed at her left ankle and leg. During a concurrent interview, ADON stated Resident 8 might have already received medication for pain, and continued the dressing change, while Resident 8 stated continuously, "hurts, hurts, hurts!" ADON finished the dressing change, and left the room stating she would check to see if Resident 8 had already FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 10 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE received pain medication. ADON returned to the room and stated Licensed Vocational Nurse 1 (LVN 1) would be in to give Resident 8 pain medication. During an observation on 5/21/19 at 9:48 a.m., LVN 1 administered pain medication to Resident 8. During an interview with ADON on 5/21/19 at 9:45 a.m., ADON stated she heard Resident 8 complain of pain, and knew Resident 8's wound was very sensitive to touch. ADON stated she rewrapped Resident 8's wound because the dressing was wet after the shower; the nurse routinely changed the dressing once a day, in the afternoon. During an interview with ADON on 5/22/19 at 11:30 a.m., ADON stated nursing staff ask should ask if residents were in pain before providing care. ADON stated Resident 8 normally received pain medication before the afternoon dressing change, but ADON needed to change the dressing because it was wet after the shower.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 06/11/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 11 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the steam table (used to keep prepared food warm), stove hood (a venting device over the cooking stove that removes air-borne grease and smoke), microwave, and eight serving plates were clean before use. This failure had the potential for a resident receiving food from the kitchen to contract food-borne illness. Findings: During an observation and interview with Dietary Supervisor (DS) on 5/21/19 at 12:24 p.m., DS confirmed the steam table and the stove hood had thick layers of dried, brown and white colored, greasy material, and the inside of the microwave had brown debris. DS stated staff cleaned the steam table, hood, and microwave once a week on Wednesday. A review of the facility kitchen policy, "Weekly Cleaning Duties," revised 3/1/18, indicated weekly cleaning duties included: clean steam table-top, bottom, & underneath, degrease trays & pans. During an observation and interview with DS on 5/21/19 at 12:30 p.m., DS confirmed the steam table had a stack of plates for use during the lunch service. DS confirmed eight plates with a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 12 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dried yellow substance were included in the stack of plates; DS removed the dirty plates.

F868 SS=E QAA Committee CFR(s): 483.75(g)(1)(i)-(iii)(2)(i)

F868 06/11/2019 §483.75(g) Quality assessment and assurance. §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; §483.75(g)(2) The quality assessment and assurance committee must: (i) Meet at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the Medical Director (MD) attended four of four quarterly meetings of the Quality Assessment and Assurance (QAA) committee. This deficient practice had the potential to result in an inability of the committee to identify and respond to quality deficiencies in the residents' medical care. Findings: A review of the facility's Quality Assurance and Performance Improvement (QAPI) committee sign-in sheets showed no attendance signature FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 13 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for the MD in the months of July 2018, October 2018, January 2019, and April 2019. During an interview with Director of Nursing (DON) on 5/23/19 at 12:57 p.m., DON stated MD had not attended the QAA and QAPI meetings every three months for the last year. DON was unable to provide documentation the facility had communicated QAA/QAPI committee meeting content to the MD for the missed meetings. A review of the [facility] 2017 QAPI Plan, reviewed 1/2/2019, indicated, "Physician oversight, direction, and involvement play an essential role in the QAPI process. The [facility] Medical director is the designated senior practitioner and advisor for all aspects of the QAPI program related to clinical care and safety. The Medical Director is accountable for providing leadership for, and is actively involved in the implementation of, the QAPI program. Performance accountabilities for the Medical Director include, but are not limited to, the following: Ensuring that all quality management initiatives pertaining to the delivery and management of care are clinically sound, promote consumer safety, and are based on current best practices; co-chairing the QPI Steering committee; participating in and providing support to other committees for the development of appropriate assessment and evaluation efforts, intervention strategies, and corrective action plans; involving providers and representatives of medical delivery systems in reviewing and planning the QAPI program's core activities."

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 06/11/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 14 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 15 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one (Resident 1) of 13 sampled residents received care in a manner to prevent the spread of infection. For Resident 1, the failure of Certified Nursing Assistant (CNA) 3 to perform hand hygiene after contact with Resident 4, and before feeding Resident 1, had the potential to result in transmission of pathogens (bacteria, virus, or other microorganism capable of causing infection or disease) from Resident 4 to Resident 1, and cause infection or disease. Findings: During an observation of lunch, in the main dining room, on 5/21/19 at 12:21 p.m., CNA 3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 16 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physically assisted with repositioning Resident 4 in a reclining chair, and directly went to provide feeding assistance to Resident 1, without washing their hands. During an interview with CNA 3 on 5/21/19 at 1:52 p.m., CNA 3 stated, "We are supposed to wash our hands before feeding residents." A review of the facility policy titled, "Handwashing/Hand Hygiene," revised August 2015, indicated, "All personnel shall use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water before and after direct contact with residents and before and after assisting a resident with meals."

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) 06/11/2019 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility had four of 16 multiple resident rooms that provided less than 80 square feet per resident in each room. This deficient practice had the potential to result in a lack of sufficient space for the provision of resident care both routine and emergency, and to accommodate the residents' personal belongings. Findings: During an observation on 5/22/19 at 11:45 a.m., rooms 1, 5, 6, and 12 each had two resident beds. The following measurements FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 17 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555905 (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SERENETHOS CARE CENTER, LLC 22822 Myrtle Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE were obtained: a. Resident Room 1 (two-bed room) was 14.17 feet by 11.17 feet. Each resident's personal space had 79.13 square feet. b. Resident Room 5 (two -bed room) was 14.17 feet by 11.17 feet. Each resident's personal space had 79.13 square feet. c. Resident Room 6 (two-bed room) was 14.17 feet by 11.17 feet. Each resident's personal space had 79.13 square feet. d. Resident Room 12 (two-bed room) was 14.17 feet by 11.17 feet. Each resident's personal space had 79.13 square feet. During an interview on 5/22/19 at 12:13 p.m. with the Assistant Administrator (AADM), AADM stated the facility will be requesting for an approved waiver for rooms 1, 5, 6, and 12 for this Recertification period. During an observation of random care and services from 5/21/19 to 5/23/19, there was sufficient space for the provision of care for the residents in rooms 1, 5, 6 and 12. There was no heavy equipment kept in the rooms that might interfere with resident's care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in any of the resident rooms that were less than 80 square feet. Recommend granting room size waiver. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SU9811 Facility ID: CA020000074 If continuation sheet 18 of 18