Health inspection·March 1, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During an observation on 2/22/22, at 11:20 a.m., RN 1 provided incontinent care and changed Resident 27's incontinent briefs. RN 1 was observed addressing Resident 27 as [NAME] while transferring Resident 27 from wheelchair to the bed. RN 1 pulled the privacy curtain and stated, [NAME] lay down for me .okay [NAME] turn around . During an interview on 2/22/22, at 1:58 p.m., with the DON, the DON stated, staff was expected to call the residents by first or last name and it was not okay to address the residents as mama or [NAME] unless that was resident's preference. The DON stated resident's preferences were documented under care plan section in the electronic medical record. The DON also stated staff was expected to respect the residents. During an interview and concurrent record review with the DON, on 2/22/22, at 2:04 p.m., Resident 27's care plans in the electronic medical record were reviewed. The DON stated Resident 27's care plans did not indicate if Resident 27 preferred to keep the clothing protector on for longer hours and/ or if Resident 27 preferred the facility staff to address him as [NAME]. During a record review of facility's undated policy and procedures titled, Quality of Life- Dignity indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 2 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm 2. During an observation on 2/25/22, at 8:33 a.m., Resident 23 requested assistance from Certified Nursing Assistant (CNA 3) in emptying the colostomy bag (a bag attached to an opening into the abdomen to excrete the fecal matter). Resident 23 was in lying position. Resident 23 removed the blanket from the lower part of his body while his legs and colostomy were exposed. CNA 3 handed a bed pan to Resident 23 and told him to put it in between his legs right above the genital area. Resident 23's bed was right by the door, which was wide open. CNA 3 did not pull the privacy curtain while Resident 23 emptied the colostomy bag. Residents Affected - Some During an interview with CNA 3 and Resident 23 on 2/25/22, at 8:45 a.m., at Resident 23's bedside, CNA 3 apologized for not pulling the privacy curtain during colostomy care. Resident 23 stated he would like the staff to pull the privacy curtain to provide him privacy during colostomy care. During a record review of the facility's undated policy and procedure (P&P) titled, Dignity and Privacy During Care, the P&P indicated, Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care . Based on observation and interview, the facility failed to ensure privacy and confidentiality of medical information for two of two sampled residents (Residents 23 and 30) when: 1. Resident 30's electronic medical record was left exposed at Medication Cart 1; and 2. Certified Nursing Assistant 3 (CNA 3) did not provide privacy during toileting for Resident 23. These failures had the potential for unauthorized access to Resident 30's medical information and it violated resident's right to privacy for Resident 23. Findings: 1. During a concurrent observation and interview on 2/25/22, at 9:33 a.m., with Licensed Vocational Nurse 2 (LVN 2), the computer screen was observed open to Resident 30's medical record on Medication Cart 1. The computer screen was also observed exposing Resident 30's name, vital signs, physician name, allergy status, code status, photo, care plan, and pain assessment. LVN 2 stated Resident 30's record should have been secured when she stepped away from the cart. During an interview with the Director of Nursing (DON) on 2/25/22, at 9:48 a.m., the DON stated there is a button on the computer screen for staff to use that secures the computer screen when they step away from the workstation. The DON further stated securing the computer displaying resident personal and medical information is important because the Health Insurance Portability and Accountability Act (HIPAA) requires medical records be kept confidential. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 3 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation with Certified Nursing Assistant 1(CNA 1) on 2/24/22, at 9:07 a.m., Resident 30's overbed table [a table with metal base with four wheels, a metallic leg on one side and a wooden tray on the top] was at her bedside. All four sides of the top wooden tray of the table were unfurnished, uneven and rough to touch. CNA 1 stated Resident 30 used the overbed table daily. When asked about her thoughts about overbed table being unfurnished and rough to touch, CNA 1 stated, what can I say. During an observation with Registered Nurse (RN 1) on 2/24/22, at 9:58 a.m., in Resident 30's room, RN 1 stated, most of them [overbed tables] were old in the facility. RN 1 stated, because the overbed tables were rough and uneven, that could scratch resident's hands. RN 1 stated, staff reported the facility's administration of furniture repairs needs back in 12/2021 [almost two months ago]. During another observation with RN 1 and CNA 2 on 2/24/22, at 10:04 a.m., Resident 8 and Resident 2's overbed tables were observed. The edges of the top wooden tray for Resident 8 and Resident 2 were scratched, uneven and rough to touch. The top wooden tray for Resident 8's table also had multiple chipped areas. CNA 2 stated, it could crack resident's body, we don't like it. During an interview with the Director of Nursing (DON) on 2/24/22, at 10:28 a.m., the DON stated, to ensure resident's safety, the facility checks the resident's surroundings every day, but did not notice the unfurnished overbed tables for Resident 30, 8 and 2. The DON stated unfurnished furniture's wooden particles could get mixed in resident's food and cause injuries to Resident 30, 8 and 2. During an interview and record review with the Assistant Administrator (AADM) on 2/24/22, at 11:11 a.m., the facility's Maintenance Log binder was reviewed. AADM stated, he did resident room rounds every six (6) months and the maintenance supervisor was responsible for daily rounds to ensure residents' surroundings were safe. The AADM opened the Weekly Over Bed Table Log for the month of January 2022, a section of the Maintenance log binder indicated the maintenance supervisor did not check the overbed tables for all residents after 1/27/22. The weekly overbed table log indicated, Examine all overbed tables weekly to ensure they are clean and in good repair. Wheels are clean and roll smoothly. Note location of table and comment on repairs made or need to discard or replace. AADM stated, the log did not indicate if overbed tables for Resident 30, 8 and 2 required repairs or needed to be replaced and the comment section was left blank. The AADM also stated, he did not think overbed tables for Resident 30, 8 and 2 turned into an unfurnished condition just in one month. The AADM stated, the maintenance supervisor was not available during the survey week. During a record review of the facility's undated policy and procedure (P&P) titled, Homelike Environment, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment .2 .The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .d. Personalized furniture and room arrangements . Based on observation, interview, and record review, the facility failed to provide a home like environment to five of 12 sampled residents (Resident 1, 23, 2, 8 and 30) when: 1. the room temperature for Resident 1 and 23 were too cold; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 4 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0584 2. the overbed tables for Residents 2, 8 and 30 were rough and unfurnished. Level of Harm - Minimal harm or potential for actual harm The above failures resulted in Resident 1 and 23 feeling cold, and the potential for Residents 2, 8 and 30 getting scratched and hurting themselves. Residents Affected - Some Findings: 1. A record review of Resident 1's admission Record dated 2/24/22, indicated Resident 1 was admitted on [DATE]. A record review of Resident 27's admission Record dated 2/25/22, indicated Resident 27 was admitted on [DATE]. During an interview on 2/22/22 1:02 p.m., Resident 1 stated that her room is always too cold, and she doesn't like it. During an observation and interview on 2/23/22, at 12:25 p.m., with the ADM (Administrator), the ADM stated the facility temperature is kept around 70ºF (degrees Fahrenheit). The ADM stated the nurses are responsible for changing the temperature if residents make a complaint or have a request. The ADM stated there are no temperature check logs for resident rooms. The ADM measured the temperatures of the following rooms: room [ROOM NUMBER] was 69.3º F, room [ROOM NUMBER] was 69.3ºF, and room [ROOM NUMBER] was 69.3ºF. During an interview on 2/25/22, at 1:23 p.m., Resident 23 stated, his room is too cold, all the time. Resident 23 further stated, it makes him feel his room is not homelike. A review of the facility's policy and procedure (P&P) titled, Homelike Environment, (undated), indicated, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .Comfortable temperatures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 5 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (Resident 23) received the necessary services to maintain personal hygiene when Resident 23 did not receive incontinent (inability to hold urine or bowels) care. Residents Affected - Few This deficient practice had the potential to make Resident 23 feel the lack of dignity and respect. Findings: During an interview on 2/22/22, at 11:15 a.m., with Resident 23, Resident 23 stated, there was an incident during the night shift when Resident 23 called a certified nursing assistant (CNA) to help with emptying Resident 23's colostomy bag (a plastic bag that collects fecal matter from the digestive tract through an opening in the stomach wall called a stoma). Resident 23 further stated, the CNA came to the room, handed Resident 23 the bedpan and gloves, and the CNA left the room without assisting Resident 23 with emptying the colostomy bag. During an interview on 2/23/22, at 6:44 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated, Resident 23 usually calls at night to request staff help hold the bedpan (receptacle used by a bedridden patient as a toilet) while Resident 23 empties the colostomy bag contents into the bedpan. During a concurrent observation and interview on 2/25/22, at 8:33 a.m., in Resident 23's room, Resident 23 stated, staff does not help with incontinence care. Resident 23 was observed to asking Certified Nursing Assistant 3 (CNA 3) to hold the bedpan for Resident 23 to empty their colostomy bag contents into the bedpan. CNA 3 was observed stating she did not want to hold the bedpan for Resident 23. During an interview on 2/25/22, at 10:04 a.m., with the Director of Nursing (DON), the DON stated, we empty the colostomy bag for Resident 23. The DON further stated, sometimes Resident 23 can empty the colostomy bag but staff has to help Resident 23. During a review of Resident 23's Minimum Data Set (MDS, a comprehensive health assessment) Section H - Bladder and Bowel, dated 1/17/22, the MDS Section H indicated, Resident 23 has an ostomy for bowel continence. During a review of Resident 23's MDS Section G - Functional Status, dated 1/17/22, the MDS Section G indicated, Resident 23's needs one-person physical assistance for toilet use. During a review of the facility's policy and procedure (P&P) titled, Resident Activities of Daily Living (ADL-term used in healthcare to refer to people's daily self-care activities), (undated), the P&P indicated, Each resident shall be offered and provided ADL support, while maintaining their highest practicable function, with safety, comfort and dignity. P&P also indicated If the resident has difficulty performing the activity or does not perform the activity, they may be assisted with appropriate care staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 6 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to attempt to use alternatives, explain the risk and benefits and obtain informed consent from the resident and resident representative (RR) prior to installment of the bed side rails for 29 out of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25). Also, there was no side-rail assessment conducted prior to initiation of the bed side rails for Resident 30. The facility's failure to assess bed side rail use for Resident 30 placed Resident 30 at risk for entrapment and injuries. Also, these failures resulted in 29 of 29 residents and their RR's to be unaware of risks and benefits of side rails and to be able to make an informed decision. [cross reference F835] Findings: During a record review of the facility's undated document titled, Half side rails list, it indicated all 29 residents residing at the facility had half side rails when in bed as enabler. During an observation on 2/22/22, at 11:15 a.m. through 2:00 p.m., side rails were up on both sides of the bed for all 29 residents residing at the facility. During another observation on 2/24/22, between 9:00 a.m. through 2:00 p.m., bilateral bed side rails were up again for all 29 residents. During a record review of Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25's Side rail utilization assessment-V4,it indicated, three sections: 1. Assessment criteria, 2. Rationale, and 3. Signatures. The assessment did not indicate any section pertaining to explanation of risks and benefits or if residents/ RR agreed to provide an informed consent related to side rail use. During an interview with the Administrator (ADM ) on 2/24/22, at 12:44 p.m., the ADM stated, the facility did not have any evidence indicating the facility attempted to use alternatives prior to installing bed side rails on all 29 resident's beds. The ADM stated, the only alternative for side rails would be no side rails. The ADM also stated, we don't have the informed consent documented. During an interview and record review with the Director of Nursing (DON) on 2/25/22, at 12:11 p.m., Resident 1's side rail assessment dated [DATE] was reviewed. Resident 1's assessment had the DON, Activity Director (AD) and Social Services Director (SSD) names on the assessment. The DON stated, the Inter-Disciplinary Team (IDT) names on the assessment indicated which team members discussed side rails use. The assessment also indicated, the RP [Responsible Party] under Responsible Party Signatures. The DON stated, RP meant Resident 1's RR was aware of side rail use and it's risks and benefits. When asked if she talked to Resident 1's RR to discuss side rail use, the DON stated, I haven't talked to anyone recently. The DON stated the IDT was responsible to obtain informed consent for side rail use. During an interview with the SSD on 2/25/22, at 12:42 p.m., the SSD stated, she was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 7 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many obtaining care and treatment consent from residents or RR. SSD stated she never obtained an informed consent for side rail use. The SSD further stated, she called all 29 RR's only last night on 2/24/22 to discuss the use of side rails and to obtain informed consents. During an interview with RR 1 on 2/25/22, at 1:18 p.m., RR 1 stated, the facility obtained a written informed consent for side rail use only that day (2/25/22). RR 1 further stated, the facility did not explain the risks and benefits of side rails use prior to 2/25/22. During an interview with the DON on 2/24/22, at 10:07 a.m., the DON stated, she was aware the facility needed to obtain an informed consent for side rails from the resident or RR because it could be considered a restraint. The DON stated the facility did not have documentation indicating if risks and benefits for side rail use were explained to residents and/or RR to choose or decline side rails. During a concurrent observation and interview with Registered Nurse (RN 1) on 2/24/22, at 9:58 a.m., Resident 30's bed was observed with half side rails up on both sides. RN 1 stated Resident 30's bed always had half side rail up because Resident 30 always tried to get out of bed. During an interview and record review with the Director of Nursing (DON) on 2/24/22, at 10:22 a.m., the DON was unable to locate a side rail assessment and stated, the facility did not complete the side rail utilization assessment for Resident 30. The DON stated the facility placed bedside rails on all 29 residents' beds since their date of admission. The DON further stated, Resident 30 was placed on side rails since her admission date on 1/24/22. During a concurrent interview and record review with the Activity Director (AD) on 2/25/22, at 11:54 a.m., Resident 30's side rail assessment dated [DATE] was reviewed. The assessment indicated the AD, Social Services Director (SSD) and DON's names under the signatures section in the side rail assessment for Resident 30. The AD stated, she was not aware and involved in Resident 30's side rail assessment. The AD stated, she was not aware of any risks related to side rail usage. The AD further stated, she did not recall facility staff discuss the use, risks, and benefits of side rails with residents/ families. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 8 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 - Few 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 record review, the facility failed to record and document one controlled medication (medication with potential or risk for abuse) when Norco (medication for severe pain) was not recorded and documented on the facility's Narcotics (a drug or substance that affects mood or behavior) Log for one of 12 sampled residents (Resident 26). This deficient practice had the potential for loss or diversion of Resident 26's pain medication. Findings: A record review of Resident 26's admission Record, dated 2/24/22, indicated Resident 26 was admitted on [DATE]. The admission Record also indicated Resident 26 had medical diagnoses including multiple fractures (broken bones) of ribs and a history of falls. A Record Review of Resident 26's Order Summary, dated 2/24/22, indicated Resident 26 had a physician's order, dated 2/2/22, for Norco Tablet 5-325 milligram (mg) one tablet by mouth two times a day for pain. During a concurrent observation, interview, and record review on 2/23/22, at 9:46 a.m., with Licensed Vocational Nurse (LVN 1), the Individual Patient's Narcotic Record, signed by the nurse receiving the Norco medication on 2/3/22 was reviewed. Resident 26's Narcotic Record for Norco 5-325 Tablet indicated one Norco tablet was not recorded and documented. Resident 26's Narcotic Record indicated, 19 Norco tablets were administered to Resident 26. Resident 26's Norco bubble pack (a medication pack containing designated sealed compartments for medication to be taken at a particular time of time of the day) was observed with 20 Norco tablets dispensed. LVN 1 stated, she counted the Norco at the start of her shift, and she missed one dose. During a concurrent interview and record review on 2/23/22, at 10:19 a.m., with LVN 1, LVN 1 stated, she forgot to document the Norco she gave Resident 26 on 2/22/22. LVN 1 further stated she corrected Resident 26's Narcotic Record. Review of Resident 26's Narcotic Record indicated 20 Norco tables were administered. A record review of Resident 26's Medication Administration Record (MAR) indicated Resident 26 received one Norco 5-325 Tablet on 2/22/22, at 9:00 a.m. During an interview on 2/25/22, at 12:10 p.m. with the Director of Nursing (DON), the DON stated, the narcotics count, and documentation are done between each shift. The DON further stated, it is important to document the narcotic count because the medication can be missing. During a record review of the facility's policy and procedure (P&P) titled, Controlled Substance Policy, dated 2007, the P&P indicated, when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage . a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 9 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure its medication error rate did not exceed five percent for one of 12 sampled residents (Resident 27). There were four medication errors out of 25 opportunities resulting to 16 percent (%) medication error rate when Resident 27's percutaneous endoscopic gastrostomy tube (PEG tube, a feeding tube placed through the abdominal wall and into the stomach that allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth ) was not flushed (inserting a liquid substance into a tube, usually ) with water in between administering Apixaban (blood thinner medication), Ascorbic Acid (Vitamin C supplement), Doxazosin Mesylate (high blood pressure and urinary retention medications), and Vitamin D3 (Vitamin D supplement). Residents Affected - Some This practice had the potential to jeopardize Resident 27' health, obstruct Resident 27's PEG tube, and cause unnecessary pain and discomfort to Resident 27. Findings: A record review of Resident 27's admission Record dated 2/24/22, indicated Resident 27 was admitted on [DATE]. The admission Record also indicated, Resident 27 has medical diagnoses including: Vitamin D deficiency (low Vitamin D in the body that can lead to a loss of bone density, which can contribute to a break in the bone), neuromuscular dysfunction of bladder (body lacks bladder control), and hypertension (high blood pressure). A record review of Resident 27's Order Summary dated 2/23/22, indicated a physician's order for: 1. Apixaban Tablet 5 mg (a blood thinner medication used to treat and prevent blood clots and prevent stroke) and to give one tablet via PEG tube, 2. Ascorbic Acid Tablet 500 mg (Vitamin C supplement) and to give one tablet via PEG tube, 3. Doxazosin Mesylate Tablet one mg (a medication used to treat urinary problems and high blood pressure) and to give one tablet via PEG tube, 4. Vitamin D3 Tablet (Vitamin D supplement) and to give 50000 units via PEG tube, and 5. to flush the PEG tube with 30 cc (cubic centimeter) of water pre and post medications. During a concurrent observation and interview on 2/23/22, at 08:55 a.m., with RN 1, RN 1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 10 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observed preparing and administering medications for Resident 27. RN 1 combined and crushed the following medications together at one time: one 5 mg Apixaban tablet, one 500 mg Ascorbic Acid tablet, one 1 mg Doxazosin Mesylate tablet, and one Vitamin D3 tablet. RN 1 poured the combination of crushed medications in one cup and added water. RN 1 checked Resident 27's PEG tube residual (fluid or contents that remain in the stomach) and flushed it with 30 cc of water. RN 1 administered the combination of medications to Resident 27 via PEG tube. After administering approximately half of the medication mixture RN 1 added additional water to the medication, then continued administering the rest of the medication mixture. RN 1 did not flush Resident 27's PEG tube with water after she was done administering the medication mixture. RN 1 stated, she did not flush the PEG tube after giving all the medications because she added 30cc of water to the medication mixture while she was administering it. During an interview on 2/25/22, at 9:40 a.m., with the DON (Director of Nursing), the DON stated that the facility's policy was to flush PEG tubes with 30 cc of water before giving medications and after giving medications. The DON stated the facility's policy is to crush medications individually. The DON stated the facility's policy is to administer each medication separately when administering medications via PEG tube to prevent obstruction. A record review of the facility's policy and procedure (P&P) titled, Medication Administration Enteral Tubes, dated 2007, the P&P indicated, .crushed medications should not be combined and given all at once via feeding tube . crushed medications are not mixed together .each medication is administered separately to avoid interaction and clumping . enteral tubes are flushed with at least 15mL [milliliter - often referred to as cc] of water before administering any medications and after all medications have been administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 11 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the lunch menu for 12 of 12 sampled residents (Residents 31, 26, 28, 8, 2, 17, 24, 30, 20, 11, 5, 1, 19, 14 and 7) and the Dietary Department did not notify the residents of the menu change. This deficient practice resulted in Residents 31, 26, 28, 8, 2, 17, 24, 30, 20, 11, 5, 1, 19, 14 and 7 not knowing what food items they were getting for lunch and had the potential for residents not to get the nutritional value of the food item that was on originally on the menu. Findings: During a concurrent observation and interview on 2/22/22, at 11:52 a.m., with the Dietary Manager (DM), in the kitchen, it was observed that meatballs, spiral pasta and broccoli with other vegetables were being prepared. The DM stated the chicken was still frozen, they do not have broccoli, and he could not find the couscous. The DM stated he replaced the chicken with turkey meatball, replaced the broccoli with a broccoli mixed blend, and replaced the couscous with spiral pasta. The DM stated he did not notify the residents of the menu change. During an interview on 2/22/22, at 12:22 p.m., with Resident 28, Resident 28 stated, she was not notified of the change in the menu for lunch. Resident 28 further stated, she never knows what is on the menu and if she does not like the food served, she requests for soup. During an interview on 2/22/22, at 12:30 p.m., with Resident 23, Resident 23 stated, he was not notified by anyone on the changes in the lunch menu for today. Resident 23 further stated, he just ate the meatballs and a little bit of the broccoli. During a review of the Winter Menu Week 3, undated, the Winter Menu Week 3 indicated, for noon on Tuesday (2/22/22) the following is on the lunch menu: Middle Eastern Chicken, Orange Zest Couscous, Broccoli with Red Peppers and Peach [NAME]. During a review of the facility's policy and procedure (P&P) titled, Menu Changes, dated 2014, the P&P indicated, When items on the menu are not available, due to an unavoidable circumstance, as a last alternative, a substitute from the same food group is permissible. The substitution must be of equal nutritional value. Any menu change must be documented according to these procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 12 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review the facility failed to follow the physician's order to provide a fortified diet (food that has extra nutrients added to it or has nutrients added that are not normally there) for two of 12 sampled residents (Residents 5 and 28). This deficient practice had the potential to cause Residents 5 and 28 to experience weight loss and to not meet or maintain their ideal body weight. Findings: During a concurrent observation and interview on 2/22/22, at 12:05 p.m., with the Dietary Manager (DM), Resident 5's meal tray on the kitchen cart was observed to not have any butter on it. The DM stated, they add butter to the plate for residents who have fortified diets. During a review of Resident 5's Order Summary Report, dated 2/25/22, the Order Summary Report indicated, Resident 5 was on a fortified diet. During an observation on 2/22/22, at 12:22 p.m., in Resident 28's room, Resident 28's lunch tray was observed on the overbed table with a diet card indicating Resident 28 was on a fortified diet. Resident 28's lunch tray was observed without butter on it. Resident 28 further stated she does not know what she gets on her meal tray. During a review of Resident 28's Order Summary Report, dated 2/25/22, the Order Summary Report indicated, Resident 28 was on a fortified diet, mechanical soft, ground meat texture, thin consistency, moist food diet. During an interview on 2/24/22, at 9:03 a.m., with the Registered Dietician (RD), the RD stated, it is extremely important to follow prescribed therapeutic diets. The RD stated not getting recommended diets might result in residents losing weight, not being able to function at their best, and wounds not healing. During a review of the facility's policy and procedure (P&P) titled, Resident's Rights and Responsibilities Related to Food Policy No. 390, dated 2014, the P&P indicated, The resident has the right to receive a therapeutic diet when there is a medical problem indicating the need for adjustment from the regular diet. During a review of the facility's P&P titled, Fortified Diet to Increase Calories and Protein, dated 2013, the P&P indicated, Fortified diet provides additional calories and protein in the same manner or a smaller volume at mealtimes than the Regular Diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 13 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft Avenue San Leandro, CA 94577 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: Residents Affected - Some 1. an opened lemon juice bottle, three turkey meat slices wrapped in foil, and one turkey pack with no open date were found in Refrigerator 2 (Ref 2), 2. one sliced banana in plastic wrap and five slices of oranges in an uncovered bowl with no prepared date were found in Refrigerator 1 (Ref 1), 3. one overripe banana was in Ref 1 and 11 overripe bananas was in the dry storage room, 4. Ref 1 had black crumbs on the door latch and had dried liquid drippings on Ref 1's back wall, 5. the can opener had dried matter and white hair stuck on it, 6. the dry storage area did not have a thermometer, 7. staff did not wash their hands and change gloves in between touching food items, handles, and their face mask; and 8. staff did not properly cover their hair with a hairnet. These failures placed the residents at risk for food borne illnesses. Findings: 1. During an initial tour of the kitchen with the Dietary Manager (DM) on 2/22/22, at 9:59 a.m., inside Ref 2, an opened bottle of lemon juice was observed with no labelled opened date on it. The DM was observed unwrapping a foil wrapped object with no date on it, revealing three turkey meat slices in it, and throwing the turkey meat slices in the trash bin. DM stated the undated and opened pack of turkey in Ref 2 should have been dated. 2. During the kitchen's initial tour with DM, on 2/22/22, at 9:49 a.m., inside Ref 1, one sliced overripe banana was observed in a plastic wrap with no date prepared. The DM stated they use the banana for cereal or for pureed diet and the DM stated he was going to throw it out. Further observation noted an uncovered bowl with 5 slices of orange in it without the preparation date on it. The DM stated it was fresh fruit and it was extra. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Non-Food Supplies, dated 2014, the P&P indicated, Opened containers of food will be stored in tightly closed non-corrosive containers or in sealed plastic bags. No exposed food will be stored in the storeroom, refrigerators, or freezer. Open and use-by-dates will be placed on these items. 3. During the kitchen's initial tour with DM, on 2/22/22, at 9:49 a.m., it was observed that one cut overripe banana with black spots on the banana was stored in Ref 1 and 11 overripe, black-spotted bananas were stored in the dry storage room. The DM was observed peeling a banana and the DM stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 14 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 the banana is overripe because it had a black soft area inside of it. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Storage of Food and Non-Food Supplies, dated 2014, the P&P indicated, 2.) Bananas are stored at room temperature and used as quickly as possible after ripening. Residents Affected - Some 4. During the kitchen's initial tour with the DM, on 2/22/22, at 9:49 a.m., it was observed that Ref 1 had black matter on the door latch. DM stated, the black matter looked like crumbs. It was also observed that Ref 1 had dried dark brown liquid drippings at the back of the inside of the ref 1 wall, the DM stated that it was dried liquid splashes. 5. During a concurrent observation and interview on 2/22/22, at 2:00 p.m., with the DM, a can opener in the kitchen was observed with black matter on it. The DM stated, the black matter was from the can labels that get stuck to the can opener during use. The can opener was also observed with one strand of short white hair stuck on it. During a review of the facility's cleaning log titled, Daily and Weekly Cleaning Log, dated February 2022, the Daily and Weekly Cleaning Log indicated, the refrigerators and freezers were not cleaned since February 4, 2022. During a review of the facility's P&P titled, Cleaning Procedure, dated 2014, P&P indicated Light daily cleaning is required for the can opener, hand washing sink, tray card holders, tray cards, steam table wells, refrigerator, coffee makers, range and grill, floor and mats, sink, all scoops, garbage disposer, ovens and milk dispensers. 6. During the initial kitchen tour with the DM, on 2/22/22, at 9:49 a.m., no thermometer was observed in the dry storage room. The DM stated, he could not find the thermometer and he has not checked the temperature in the dry storage area. The DM further stated, a thermometer is needed in the dry storage area room because the temperature for everything (refrigerator, freezer, storage room) should be checked. During a review of the facility's P&P titled, Storage of Food and Non-Food Supplies, dated 2014, the P&P indicated, 1) Dry storage areas will be equipped with a thermometer. 7. During an observation on 2/22/22, at 9:49 a.m., in the kitchen, the DM was observed not washing hands and changing gloves in between touching the door handle Ref 1 and freezer 1, food items (banana, sliced oranges, sliced turkey pieces) in the refrigerator, freezer and dry storage area, and opening a bag of meatballs and placing it in a pot. During an observation on 2/22/22, at 11:52 a.m., in the kitchen, the DM and Dietary Staff 1 (DS) were observed not changing gloves and washing hands between touching scoops in the tray line and touching the food cart and refrigerator handles. DS 1 was then observed touching a piece of bread during the tray line with one gloved hand and placed it on two residents lunch plates. It was also observed three times that DM was touching his face mask with his gloved hands without changing it and performing hand hygiene. During a review of the facility's P&P titled, Hand Washing Policy No. 615, dated 2014, the P&P indicated, When to wash hands: immediately before engaging in food preparation including working with non-repackaged food, clean equipment, utensils and unwrapped single use food containers and utensils; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 15 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 - Some before donning gloves for working with food; during food preparations as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; after engaging in other activities that contaminate hands. 8. During an observation on 2/22/22, at 9:59 a.m., in the kitchen, the DM was observed wearing a hair net that did not cover all his hair inside the hair net and facial hair did not have facial covering. During an observation on 2/23/22, at 6:59 a.m., in the kitchen, DS 1's hair was not entirely covered with hair net. During a review of the facility's P&P titled, Personal Hygiene and Appearance Policy No. 210, dated 2014, P&P indicated, All employees must wear hair restraints such as hats, hair coverings or nets that effectively keep hair from contacting with food or clean equipment while working in Dietary department. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 16 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 the proper disposal and refuse of garbage when the trash bin inside the kitchen did not have its lid on for four hours, and the dumpster outside the facility was left open. Residents Affected - Some This deficient practices had the potential to attract rodents and insects and cross-contamination of food. Findings: During an observation on 2/22/22, at 9:59 a.m., during the initial tour of the kitchen, a yellow trash bin near the dishwashing area had no lid on it. During an observation on 2/22/22, at 11:51 a.m., during tray line observation, a yellow trash bin was observed with no lid on it and the trash bin lid was tucked in between the trash bin and the wall. During an additional observation on 2/22/22, at 2:00 p.m., in the kitchen, the yellow trash bin lid was still observed with no lid on it. During a concurrent observation and interview on 2/23/22, at 6:59 a.m., with the Dietary Manager (DM), the dumpster outside the facility was observed open and the trash bin inside the kitchen was observed without a lid on it. The DM stated the trash bin and dumpster lids should be kept closed to not attract rodents. During an interview on 2/24/22, at 9:03 a.m., with the Registered Dietician (RD), the RD stated, trash bin and dumpster lids should be closed, especially, when trash is building up. The RD stated, bacteria could form in the trash bin and dumpster, leading to hazardous food conditions; and it is not sanitary to keep the trash bin and dumpster open. The RD further stated proper disposal of garbage include taking out the garbage when it is three fourths full and having the lids on at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 17 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility's administration failed to identify, update and implement it's outdated policy and procedure for bed side rail use. The facility failed to administer bed side rails without reviewing risks and benefits; obtaining an informed consent from residents/ resident representatives; and without using less restrictive alternatives prior to installing bed side rails to 29 of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25) residing at the facility. Residents Affected - Many This failure placed all 29 residents residing at the facility at risk for avoidable injuries. [cross reference F700] Findings: During a record review of the facility's undated document titled, Half side rails list, it indicated all 29 residents residing at the facility had half side rails when in bed as enabler. During an observation on 2/22/22, at 11:15 a.m., bed side rails were up on both sides of the bed for all 29 residents residing at the facility. During another observation on 2/24/22, at 9:00 a.m., bilateral (both sides) bed side rails were up again for all 29 residents. During an interview with the Director of Nursing (DON) on 2/24/22, at 10:17 a.m., the DON stated, the facility did not have documented informed consent for bed side rail use for all 29 residents residing at the facility. The DON stated, If we have to, we can create the consent. During an interview with the ADM on 2/24/22, at 12:44 p.m., the ADM stated, the facility did not have any evidence indicating the facility attempted to use alternatives prior to installing bed side rails on all 29 resident's beds. The ADM stated, the only alternative for side rails would be no side rails. During an interview and record review with the Assistant Administrator (AADM), on 02/24/22, at 11:11 a.m., the facility's (P&P) titled, Health Information Management Policy and Procedure Manual Approval Sheet was reviewed. The P&P indicated three columns: Review/Revision Date, Approval Date, and Approved by. Nine staff, including the Administrator (ADM), DON, Social Services Director (SSD) and Activities Director (AD) signed their names on the Approved by column and dated it 5/19/21 on the Approval Date column. The AADM stated, the facility reviewed and revised its P&P on an annual basis and the most recent P&P review and revision was conducted on 5/19/21. During a record review with the ADM on 2/24/22, at 12:44 p.m., the State Operations Manual Appendix PP (a manual that contains the primary survey and certification rules and guidance from the Centers for Medicare and Medicaid Services), revised on 11/22/17 was reviewed. Under F700 (a regulatory tag), it indicated, The facility must attempt to use appropriate alternatives prior to installing a side or bed rail . Assess the resident for risk of entrapment from bed rails prior to installation .Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 18 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete During a concurrent interview and record review with the Administrator (ADM), on 2/24/22, at 12:44 p.m., the facility's undated P&P titled, Siderails as enabler was reviewed. The ADM stated, he was a part of the policy review team back in 2021, however, the facility's current bed side rails P&P was not updated since 2017. The ADM further stated, the facility's P&P did not reflect the current requirements to explain the risks and benefits and to obtain an informed consent from residents or RPs prior to placing the bed side rails on residents' beds. Event ID: Facility ID: 055107 If continuation sheet Page 19 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft Avenue San Leandro, CA 94577 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their practices to maintain a clean and sanitary environment to prevent the spread of infections for five of 12 sampled residents (Resident 26, 16, 19, 25, and 27) when: Residents Affected - Some 1. Resident 26 and 19's oxygen tubing was not dated and were observed on the floor and Resident 26's humidifier was not dated, 2. Resident 19's Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) was laying on the floor; and 3. Registered Nurse 1 (RN 1) did not perform hand hygiene before preparing medications for Resident 25, 16, and 27. These deficient practices had the potential to expose Resident 26, 16, 19, 25, and 27 to possible infection. Findings: 1. During an observation on 2/22/22, at 11:00 a.m., in Resident 26's room, oxygen tubing was observed on the floor. The oxygen tubing and humidifier (a bottle that puts moisture into the air) were observed not having a date and time when it was changed. During an interview on 2/23/22, at 10:27 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, it was not ok for oxygen tubing to be touching the floor because it would expose the resident to germs and bacteria, and it could cause a possible infection. During an interview on 2/24/22, at 9:59 a.m., with the Director of Nursing (DON), the DON stated, it is important to put a date on the oxygen tubing and humidifier so nurses would know when to change the oxygen tubing and humidifier. The DON further stated, if the oxygen tubing and humidifier are used for a long-time, bacteria could grow and open a chance for infection. During a review of Resident 26's Order Summary Report, dated 2/25/22, the Order Summary Report indicated, to change the humidifier bottle every night shift every three days and to change the nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) every Tuesday night shifts. A record review of Resident 19's Order Summary dated 2/25/22, indicated a physician's order to change the nasal cannula every night shift every 6 days. During an observation on 2/22/22, at 10:18 a.m., part of Resident 19's oxygen tubing was observed on the floor while Resident 19 was using it. Resident 19's oxygen tubing was not changed for 19 days. During a concurrent observation and interview on 2/22/22, at 11:01 a.m., with LVN 1, LVN 1 stated, Resident 19's oxygen tubing was labeled on 2/3/22. LVN 1 stated the oxygen tubing should be changed every week or it can cause an infection to the resident. LVN 1 stated the oxygen tubbing should not be on the floor because it can cause infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 20 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft Avenue San Leandro, CA 94577 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 2/25/22, at 9:40 a.m. with DON stated oxygen tubing should not be on the floor and should be changed weekly to prevent infection. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy Equipment, (undated), the P&P indicated, It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner. The P&P also indicated the mask or cannula should be changed weekly and as needed to keep it free of respiratory secretions and mucus. 2. A record review of Resident 19's admission Record, dated 2/25/22, indicated Resident 19 was admitted on [DATE]. A record review of Resident 19's Order Summary dated 2/25/22, indicated a Physicians order for a Foley catheter. During an observation on 2/22/22, at 10:18 a.m., Resident 19's Foley catheter was laying on the floor. During a concurrent observation and interview on 2/22/22 at 11:01 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 confirmed Resident's 19's Foley catheter bag was laying on the floor. LVN 1 further stated the Foley catheter bag should not be on the floor because it can cause infection. During an interview on 2/25/22, at 9:40 a.m., with the Director of Nursing (DON), the DON stated the resident's Foley catheter bag should not be on the floor because of risk of infection. A record review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary (undated), the P&P indicated, be sure the catheter tubing and drainage bag are kept off the floor. 3. A record review of Resident 25's admission Record, dated 2/24/22, indicated Resident 25 was admitted on [DATE]. During an observation on 2/23/22, at 8:09 a.m., RN 1 was observed coming out of a Resident room and proceeded to prepare medications for Resident 25, without performing hand hygiene first. During an interview on 2/25/22, at 9:40 a.m., with the DON, the DON stated, hand hygiene should be performed before and after administering medications, and between residents to prevent risk of resident infection. A record review of Resident 16's admission Record, dated 2/24/22, indicated Resident 16 was admitted on [DATE]. During an observation on 2/23/22, at 8:31 a.m., RN 1 was observed dropping her medication cart keys on the floor, then placing it on the medication cart counter. RN 1 did not sanitize her keys or perform hand hygiene after handling her keys that fell on the floor. After RN 1 put her keys on the medication cart counter, RN 1 prepared Resident 16's medications on the medication cart counter. RN 1 did not sanitize the medication cart counter before preparing Resident 16's medications on it. During an interview on 2/25/22, at 9:40 a.m., with the DON, the DON stated, it is not ok to put medication keys that fell on the floor, on the medication cart counter. The DON stated, it is a risk for resident infection. The DON further stated, keys that fell on the floor should be cleaned first, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 21 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft Avenue San Leandro, CA 94577 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 and hand hygiene should be performed after touching the keys and before preparing medications. Level of Harm - Minimal harm or potential for actual harm A record review of Resident 27's admission Record, dated 2/24/22, indicated Resident 27 was admitted on [DATE]. Residents Affected - Some During an observation on 2/23/22, at 8:31 a.m., RN 1 prepared Resident 16's medication and placed them on a medication tray. Then RN 1 carried the medication tray inside Resident 16's room and placed it on Resident 16's food tray. After RN 1 administered Resident 16's medication, RN 1 took the medication tray outside the resident room and placed it on the medication cart counter. RN 1 did not sanitize the medication tray before putting it on the medication cart counter. RN 1 proceeded to then prepare medications for Resident 27 on the medication cart counter. RN 1 did not sanitize the medication cart counter before preparing medications for Resident 27. During an interview on 2/25/22, at 9:40 a.m., with the DON, the DON stated, if a medication tray is taken in a Residents room and placed on a resident's food tray, it should be cleaned with Clorox wipes after because it is a risk for infection. A record review of the facility's P&P titled, Hand Hygiene, (undated), the P&P indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-anti-microbial) and water for the following situations: . Before preparing or handling medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 22 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility to ensure kitchen equipment was maintained when the dishwasher temperature gauge (a device that measures the dishwasher temperature) did not measure the correct dishwasher water temperature. Residents Affected - Some This deficient practice resulted in inaccurate measurements and documentation of dishwasher water temperatures and had the potential for dishes to not be cleaned and sanitized at the recommended temperature. Findings: During a concurrent observation and interview on 2/23/22, at 6:59 a.m., with the Dietary Manager (DM), in the kitchen, the dishwasher gauge was observed with the recommended temperature printed on its surface, which indicated 120 degrees Fahrenheit (F, a scale of temperature) minimum. The dishwasher gauge was observed registering water temperatures below the recommended temperature on three separate dishwashing cycles: 100 degrees F on the first cycle, 114 degrees F on the second cycle, and 116 degrees F on the third cycle. The DM stated the temperature of the dishwasher water should be at 120 degrees F. During an interview on 2/23/22, at 9:53 a.m., with Dietary Staff 1 (DS 1), DS 1 stated, she just finished washing the dishes and took the dishwasher temperatures which measured between 90 degrees F and 110 degrees F. During a concurrent observation and interview on 2/23/22, at 9:53 a.m., with the DM, the DM was observed test running the dishwasher and the dishwasher gauge was observed registering a temperature of 110 degrees F. The DM was observed manually measuring the dishwasher water with a thermometer and the thermometer indicated 120 degrees F. The DM stated, the dishwasher gauge needs to be calibrated. During a follow-up observation on 2/23/22, at 2:00 p.m., in the kitchen, with the DM, the DM was observed test running the dishwasher and the dishwasher gauge registered a temperature of 118 degrees F during the test cycle. The DM was observed manually measuring the dishwasher water temperature and the thermometer indicated 122 degrees F. During an interview on 2/24/22, at 9:03 a.m., with the Registered Dietician (RD), the RD stated, the dishwasher would not properly clean the dishes if the water does not get to the recommended temperature. RD stated, it might cause food borne illness if dishes are not properly cleaned FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 23 of 24 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 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide one of one sampled resident in room [ROOM NUMBER] with at least 80 square feet per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside. After observation and interview, there was adequate space for the resident and staff to move about without obstruction. Recommend granting waiver. Findings: During a concurrent observation and interview, on 2/24/22 at 11:30 a.m., with the Administrator (ADM), room [ROOM NUMBER] was observed with two beds. The room measured 181.5 inches by 121 inches, with a total of 152.5 square feet. The ADM stated the room is below the standard of 80 square feet per resident and a double occupancy room should measure 160 square feet. There were no negative consequences attributable to the decreased space in room [ROOM NUMBER]; nor were any safety concerns noted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 24 of 24