Health inspection·November 16, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and record review, the facility failed to ensure one (Resident 24) sampled resident's Pre-admission Screening Resident Review (PASRR) for serious mental illness was accurately completed and referred to the appropriate state mental authority for Level II evaluation and determination. This failure had the potential to prevent Resident 24 from receiving appropriate required mental health services. Findings: Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 10/13/23, indicated the PASRR was coded zero-meaning, Resident 24 was not considered by the State Level II PASRR process to have a serious mental illness. However, Resident 24's diagnoses included Bipolar disorder (mood disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the PASRR screening dated 9/13/22 indicated Resident 24 did not have a diagnosed mental disorder such as depression, anxiety, panic and/or mood disorder. During an interview and concurrent record review, on 11/14/23 at 11:10 a.m., with Registered Nurse/MDS coordinator (MDS), MDS stated the Administrator (Admin) or designee was responsible for completing the PASRR. MDS stated Resident 24's PASRR was not completed accuratelyand Resident 24 diagnosis included Bipolar disorder a mental illness. MDS further stated Resident 24 was not referred to the State Mental Authority for specialized mental health services. During an interview on 11/15/23 at 9:28 a.m., Admin stated he or the Business Office Manager completed the residents' PASRRs. Admin stated he did not recognize that Resident 24's diagnosis included Bipolar disorder when the PASRR was completed. Review of the facility's policy and procedure titled, PASRR Screening (undated), indicated the facility will complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 2 of 6 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 11/16/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement the nutritional interventions for one (Resident 29) of one sampled resident with significant weight loss. Residents Affected - Few This failure had the potential to result in continuous weight loss, fluid imbalance, and dehydration. Findings: Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 8/18/23, indicated Resident 29 had weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Resident 29 was not on a physician-prescribed weight-loss regimen. Resident 29 had diagnoses that included heart failure (e.g. congestive heart failure or CHF and pulmonary edema- a chronic condition in which the heart doesn't pump blood as well as it should) and diabetes mellitus (high blood sugar). Review of the weight and vital summary, dated 4/1/2023 through 11/30/2023, indicated Resident 29's weight record as follows: 4/2/23 - 89 lb 7/7/23 - 80 lb 10/1/23 - 75.9 lb 11/5/23 - 71.4 lb Review of the Nutrition/Dietary Notes dated 10/13/23, indicated Resident 29 has a significant weight loss of 7.4 lb weight loss in 90 days and 13.4 lb weight loss in 180 days. Resident 29 ate on average, 25% of meals during the last 14 days. Resident 29 refused 3 meals during the last 14 days. The interventions included a liberalized diet, provide magic cup (reduced sugar) daily, provide diabetic snack at hour of sleep, honor resident's food and beverage preferences, Med Plus 2.0 (4 oz) twice a day, provide high caloric snacks in between meals, Vitamin C 500 mg (milligram) or anemia, folate, iron, and B 12 supplements for anemia, check for dehydration signs and symptoms, fluids less or equal to 1,450 ml (milliliter) /day (CHF), 800 ml/day from nursing (staff) and 2-3 cups/day from dietary. Review of the unplanned weight loss care plan initiated 12/13/22, indicated Resident 29 had unexpected weight loss related to poor meal intake, and interventions included to alert the dietician if consumption is poor for more than 48 hours, and if (weight) loss persists, contact the physician and dietician immediately and offer substitutes as requested or indicated. During an interview on 11/15/23 at 12:16 p.m., with Registered Dietician (RD), RD stated Resident 29 had significant weight loss. RD stated Resident 29 had an individual, liberalized diet and on comfort care. RD stated she expected staff to implement Resident 29's nutrition interventions, including fluid requirement due to diagnosis of CHF. RD stated she expected a fluid intake record to be kept in Resident 29 medical records. RD stated she communicated Resident 29's nutrition interventions with the Director of Nursing (DON), Dietary Supervisor (DS) and Administrator(Admin). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 3 of 6 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 11/16/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and concurrent record review on 11/15/23 at 2:12 p.m., with Registered Nurse (RN 1), RN 1 stated she was not aware Resident 29's fluid intake needed to be recorded and was not recorded or aware of the 10/13/23 nutrition interventions. During an interview and concurrent review of Resident 29's nutrition interventions, on 11/15/23 at 2:30 p.m., DON stated Resident 29's nutrition interventions were not acted upon because Resident 29 was on comfort care and and there was no need to monitor Resident 29's fluid intake. DON stated the RD and physician were not informed that Resident 29's nutrition interventions would not be acted upon. During an interview on 11/16/23 at 9:09 a.m., DON stated RD notified her of Resident 29 nutrition interventions and recommendations. DON stated Resident 29's nutrition interventions were not implemented or acted upon. Review of the facility's policy and procedure titled, Weight Assessment and Intervention, undated, indicated the interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Interventions for undesirable weight loss shall be based on careful consideration of the followings: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 4 of 6 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 11/16/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (Resident 20) of five sampled residents was free from unnecessary drugs when the pharmacist's recommendation for reviewing the justifciation of the continued use of Benadryl (antihistamine/allergy) medication ordered PRN (as needed) was not acted upon. Definition: Benadryl is an antihistamine drug use for relief of allergic symptoms with warning that included central nervous depression which may impair physical or mental abilities, patient must be caution about performing tasks that required alertness}. Reference: https://online.[NAME].com. This failure had the potential for adverse medication side effects and not identifying other causes of itchy skin (dry skin, allergic reactions or other skin conditions). Findings: Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 9/27/23, indicated Resident 20 had diagnoses that included chronic lung disease. Resident 20 was on hospice (end-of life) care. Review of the physician order dated 6/23/2023 indicated Resident 20 to receive Benadryl allergy oral tablet 25 mg (mill8gram) give one tablet by mouth every 4 hours as needed for itching. Review of the Medication Administration Record (MAR), dated 10/1/2020 through 10/31/2023, indicated Resident 20 received Benadryl 25 mg one tablet as needed one to three times a day for itching. Further review of the MAR, dated 11/1/23 through 11/1/15, indicated Resident 20 received Benadryl 25 mg one tablet as needed one to two times a day. Review of the Consultant Pharmacist (CP) Medication Regimen Review (MRR) dated 9/8/23 indicated Resident 20 has been taking Benadryl mostly at bedtime for itching. Please clarify the reason for this condition and if there is any other treatment we are doing to resolve this condition. During a review of Resident 20's MRR and concurrent interview on 11/14/23 at 12:52 p.m., with the Director of Nursing (DON), DON stated for Resident 20, CP's recommendations dated 9/8/23 was not acted upon. DON stated there was no stop date for Benadryl as needed because Resident 20 continued to request Benadryl. DON further stated there was no monitoring of Benadryl for adverse side effects. During an interview on 11/16/23 at 9:59 a.m., with Registered Nurse (RN 1) RN 1 stated when an as needed order has no stop date, the physician will be called for clarification. RN 1 said Resident 20 was on hospice care. RN 1 stated she did not know what to do regarding as needed medication orders for residents on hospice care. Review of the facility's policy and procedure, Titled, Medication Regimen Review undated indicated, the primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medication appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 5 of 6 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 11/16/2023 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 and interview, the facility failed to ensure storage of food under sanitary conditions when; Residents Affected - Some - one carton of thickened Apple Juice from concentrate was opened with no use- by-date; - three containers of mayonnaise opened with no use-by-date; - five brownish, discolored juice cups ready for use; - one container of chopped garlic in oil opened with no use- by-date; - staffs' personal food items of tea, cooked eggs and cell phone were placed on the kitchen preparation table; - two bags of vegetables placed on the 2-compartment sink next to dishwashing area. These failures had the potential to result in food borne illness for residents who received food from the facility's kitchen. Findings: During the initial tour of the kitchen on 11/13/23 at 9:10 a.m., accompanied by the Dietary Manager (DM), the following were observed: one cartoon of thickened Apple Juice from concentrate was opened with no use- by-date; three containers of mayonnaise opened had no use-by-date; five brownish discolored juice cups ready for use, and one container of chopped garlic in oil opened with no use- by-date. During a follow up visit to the kitchen on 11/13/23 at 10:18 a.m., accompanied by DM, observed staffs' food items of tea, cooked eggs, cell phone placed on the kitchen table and two bags of vegetable were placed on the two compartment sink next to the dishwasher. During an interview on 11/13/23 at 10:18 a.m., DM stated the cooked eggs, cup of tea, and cell phone belonged to staff. DM stated staff are not allowed to eat in the kitchen. DM said the two-compartment sink are supposed to be used for dish washing during emergencies. During an interview on 11/14/23 at 11:31a.m., [NAME] (CK), CK stated the two-compartment sink was used for thawing food items, such as meat, vegetables etc. During an interview on 11/16/23 at 9:48 a.m., DM stated the kitchen did not have enough space for a food prep sink and that was the reason the vegetable and meat are thawed in the two- compartment sink. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 6 of 6