Health inspection·October 10, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 22's POLST form dated 2/16/23, the form indicated no information on the presence of an advanced directive. During a review of Resident 24's admission Record, dated 10/8/24, the record indicated Resident 24 was admitted to the facility on [DATE]. Residents Affected - Some During a review of Resident 24's MDS dated [DATE], the MDS indicated Resident 24's cognition was moderately impaired. During a review of resident 24's POLST form dated 4/24/23, the form indicated no information on the presence of an advanced directive. During a concurrent interview and record review on 10/7/24, at 3:30 p.m., with SSD, Resident 17, 2, 22 and 24's medical records were reviewed. SSD stated advanced directives were discussed with the Resident 17, 2, 22, and 24's responsible parties, but SSD was not able to provide documentation. During an interview on 10/9/24, at 3:31 p.m., with SSD, SSD stated the importance of advanced directive was for the residents' wishes regarding health decisions to be honored. During an interview on 10/10/24, at 11:25 a.m., with the Director of Nursing (DON), the DON stated the importance of advance directives was to help ensure that the residents' wishes for medical care were carried out in case the resident becomes incapacitated. During a review of the facility's policy and procedure (P&P) titled (Advanced Directives), indicated, . 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advanced directives. 4. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. 5. If the resident indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 2 of 17 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 10/10/2024 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** Based on observation, interview and record review, the facility failed to ensure two of two sampled residents' (Resident 4 and 21) rooms had comfortable and safe temperature levels. This failure had the potential to cause overheating in residents and discomfort during severe hot weather. Findings: During a review of Resident 4's Annual Minimum Data Set (MDS - Resident assessment and care guide tool), dated 5/24/24, the MDS indicated Resident 4's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 14 and indicated intact mental status. The MDS indicated Resident 4 was able to recall the correct year and month. The MDS indicated Resident 4 had clear speech, able to express her ideas and wants, and understood what others said to her. Resident 4's diagnoses included stroke. During a concurrent observation and interview on 10/08/24 at 8:03 a.m. Resident 4 laid in bed with loose-fitted clothes, awake and verbally responsive. Resident 4 stated her room was hot and uncomfortable in the afternoon despite the use of fan. Resident 4 stated her room temperature was 83 degree Fahrenheit (º F) at nighttime. Resident 4 stated she sweated through the night. Resident 4 said facility had no air conditioning. Resident 4 showed surveyor a table thermometer she kept at her bed side indicated room temperature was 80º F. Resident 4 said facility placed a fan in the hallway that blows hot air into her room. Resident 4 stated it was uncomfortable to sleep. During a facility tour on 10/08/24 at 8:51 a.m. with Environment Supervisor (ES), observed one big standing fan in the hallway next to Resident 4's room. The following rooms air temperature were checked: Resident 4's room was 80.4 ºF, room [ROOM NUMBER] was 78ºF, room [ROOM NUMBER] was 80.9ºF, room [ROOM NUMBER] was 81.3ºF, room [ROOM NUMBER] was 80.ºF, and room [ROOM NUMBER] was 80.2º F. During an interview on 10/8/24 at 8:51 a.m. with ES, ES stated facility had no air-conditioning. ES stated Certified Nursing Assistants (CNAs) informed him that residents' room [ROOM NUMBER] and 12 were hot. ES stated he checked room temperature and placed a fan close to the room. ES stated he did not document the temperature readings for residents' rooms. During a review of Resident 21's Annual Minimum Data Set, dated [DATE], the MDS indicated Resident 21's Basic Interview of Mental status score was 14 and indicated intact mental status. The MDS indicated Resident 21 was able to recall the correct month and day of the week. The MDS indicated Resident 21 had clear speech, able to express her ideas and wants, and understood what others said to her. Resident 21's diagnoses included Asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). During a concurrent observation and interview on 10/08/24 10:01 a.m. with Resident 21, Resident 21 sat up in bed in her room, awake and verbally responsive. Resident 21 stated she wore loose clothing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 3 of 17 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 10/10/2024 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 because it was hot in her room. Resident 21 stated at night she opened up all the windows in her room. Resident 21 stated it was uncomfortable to sleep. During an interview on 10/8/24 at 9:21 a.m. with the Administrator (Admin), Admin stated she was aware that facility had no air conditioning. Admin stated she was concerned and provided in service to the staff about heat wave and what to do. Admin stated she discussed her concern with the management. Admin said facility will address what to do for nighttime heat. During an interview on 10/08/24 at 12:05 p.m. with CNA 1, CNA 1 stated over the weekend room [ROOM NUMBER] was very hot on Saturday. CNA 1 stated the fan in resident room [ROOM NUMBER] was faulty and was not working. CNA 1 stated she asked laundry staff but there was no available replacement fan. CNA 1 stated she did not notify the charge nurse that room [ROOM NUMBER]'s fan was not working, and no replacement fan was available. CNA 1 stated she kept the residents' comfortable with light clothing. During an interview on 10/08/24 at 12:10 p.m. with the Operations Manager (OPM), OPM stated the facility was an old building and did not have air-conditioning. OPM stated he had discussed issue of heat with the owner with consideration for installing air conditioning. During a review of the National Weather Service (NWS) Advisory Hazardous Heat Warning, dated 10/5/24, the NWS indicated, Hazardous heat will be ever present this weekend. Dangerously hot conditions with temperatures up to 105º F. Excessive heat warning remains in effect for Alameda, Contra [NAME], San Francisco and Santa [NAME] counties. {Reference : https://x.com/NWSBayArea/status}. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, undated, the P&P indicated: The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflects 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 4 of 17 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 10/10/2024 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 0641 Ensure each resident receives an accurate assessment. 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 ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), accurately reflect the assessment status for two (Resident 4 and 12) of fourteen sampled residents when Residents Affected - Few 1. Resident 4's MDS section G did not reflect limitation in range of motion to upper and lower extremities (hip, knee, ankle, foot), and 2. Resident 12's MDS section K did not reflect a significant weight loss. These failure had the potential for residents to not receive appropriate care and services. Findings: 1. During a review Resident 4's admission Record (AR), AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis of knee (the wearing down of the protective tissue at the ends of bones cartilage occurs gradually and worsens over time). During a review of Resident 4's care plan review date 9/11/24, the care plan indicated Resident 4 had limited physical mobility to upper and lower extremities related to weakness, osteoarthritis of knee and total care. During a review of Resident 4's Annual Minimum Data Set (MDS), Resident Assessment and Care Screening tool used to guide care, dated 5/24/24, Section G indicated Resident 4 had no limitation in range of motion to upper and lower extremities. During a concurrent observation and interview on 10/9/24 at 12:15 p.m. with the Director of Nursing (DON), and Registered Nurse/MDS coordinator (RN 1), in Resident 4's room, Resident 4 laid in bed both feet elevated on pillow, awake and verbally responsive. Resident 4 stated her right foot dragged to the side when she laid in bed and had to call for assistance to pull her foot back to position. Resident 4 stated she needed exercise therapy. During a concurrent interview and record review on 10/9/24 at 12:25 p.m. with RN 1, Resident 4's MDS section G dated 5/4/24 was reviewed. MDS section G indicated Resident 4 had no limitation in range of motion to lower extremities. RN 1 stated Resident 4's MDS section G limitation in range of motion was not coded accurately. 2. During a review Resident 12's admission Record (AR), AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included Dysphagia (difficulty swallowing). During a review of Resident 12's Annual Minimum Data Set (MDS), Resident Assessment and Care Screening tool used to guide care, dated 7/29/24, Section K weight loss indicated, Resident 12 had no weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. During a concurrent interview and record review on 10/09/24 at 1:26 p.m. with the Registered Dietician (RD), Resident 12's Nutrition/Dietary Note, dated 7/18/2024 was reviewed. The Nutrition note indicated, Resident 12 had a significant 9.3-pound weight loss in 90 days (5.8%) in 90 days, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 5 of 17 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 10/10/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few significant 17.4-pound weight loss in 180 days (10.3%) in 180 days (from dates December 2023-June 2024). RD stated Resident 12 had significant weight loss in the last six months. During a concurrent interview and record review on 10/10/24 at 9:46 a.m. with the Dietary Manager (DM), Resident 12's weight record was reviewed. Resident 12's weight record indicated the following: 6/4/24 = 152.5 pounds (#), 7/2/24 = 143#, 8/2/24 = 147#, 9/3/24 = 138# and 10/1/24 = 128#. DM stated he was responsible for entering data for section K weight loss. DM stated Resident 12 had significant weight loss. DM stated MDS section K was not coded accurately. DM stated he did not calculate the weight variance correctly. During a review of the facility's policy and procedure (P&P) titled, MDS-Comprehensive Assessments undated, the P&P indicated, Comprehensive assessment are conducted to assist in developing person-centered care plans. A significant error is an error in an assessment where the resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an inappropriate plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 6 of 17 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 10/10/2024 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 use the communication binder (a communication visual tool that is used to help residents communicate their needs) for three of three sampled non-English speaking or aphasic (a language disorder that affects how you communicate) residents (Resident 25, Resident 24, and 17) when: Residents Affected - Some 1. Resident 25 and 24's communication binders were not used, and 2. Resident 17 did not have a communication binder. This failure had the potential for Residents 25, 24 and 17 not to understand and carry out activities of daily living (ADL). Findings: 1. During a concurrent observation and interview on 10/9/24, at 10:00 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 25's room, LVN 1 could not understand Resident 25 as Resident 25 spoke only in her native language. LVN 1 stated she could only communicate with Resident 25 through gestures and pointing. LVN 1 stated she did not know what language Resident 25 spoke. During a review of Resident 25's admission Record, dated 10/10/24, indicated Resident 25 was admitted to the facility on [DATE] and the resident's primary language was [NAME] (language of the country [NAME]). During a concurrent observation and interview on 10/9/24, at 10:40 a.m., with the Director of Nursing (DON), in Resident 25's room, the DON found Resident 25's communication binder inside Resident 25's bedside table drawer. The DON stated the binder should be on top of the bedside table so it was easily seen and used by staff. During a review of Resident 24's admission Record, dated 10/10/24, the record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity). The record further indicated Resident 24's primary language was Chinese. During a review of Resident 24's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/24, the MDS indicated Resident 24's cognition was mildly impaired. During a concurrent observation and interview on 10/9/24, at 10:09 a.m., with the DON, in Resident 24's room, the DON found Resident 24's communication binder inside Resident 24's bedside table drawer. During an interview on 10/10/24, at 10:30 a.m., with the Certified Nursing Assistant (CNA) 3, stated he could only communicate with the resident through gestures and pointing. CNA 3 stated he did not know that the resident had a communication binder. 2. During a review of Resident 17's admission Record, dated 10/10/24, the record indicated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 7 of 17 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 10/10/2024 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 17 was admitted to the facility on [DATE] with diagnoses that included aphasia following cerebral infarction (aphasia is a disorder that affects how a person communicates, cerebral infarction is a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die). During a review of Resident 17's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 6/28/24, the MDS indicated Resident 17 only sometimes understood others and was only sometimes understood by others. During a concurrent observation and interview on 10/9/24 at 10:45 a.m., with the DON in Resident 17's room, the DON could not find Resident 17's communication binder. DON further stated Resident 17 was supposed to have the communication binder at bedside to be able to communicate needs. During a review of the facility's policy and procedure (P&P) titled (dignity and communication), indicated, . 6. Residents who speak a different primary language other than the primary language of the facility can use some of the following resources: a. translators, including language applications for real-time translations. b. language communication boards . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 8 of 17 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 10/10/2024 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 observation, interview and record review, the facility failed to ensure one (Resident 32) sampled resident on tube feeding (Tube feeding refers to the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum. It is also referred to as an enteral feeding.) maintained acceptable nutritional status and body weight range when Resident 32's unplanned weight loss was not reevaluated with appropriate interventions by the Registered Dietician (RD), and the facility did not notify the physician and responsible party of Resident's 32 unplanned weight loss. Residents Affected - Few This failure had the potential to result in Resident 32's dehydration and unplanned weight loss. Findings: During a review of Resident 32's admission Minimum Data Set (MDS - Resident assessment and care guide tool), dated 7/29/24, the MDS indicated Resident 32's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 00 and indicated impaired mental status. The MDS indicated Resident 32 received nutrition through abdominal feeding tube Resident 32's diagnoses included stroke and Non-Alzheimer's Dementia ((a group of diseases characterized by progressive deficits in behavior, executive function, or language). During a review of Resident 32's Order Summary Report, dated 7/3/24, the order indicated, physician prescribed Resident 32 to receive tube feeding diet, tube feeding texture and NPO (nothing by mouth). Further review of Resident 32's order summary report dated 7/6/24 indicated physician prescribed Jevity (calorically dense, fiber-fortified therapeutic nutrition and liquid food) 1.2 kcal, 45 ml/hr. for 20 hours per day via continuous drip 4 hours off per day. Provide total volume of 900 ml, 1080 kcals, 50 grams protein and 725 ml free water. During a review of Resident 32's weight summary report, dated 7/3/24 through 10/7/24, the report indicated: 7/3/24 Resident 32 weighed 94 pounds (#) 7/9/24 Resident 32 weighed 92.5# 7/16/24 Resident 32 weighed 84# 7/23/24 Resident 32 weighed 84#. 7/30/24 Resident 32 weighed 83.5# 8/2/24 Resident 32 weighed 83.1# 9/6/24 Resident 32 weighed 81# 10/7/24 Resident 32 weighed 82# (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 9 of 17 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 10/10/2024 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 Further review of Resident 32's weight summary report dated 7/3/24 through 10/7/24, indicated: Resident 32 had weight loss of 7.5% or 10.5 # change comparison weight on 7/9/24 and 10% change weight comparison 12# weight loss in 3 months. During a concurrent interview and record review on 10/9/24 at 1:41 p.m. with Registered Dietician (RD), Resident 32's weight summary record dated 7/3/24 through 10/7/24 was reviewed. The weight report indicated Resident 32 had a significant weight loss of 10.5# comparison weight 7/9/24 and 12# weight loss in 3 months. RD stated Resident 32 was on tube feeding and had nothing by mouth. RD stated Resident 32 weight loss was unplanned weight loss. RD said she did not notice that Resident 32 had a weight loss. RD stated she had not reevaluated Resident 32 tube feeding intake. RD stated she was not informed of Resident 32's weight changes. During a concurrent interview and record review on 10/9/24 at 1:20 p.m. with Licensed Vocational Nurse (LVN 3), Resident 32's weight summary record dated 7/3/24 through 10/7/24 was reviewed. LVN 3 stated Resident 32 had significant weight loss. LVN 3 stated he did not notify the physician and responsible party of Resident 32's significant weight loss. LVN stated he believed the Director Of Nursing (DON) will follow up on weight loss. LVN 3 stated was supposed to notify the family and doctor. During a review of Resident 32's potential nutritional care plan, Resident 32's nutrition risk care plan did not address significant weight loss with appropriate interventions. During a concurrent interview and record review on 10/9/24 at 11:05 a.m. with DON, Resident 32's Progress Notes dated 7/3/24 to 10/3/24 was reviewed. DON stated there was no documentation that Resident 32's responsible party and physician were notified of significant weight loss. DON stated facility's protocol was for licensed nurses to notify family and physician. DON stated its important to notify physician to reevaluate residents' nutritional status and for residents to get adequate and proper nutrition. DON stated residents' family should be notified of weight loss because responsible parties have the right to know and may have input to support care. DON stated RD had the access to electronic record to review residents weight variances. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention undated, the P&P indicated, The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change have been met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 10 of 17 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 10/10/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one (Resident 18) sampled resident was free from unnecessary drugs when Resident 18 with diagnosis of Alzheimer Dementia was administered Seroquel (Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior) medication without adequate clinical indication for continued usage. This failure had the potential for Resident 18 to receive unnecessary medications and had the potential for the Resident 18 to suffer adverse medication side effects. Findings: During a review of Resident 18's Significant change in status-Minimum Data Set (MDS, Resident Assessment and care guide tool), dated 5/17/24, indicated Resident 18's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 18's score was 01 and indicated poor cognition. Resident 18 had no physical or verbal behavioral symptoms directed towards others e.g., hitting, kicking, pushing, scratching, grabbing or screaming at others. MDS indicated Resident 18 did not exhibit behavior of rejection of care. Resident 18's diagnoses included Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 1's Order Summary Report dated 3/2/24, the order indicated the physician prescribed Resident 18, Seroquel oral tablet 25 mg give one tablet by mouth two times a day related to unspecified dementia without behavioral disturbance, psychotic disturbances manifested by kicking/hitting to others. During a review of the Medication Administration Record (MAR), dated 9/1/24 to 9/31/24 indicated Resident 18 was administered Seroquel 25 mg one tablet by mouth two times a day related to unspecified dementia manifested by kicking/hitting others. During an observation on 10/7/24 at 10:08 a.m. Resident 18 sat up in bed awake, alert and non-English speaking. Resident 18 had a laptop on her and listened to non-English program. During an interview on 10/8/24 at 2:35 p.m. Social Service Director (SSD) stated Resident 18 had no behavioral symptoms of hitting or kicking. SSD stated Resident 18 attended activities every day and had supportive family that visited daily. During an interview on 10/8/24 at 2:40 p.m. with Certified Nursing Assistant (CNA 4), CNA 4 stated Resident 18 had no behavior of hitting or kicking during care. CNA 4 stated Resident 18 attended activities and her family visited every day During an interview on 10/09/24 at 9:16 a.m. with the Director of Nursing (DON), the DON stated she was informed by CNAs that Resident 18's behavior symptoms included kicking and hitting care giver during evening time. The DON stated Resident 18 did not have behavior all the time but it depended on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 11 of 17 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 10/10/2024 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 0758 from day to day. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 18's Preadmission Screening and Resident Review (PASRR) screening dated 1/25/24, the PASRR (Preadmission Screening and Resident Review is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.) indicated Resident 18 had no Serious Mental illness. Residents Affected - Few According to the Seroquel manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular (e.g. heart failure, sudden death). [Reference: https://www.[NAME].com/seroquel]. During a review of facility's policy and procedure (P&P) titled, Antipsychotic Medication Management undated, the P&P indicated Residents will not receive medications that are not clinically indicated to treat a specific condition. Antipsychotic medications will not be used if the only symptoms are one or more of the following; wandering, restlessness, impaired memory, inattention or indifference to surroundings, nervousness, uncooperativeness . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 12 of 17 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 10/10/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling when: 1. One box of expired blood glucose test strips (small, disposable plastic strips that measure blood sugar levels) for Resident 137 was stored in the medication room, 2. A bottle of liquid Lorazepam (medication used to treat anxiety) which belonged to a deceased resident was stored in the refrigerator in the medication room, and 3. A bottle of expired Senna (laxative) tablets was stored in the medication cart 2. These failed practices could contribute to unsafe medication use in the facility. Findings: 1. During a concurrent observation and interview on 10/7/24 at 10:20 a.m. with the Director of Nursing (DON), one box of expired blood glucose test strips with an expiration date of 2/25/21 for Resident 137 was found stored in the medication storage room. DON stated the expired blood glucose strips should have been disposed. Review of Resident 137's admission Record (AR) dated 10/10/24, indicated Resident 137 was admitted on [DATE] with diagnoses that included Diabetes Mellitus (a disease of inadequate control of blood levels of sugar). The AR indicated Resident 137 was discharged on 3/19/20. Review of Resident 137's Physician's Order indicated an order with a start date of 2/28/20 of Sliding Scale Insulin before meals and bedtime (Insulin is a hormone that regulates blood sugar levels in the body. Sliding scale meant the insulin dose the resident would receive before the resident's meals and bedtime was based in the blood sugar level result). 2. During a concurrent observation and interview on 10/7/24 at 10:25 a.m. with the DON, one bottle of liquid Lorazepam that belonged to Resident 15 was found stored in medication room refrigerator. DON stated that the resident was already deceased . DON also stated the Lorazepam should have been disposed. Review of Resident 15's AR dated 10/10/24 indicated Resident 15 was admitted to the facility on [DATE]. The AR also indicated that Resident 15 expired on 9/27/24. Review of Resident 15's Physician's order indicated an order with a start date of 8/15/24, of Lorazepam 2mg./ml., give 0.5 ml. by mouth every 12 hours as needed (mg. is milligrams and ml. is milliliters, mg. and ml. are forms of measurement). 3. During a concurrent observation on 10/7/24 at 3:00 p.m. with the DON present, the medication cart 2 had a bottle of the medication Senna (laxative) tablets with an expiration date of 6/2023. During an interview on 10/10/24, at 11:25 a.m., with the DON, the DON stated the expired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 13 of 17 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 10/10/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete medications should have been disposed because the residents might suffer adverse side effects if they received the expired medications. During a review of the facility's policy and procedure (P&P) titled Medication Storage, Storage of Medication dated 2007, the P&P indicated, .14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock disposed of according to procedures for medical disposal . Event ID: Facility ID: 055107 If continuation sheet Page 14 of 17 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 10/10/2024 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 - Few 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 ensure one (Resident 7) sampled resident received and consumed foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician when Certified Nursing Assistant (CNA 5) served Resident 7 a meal tray of pureed diet that belonged to Resident 13. This failure had the potential to cause residents to receive and consume foods that are not in the appropriate texture and nutrient content to support the resident's needs cause choking or food allergy. Findings: During a review of Resident 7's Significant change in status-Minimum Data Set (MDS - Resident assessment and care guide tool), dated 12/25/23, the MDS indicated Resident 7's was on a mechanically altered diet. Resident 7 needed partial to moderate assistance with eating. The MDS indicated Resident 7's diagnoses included Aphasia (a language disorder that affects a person's ability to communicate) and stroke. During an observation on 10/8/24 at 12:10 p.m. in the Dining Room (DR) there were six residents eating in the dining room. Observed Certified Nursing Assistants (CNAs) serving meal trays to residents. Residents started eating, light music played with activity staff present in the dining room. Resident 7 was served a tray of puree food by CNA 3. Resident 7 started to eat from the plate. During an observation on 10/8/24 at 12:25 p.m., CNA 2 came into the dining room with a meal tray, presented a meal tray to Resident 7, swapped his meal and left. During an interview on 10/8/24 at 12:26 p.m. with CNA 2, CNA 2 stated she swapped Resident 7's meal tray because Resident 7 was served Resident 13's meal tray. CNA 2 stated it was very important to check that the right resident received the correct meal tray for residents' safety. During a review of Resident 7's physician order dated 3/14/24, physician ordered Resident 7 to receive regular diet mechanical soft texture, thin consistency for increase fiber. During a review of Resident 13's physician order dated 6/9/21, the physician ordered Resident 13 to receive fortified diet pureed texture, honey consistency, related to dysphagia, oropharyngeal large portion. During an interview on 10/8/24 at 12:13 p.m. with CNA 3, CNA 3 stated it was important to check names to make sure the right resident received the right diet order. CNA 3 stated it was also important because some residents were diabetic or allergic to some food items. During an interview on 10/8/24 at 12:53 p.m. with the DON, the DON stated the facility's protocol was that licensed nurses were responsible to check meal trays before CNAs served residents. The DON stated CNAs should also check the names on the tray. The DON stated residents should receive the right diet as ordered to prevent choking or allergy. During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals undated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 15 of 17 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 10/10/2024 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 the P&P indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Facility staff will serve resident trays accurately and will help residents who require assistance with eating. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 16 of 17 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 10/10/2024 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 had one residents' room (room [ROOM NUMBER]) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied this room. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings. Findings: During an observation on 10/8/24 at 12:14 p.m., in room [ROOM NUMBER], in the presence of Certified Nursing Assistant (CNA) 1, room [ROOM NUMBER]'s corresponding sq. ft per bed was identified: Room Floor Area 12 76.26 sq. ft During an observation on 10/8/24 at 12:14 p.m., room [ROOM NUMBER] had two beds with residents laid in bed awake and nonverbal. During a concurrent observation and interview on 10/8/24 at 12:15 p.m. with CNA 1 in room [ROOM NUMBER], CNA 1 stated there was enough space to conveniently provide care for residents in the rooms and for residents that needed Hoyer lift. CNA 1 stated bed was lowered and moved to use the Hoyer lift. CNA 1 stated there was no heavy equipment kept in the room that might interfere with residents' care and each resident had adequate personal space and privacy. There were no negative consequences attributed to the decreased space in room [ROOM NUMBER]. Granting of room size waiver recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055107 If continuation sheet Page 17 of 17