Health inspection·May 27, 2021

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation and interview, the skilled nursing facility's staff did not maintain an environment free from abuse for two, Residents 9 and 353 of 17 sampled residents. Resident 353 and 9 were engaged in verbal abuse and not separated by staff as soon as possible. This failure resulted in unnecessary verbal abuse. Findings: During an interview with Resident 353 on 5/25/21 at 9 a.m., Resident 9 (roommate) was observed yelling out, Nurse, nurse! Resident 353 said to Resident 9 Shut up. Resident 9 then stated, No, you shut the h### up! In an interview, on 5/25/21 at 9:10 a.m. Licensed Vocational Nurse 3 (LVN 3) stated she was not aware of any issues between Residents 353 and 9, but she would Let the social worker know. LVN 3 did not initiate separating the roommates. In an interview on 5/25/21 at 9:12 a.m., the Certified Nursing Assistant 5 (CNA 5) stated, Sometimes his roommate (Resident 353) is in a bad mood. In an interview on 5/25/21 at 9:15 a.m., Resident 353 stated, Did you hear him yell? Did you hear that? See what I have to put up with? I want him to move to another room. In an interview on 5/25/21 at 10:30 a.m., the facility's Director of Nursing (DON) stated she went to check on Residents 353 and 9 and believed the situation was under control. However, as DON was walking out of the room, she overheard the roommates bickering, I did not say that. Yes, you did. No I didn't. DON confirmed she did not further investigate what they were arguing about and did not separate the residents. In an interview on 5/25/21 at 2:50 p.m., (5 hours and 50 minutes since staff were first made aware of the verbal altercation), the facility's Social Service Director (SSD) stated no one told him about the negative interactions between Residents 535 and 9. SSD stated he would take care of the situation and then Resident 535 was moved to another room. Record review of the document, Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime in the Facility Policy and Procedure, (not dated) showed, This facility prohibits and prevents abuse .a). The facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation. This includes responding immediately with providing a safe environment for resident(s) as indicated by the situation. b. If the suspected perpetrator is another resident .I. separate the residents immediately so they do not interact with each other until circumstances of the of the reported incident can be determined. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 2 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to ensure the ombudsman (an official appointed to advocate and investigate resident complaints) was notified before discharging one (Resident 52) of three sampled residents from the facility. This deficient practice had the potential to deny protection and advocacy rights from the Ombudsman on behalf of Resident 52 from a possible inappropriate discharge or explore other available options. Findings: During a review of Resident 52's discharge records, the facility was unable to find the ombudsman notification of Resident 52's discharge from the facility. During an interview on 05/27/21 at 10 AM with the Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated They (staff) need to inform the Ombudsman for residents who are going to be discharged , and for Resident 52, they did not do that. LVN 2 she did not know why staff forgot to inform the Ombudsman about Resident 52's discharge as required. During a review of the facility's policy and procedure, Notice Requirements Before Transfer/Discharge (undated) indicated, . c. the facility will send a copy of the notice to a representative of the office of the state long-term care ombudsman . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 3 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 Based on observation, interview, and record review, the facility failed to ensure that staff consistently used available methods to communicate with Resident 36. The certified nursing assistant 1 (CNA 1) did not know the resident's primary language (Russian) and spoke Spanish to Resident 36. For Resident 10, staff failed to assist in positioning the resident appropriately for eating breakfast. Residents Affected - Few These failures resulted in staff not communicating in Resident 36's preferred language with the use of a communication board (symbols in primary language) to enable Resident 36 to communicate needs. Resident 10 ate his breakfast at a 30 degree lying position which did not promote digestion. Findings: During an observation and interview on 5/25/2021, at 10:30 a.m., Resident 36, was not speaking in English. Resident 36 did not have a posted communication board or visible communication binder in Resident 36's room. During a record review of Resident 36's admission record dated 10/12/2020,which reflected the resident's primary language is Russian. During a concurrent observation and interview, on 5/25/2021 at 10:55 a.m., CNA 2 was at Resident 36's bedside, and stated CNAs communicate with Resident 36 by using hand gestures, making eye contact, and speaking clearly and slowly. CNA 2 stated she speaks Spanish to the resident, and thinks the resident speaks Portuguese. CNA 2 further stated Resident 36 doesn't have one (communication board), and has not received an in-service on using communication boards. During a concurrent observation and interview, on 05/25/21 at 11:10 a.m., with Registered Nurse1 (RN 1), RN 1 stated non-English speaking residents, Should have one (communication binder above the Resident's bed. When RN 1 entered Resident 36's room, CNA 3 was in the room and stated, It (binder) was found in the Resident's closet. RN 1 stated the communication binder should be kept in the open and easy to find for staff. During a review of Resident 36's care plan titled, The resident has a communication problem (undated), indicated the primary language was Russian. Interventions included for staff to use alternative communication tools as needed. Monitor effectiveness of communication strategies and assistive devices .Nurse to evaluate resident's dexterity/ability to use communication board . During a review of the undated policy and procedure (P&P), Communication Barriers, Reduction of indicated, It is the policy of this facility to provide methods of communication to assure adequate communication between the resident and staff. 2. Review of Resident 10's admission record indicated he was admitted to the facility, and had diagnoses that included cognitive communication deficit, and unspecified encephalopathy (damage or disease that affects the brain). During a dining observation on 5/25/21, at 7:40 a.m., Resident 10 was unattended and lying on his left side with the head of bed slightly raised to a 30 degree angle. Resident 10 was supporting his head with his left hand, as he was facing the over-bed table and breakfast tray. Resident 10 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 4 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 picking his food with his right hand. Level of Harm - Minimal harm or potential for actual harm During an interview with the Licensed Vocational Nurse 2 (LVN 2) on 5/25/21 at 7:55 a.m., LVN 2 stated there should be no urinal on any meal tray. The urinal needs to be emptied immediately after use, disinfected, dried and kept in the drawer of Resident 10. LVN 2 further stated the head of the bed of Resident 10 should be raised higher so Resident 10 could be in an upright position while eating. Residents Affected - Few Record review of the facility policy, Serving In-Room Meals dated April 2001 indicated, the resident should be positioned so his or her head and upper body are as upright as possible, and with the head tipped slightly forward. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 5 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 provide personal hygiene assistance for two (Residents 2 and 3) of 17 sampled residents. Residents 2 and 3 had long, chipped and dirty fingernails containing a black substance underneath the nails. Residents Affected - Few This failure had the potential for the development of infection and /or skin injuries for Residents 2 and 3. Findings: A review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 2/11/2021 indicated, Resident 2 required extensive assistance for all personal hygiene activities, including cleaning of the face and hands. During an observation on 5/24/2021 at 11:30 a.m. , the chipped fingernails on Resident 2's contracted right hand extended beyond the end of the fingertips, with brown substances visible underneath the fingernails and were folded inside his palm. During an interview with the Certified Nursing Assistant 5 (CNA 5) on 5/25/2021 at 8: 45 a.m., CNA 5 stated their daily CNA routine is to cut or trim the resident's fingernails. CNA 5 further stated she had no time to trim Resident 2's fingernails. A review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/16/2021 indicated Resident 3 required total assistance for all personal hygiene activities including cleaning of face and hands. During an observation on 5/25/2021 at 11:25 a.m., the fingernails on Resident 3's right and left hand had one half-inch long nails with a black substance underneath the fingernails. During an interview with CNA 5 on 5/26/2021 at 1 p.m., CNA 5 stated she is aware Resident 3's fingernails are long with black substance underneath. CNA 5 further stated Resident 3 is combative and resistive to care so they do not cut his fingernails. Staff did not consider filing or having licensed staff assess and problem solve the resident's nail care needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 6 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to provide necessary care and services for one (Resident 2) of 17 sampled residents when Resident 2 did not have interventions in place to prevent the loss of function/mobility of Resident 2's right hand. This failure had the potential for Resident 2's contractures (a condition of shortening and hardening of muscles, tendons or other tissues, often leading to deformity and rigidity of joints) to worsen. Findings: During an observation on 5/25/2021 at 11: 48 a.m., Resident 2 was sitting in his wheelchair next to the nurses Station with his right contracted hand resting on his lap. Resident 2 was unable to move his right hand and his fingers were folded inside his palm. During an interview on 5/25/2021 at 12: 45 p.m., the Certified Nursing Assistant 5 (CNA 5) stated Resident 2 had a contracture on his right hand and was unable to open his fingers and did not do anything for his hand because Resident 2 has a restorative nursing assistant (RNA) program (certified nursing assistant with specialized training in restorative care that helps patients increase their level of strength and mobility). A review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 2/11/2021 indicated Resident 2 had upper and lower extremity impairment. Further review indicated Resident 2 was admitted with right hand contracture and right hemiplegia (partial or total paralysis on one side of the body) . During an interview and concurrent record review on 5/25/2021 at 1:15 p.m., with Registered Nurse 1 (RN 1), when asked if she was aware of Resident 2's right hand contracture RN 1 stated, I don't know, I should have trimmed his fingernails and made referral to Physical Therapy for a device. During an interview and concurrent record review on 5/25/2021 at 3: 45 p.m., with Physical Therapy 1 (PT 1), PT 1 confirmed the physician's order dated 2/1/2021 to exercise both extremities, three times a week, for three months. He reviewed the referral on 5/12/2021 but there was no intervention or treatment for Resident 2's right hand contracture. During an interview on 5/26/2021 at 11:56 a.m., RNA 1 confirmed Resident 2's right hand contracture and the nurses are aware of it. Resident 2 was unable to open his hand and fingers due to pain even when she applied baby oil. RNA 1 stated, There should be a hand roll or a carrot roll to prevent increased contracture to Resident 2's right hand. During a review of the undated P&P titled,Restorative Nursing Program indicated, 3. The facility restorative nursing program will include but not limited to the following programs: b. Mobility- transfer and ambulation, including walking, prosthetic and or splint application with or without active and or passive range of motion, bed mobility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 7 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to maintain supervision for one (Resident 12) to ensure the safety of all residents. Resident 12 had a history of striking out at other residents and staff. This failure resulted in an unsafe environment for all residents due to a lack of continued supervision. Findings: Record review on 5/25/21 of the document, admission Record showed the facility admitted Resident 12 with diagnoses that included Dementia (decline in mental ability severe enough to interfere with daily life) with behavioral disturbances (agitation which can include verbal and physical aggression). Review of the nurse's Progress Notes dated 12/20/2020, showed Resident 12 was found in another resident's room, and asked Resident 12 to come out. Resident 12 was found holding the nursing assistant's face shield. When the CNA (certified nursing assistant) asked for the face shield, Resident 12 hit her arm several times. Resident 12 was escorted back to his room by nurse and CNA. Resident 12 came out of his room and resumed pacing. Review of the document, SBAR (situation, background, assessment and recommendation) -Change of Condition dated 5/4/21, showed Resident 12 hit another resident on the face, For no apparent reason, as he passed by. Review of the nurse's Progress Note dated 5/6/21, showed Resident 12, Still noted with episodes of striking and resistive to ADL (activities of daily living, such as bathing, eating and toileting) care. Review of the Psychosocial Note dated 5/6/21, showed Resident 12 refused to talk to the Social Services Director (SSD) and Just paced away .he does a lot of pacing in the halls. Review of the plan of care titled, Hit another resident on the face r/t (related to) behavior of striking out dated 5/4/21, showed the goal was to have no further incidence of hitting others for one month. Staff interventions included medication as ordered and to redirect Resident 12 as needed, whenever he got close to other residents. On 5/25/21 at 12:55 p.m., Resident 28 was observed sitting in his wheelchair in the hallway. Resident 12 walked down the hallway in the opposite direction. Resident 12 suddenly and without warning, clenched his fist and hit Resident 28 in the right arm. Resident 12 continued to walk down the hall. Resident 28 yelled out in pain. The licensed staff assisted and assessed Resident 28. Staff did not follow Resident 12 who was then observed pacing alone in the activity room which had other residents. Resident 12 was sent out to the hospital for evaluation. In an interview on 5/27/21 at at 9:09 a.m. , CNA 7 was observed sitting in the activity room with Resident 12. CNA 7 stated she was assigned to be with Resident 12 at all times. CNA 7 stated Resident 12 can get angry, and has hit staff and residents and has never been 1:1 (staff member stays with the resident at all times for monitoring and intervenes as needed), until now (during survey). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 8 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 0689 Level of Harm - Minimal harm or potential for actual harm In an interview on 05/27/21 at 9:18 a.m., the Licensed Vocational Nurse 5 (LVN 5) stated Resident 12 likes to walk the halls, and one day, it appeared he was eloping (leaving without permission) from the building. LVN 5 stated she intervened and asked him to return. Resident 12 then looked as if he were about to hit her so she Ran away. LVN 5 stated staff have been afraid of him. LVN 5 stated Resident 12 has never had a 1:1 before. Residents Affected - Some In an interview on 5/27/21 at 11:30 a.m., the Director of Nursing (DON) stated after the incident in May 2021, when Resident 12 hit another resident in the face, the plan was to keep him in our Line of sight at all times. DON further stated she was not aware of other interventions to ensure Resident 12 did not assault other residents. Record review of the document, Safety and Supervision of Residents dated July 2017 indicated, The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and Assistive devices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 9 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to ensure one resident (Resident 23) was seen at least once, every 60 days by the physician. The Attending Physician (MD) did not personally conduct alternate visits with Resident 23 as required. Residents Affected - Few This failure had the potential for inadequate medical care and treatment when the physician did not evaluate Resident 23. Findings: During a review for of the face sheet for Resident 23, Resident 23 had a diagnoses that included schizophrenia (a long-term mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal, from reality or fantasy). Record review of the physician's progress notes dated 1/3/21, 1/8/21, 2/6/21, 2/11/21, 2/20/21, 2/28/21, 3/6/21, 3/21/21, 3/27/21, 4/3/21, 4/10/21, 4/19/21, 4/21/21, 5/15/21 and 5/22/21 reflected the visits were all performed and documented by the nurse practitioner (NP). The NP documented on 4/10/21, That nurses informed that patient refuses to take pills. Will DC (discontinue) certain pills. Continue to monitor. The History and Physical (H&P) dated 3/21/19 indicated MD last visited Resident 23 on 3/21/19 for the annual medical evaluation. (MD was not available for an interview). During an interview on 5/25/21 at 10:45 a.m., the Social Service Designee (SSD), stated Resident 23 had manifested aggressive behavior throughout her stay at the facility, and not taking any psychotropic (antipsychotic, anti-anxiety, antidepressant, mood stabilizer, or stimulant) medication. SSD further stated MD was not available and had not seen or visited Resident 23, and there was a psych (psychiatric or psychologist) order and Resident 23 refused to allow them in her room. Record review of the Behavioral Consultation notes dated 8//24/20 indicated Resident 23 will not be able to function with her day-to-day life without the support of psychotropic medication. Discussed with the treatment team to try to find appropriate placement for her. If symptoms persist and worsen, Resident 23 will benefit from inpatient psychiatric hospitalization for stabilization of symptoms. During an interview on 5/26/21 at 8:02 a.m., the Licensed Vocational Nurse 1 (LVN 1) stated Resident 23 refused psychotropic medications and the medication was discontinued. LVN 1 further stated MD had not visited Resident 23. During an interview on 5/27/21 at 8:34 a.m., the Director of Nursing (DON) could not provide MD's reevaluation of Resident 23 after 3/12/19. DON stated Resident 23 can be verbally abusive and aggressive, accusatory, refusing care, food, rehabilitation services, and refusal of medications. DON further stated she was not aware of the behavioral consultation report and recommendations dated 8/20/20 and MD was not available due to a health condition. During an interview on 5/25/21 at 9:39 a.m., the Administrator (Admin) stated MD had not visited Resident 23 because he was not available. (Note: There were no provisions to have another physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 10 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 0712 substitute to meet the regulatory requirement). Level of Harm - Minimal harm or potential for actual harm The facility's policy and procedures titled, Physician Services revised April 2006 indicated, Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA (Omnibus Budget Reconciliation Act which is to establish uniform standards for nursing homes and ensure the protection and safety of residents) regulations and facility policy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 11 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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. Based on observation, staff interview, and record review, the facility failed to identify expired narcotics (medications used to relieve pain) in the e-kit (emergency kit: a locked box which contains a limited supply of medications for the facility to use during emergency situations, and after pharmacy hours). This failure had the potential for residents to experience inadequate pain control. Findings: During a tour of the medication room with the Director of Nursing (DON), on 5/25/21, at 9:45 a.m , the narcotics e-kit had a yellow lock tag. Further inspection of the narcotics e-kit contained 2 vials of Hydromorphone (Dilaudid) 2mg/ml (milligram/milliliter) 1 ml injectable and expiration date of 5/21. During an interview with the Director of Nursing (DON) on 5/25/21 at 9:55 a.m., DON stated the pharmacy consultant is supposed to check the e-kits during the monthly pharmaceutical reviews. The pharmacy consultant had not visited the facility since the start of the COVID-19 pandemic. DON confirmed the 2 vials of Hydromorphone were expired and DON is responsible for checking the e-kits in the medication room for expired medications. An undated pharmacy policy and procedure titled, Controlled Medications-Disposal indicated, The director of nursing and the consultant pharmacist shall be responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 12 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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** 2. Review of the clinical record indicated Resident 3 was admitted to the facility with diagnoses that included dementia with behavioral disturbance, (a progressive disease that destroys memory). Review of the facility's Consultant Pharmacist (CP) MRR dated 3/31/2021, indicated Resident is on Buspirone (anxiety disorder) 5 mg, three times a day and Ativan (anti-anxiety) 0.5 mg two times a day. The CP recommendation indicated, Is a dose reduction indicated? This therapeutic duplication may increase the potential for adverse effects. Please evaluate and document risk/benefits/rationale if the medications continue to be indicated concurrently. If the same dose is to continue, please document the reason in the chart. During an interview with DON on 5/26/2021 at 1:25 p.m., DON stated CP would email the recommendations after CP's visit. CP is responsible to follow up with the physicians or gives it to the nurses to follow up with the physicians. DON further stated, We need to take care of it as soon as possible. During a telephone interview with CP on 6/8/2021 at 2:59 p.m., CP stated the facility has 72-hours to complete the MRR after the date the facility receives the recommendations. 3. Review of the clinical record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included schizophrenia ( a mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior) and major depressive disorder, recurrent. During an interview with Resident 37 on 5/25/2021 at 11:55 a.m., Resident 37 stated, I mentioned to the nurse that maybe the reason I had multiple falls is because of my medications. Resident 37 further stated he would like to decrease his medications. During an interview on 5/25/2021 at 12:35 p.m., LVN 1 stated Resident 1 is currently receiving multiple antipsychotic medications and had multiple falls since admission. LVN 1 further stated there was no MRR done for Resident 37. During an interview and concurrent record review on 5/27/2021 at 10:55 a.m., DON confirmed Resident 37's MRR had not been reviewed for 45-days from the date of admission. DON further stated, I sent an email message to CP on 5/17/2021 requesting a MRR. DON was unable to show if Resident 37's medication list for MRR was faxed to the pharmacy. Based on interview and record review, the facility failed to maintain the resident's highest practicable level of physical, mental, and psychosocial well-being and prevent or minimize adverse consequences related to medication therapy, for three of three sampled residents, (Resident 30, Resident 37 and Resident 3) when the facility did not inform the physicians about the pharmacist's recommendation of changing the medication dosages for Resident 30. The drug regimen review was not done within 30-days by the licensed pharmacist for Residents 3 and 37. These failures had the potential to receive unnecessary medication for Resident 30. For Resident 37 and Resident 3, this had the potential of adverse side effects of the medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 13 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 Findings: Level of Harm - Minimal harm or potential for actual harm 1. During a review of the Consultant pharmacist's Medication Regimen Review (MRR) for Resident 30 dated 3/31/21, showed the pharmacist recommended a gradual dose reduction of venlafaxine (antidepressant medication) 75 milligrams daily for Resident 30. Residents Affected - Few During an interview with the physician (MD) on 05/26/21 at 1:06 p.m., MD stated she usually responds to the facility's faxes or emails within 24 hours, and was expecting the facility to reach her for any MRR recommendations as soon as the facility received them from the pharmacist. During an interview with Director of Nursing (DON) on 05/26/21 at 1:15 p.m. DON stated, They (staff) put all the MRR recommendations in the binder since March 2021 for MD to sign but the nurses misplaced the binder and never asked MD to review the MRR recommendations by the pharmacy. During an interview with the Licensed Vocational Nurse 2 (LVN 2) on 05/26/21 at 01:20 p.m., LVN 2 stated, That it is important to address and follow up with the pharmacy recommendations with the doctors because the residents may receive the wrong dose of the medication. Review of the facility's policy and procedure, Pharmaceutical Services Policy and Procedure Manual undated indicated, . c. The consultant pharmacist and the facility shall follow up on his/her recommendations to verify that appropriate action has been taken . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 14 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, for one (Resident 37) of 17 sampled residents, the facility failed to accurately monitor, document, and communicate the effects of anti-psychotic (Seroquel) medication therapy. Residents Affected - Few This failure had the potential for adverse side effects of Seroquel and possible need to adjust the medication dosage. Findings: Review of the clinical record indicated Resident 37 was admitted to the facility with diagnoses that included schizophrenia (a mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior) and major depressive disorder, recurrent (repeated episode of depression). During a review of Resident 37's physician orders dated 4/28/2021, indicated Seroquel (also called Quetiapine) ER (extended release) 400 milligrams (mg), two tablets by mouth at bedtime and Seroquel 50 mg, one tablet by mouth at bedtime related to schizophrenia. During an interview with Resident 37 on 5/25/2021 at 11:55 a.m., Resident 37 stated, I mentioned to the nurse that maybe the reason I had multiple falls is because of my medications. Resident 37 further stated he would like to decrease his medications. During an observation and concurrent interview on 5/25/2021 at 3: 33p.m., with Resident 37, Resident 37 was walking around his room. He stated he could walk around his room multiple times with extra precaution. During an interview and concurrent record review on 5/26/2021 at 10:25 a.m., with Licensed Vocational Nurse (LVN)1, LVN 1 stated they (staff) are not monitoring the behaviors as indicated on the Medication Administration Record (MAR). They only answer yes/no or put a check mark. LVN further stated putting a check mark does not mean anything. During an interview on 5/26/2021 at 1:10 p.m., with LVN 4, LVN 4 stated staff should be monitoring, and documenting the number of episodes to be able to quantify on the monthly psychopharmacology drug summary sheet and psychoactive medication quarterly evaluation sheet to evaluate the effectiveness of the medication. During an interview on 5/27/2021 at 11 a.m., with the Director of Nursing (DON) stated, Nurses are not monitoring Resident 37's behaviors. The DON further stated, I will give an in-service to the licensed staff. During a review of the undated P&P titled, Psychoactive Drug Monitoring indicated, Residents who receive anti-depressant, hypnotic, antianxiety, or antipsychotic medications should be monitored to evaluate the effectiveness of the medication. h. For deviation from the recommended dosage reduction criteria, the clinical record shall contain evidence to support justification for use of a drug not meeting the dosage criteria but considered clinically appropriate by the physician. Examples include: 2. Physician, nurse, or other health professional documentation that the resident is being monitored for adverse consequences or complications of therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 15 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one (Resident 46) of 17 sampled residents was free of significant medication error when Licensed Staff administered Omeprazole (reduces the amount of acid in the stomach) after the medication was discontinued. Residents Affected - Few This failure had the potential for Resident 46 to be exposed to more side effects from taking the medication longer than expected. Findings: Review of the admission Record indicated Resident 46 was admitted to the facility with multiple diagnoses that included malignant neoplasm of unspecified part of the bronchus or lung (cancerous abnormal mass of tissue). Review of the facility's Consultant Pharmacist (CP) Medication Regimen Review (MRR) for Resident 46 dated 4/30/2021, indicated this Resident has been receiving the proton pump inhibitor Omeprazole, could the ongoing need for this therapy be re-assessed at this time? MRR indicated the physician wrote an order Ok to Discontinue. During an interview and concurrent record review on 5/26/2021 at 10:30 a.m., with Licensed Vocational Nurse 1 (LVN 1) , LVN 1 confirmed Omeprazole was discontinued. LVN 1 stated, It was faxed to the physician's office on 5/17/2021 but not aware of the exact date it was discontinued. LVN 1 further stated, When this specific physician comes to visit, the medical record staff will gather all the resident charts and put them in the medical record office. The medical record Staff will put back all the charts in the chart holder without us knowing if there are new physician orders. LVN 1 added she told the Medical Record not to put back the residents chart in the chart holder until we checked for new orders. During an interview on 5/26/2021 at 11:53 a.m., with the Director of Nursing (DON), the DON stated she would provide in-service to the Licensed Staff. During a review of the undated P&P titled, Medication Administration- General Guidelines, indicated, c. prior to administration, the medication and dosage schedule on the residents MAR shall be compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders shall be checked for the correct dosage schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 16 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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. Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly after they have been discontinued. This failure had the potential of exposing residents to drugs and biologicals with questionable potency and efficacy. 1. Two Glucagon (medication for low blood sugar) kits were found at the bottom drawer of the refrigerator in the medication room. 2. The refrigerator freezer in Station 2's medication room had a thick layer of frost. 3. Narcotic medications that were discontinued were kept stored in Medication Cart B. Findings: 1. During an inspection of the Station 2 medication room and concurrent interview with the Director of Nursing (DON), on 5/25/21 at 10 a.m., two Glucagon kits were found in the bottom drawer of the refrigerator. The two Glucagon kits did not have resident names nor expiration dates on them. DON stated the two Glucagon kits should have been destroyed after their original labels were removed. 2. During a concurrent tour and interview in the medication room on 5/25/21, at 10:05 a.m., an inspection of the refrigerator showed frost build-up. DON acknowledged the freezer was caked in frost. DON indicated the schedule for defrosting (process of melting the frost build-up in a freezer), is every Wednesday during the night shift, and the freezer was not defrosted last Wednesday. 3. The narcotic box (medication cart locked drawer where drugs that relieve severe pain are kept) had blister packs (plastic packaging for pills) of Morphine Sulfate 30 milligrams (mg) and Morphine Sulfate IR (immediate release) 30 mg. LVN 1 stated Morphine Sulfate 30 mg and Morphine Sulfate IR 30 mg were both discontinued, and these medications should have been given to DON for destruction with the pharmacy consultant. The facility policy and procedure titled, Storage of Medications (undated) indicated, .Medication storage conditions shall be monitored on a monthly basis and corrective action taken if problems are identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 17 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices safety for 51 of 51 residents who were residing at the facility. Multiple items were found in the kitchen that were not dated or had expired. This deficient practice had the potential health risk of foodborne illness because of their compromised health status. Findings: During an observation on 05/24/21 at 10:23 a.m., the following items in the freezer were undated: 16 bags of pancake containing 8 pancakes each, 16 pieces of pizza in a bag, 2 bags of 3 lbs (pounds) diced potatoes, 21 muffin pieces in bags, 24 pieces of biscuits, 2 bags of cream puffs, 5 plates of pies, 6 French toasted bread items, each one included 6 pieces, dinner rolls 1 bag, 15 whip cream bags, each one 1 lb, 1 gallon of thousand island dressing, cooked 5 lb Italian sausage, one bag of diced chicken 2 lb, bag of fried ham 2 lb, 1 bag of beef hot dogs, 5 boxes of concentrated juice (each one 55 lb),(grapes, apple, orange, cranberry, pineapple), 3 gallons of opened vanilla ice cream, feta cheese 3.6 kg (kilogram). The following items were found to be expired: 5 lb ricotta cheese expired 8/19/20, one bag of 2 lb shredded carrots expired 5/18/21, and one box of 55 lb of thickened water expired on 11/27/19. During an interview with the Dietary manager (DM) on 05/24/21 at 12:50 PM, DM stated She had no idea the juices from the company will expire and they should not serve any expired juices to the residents, and for the undated items, she did not know the opened dates, delivery dates or expired dates on them. DM stated, They (kitchen staff) are not supposed to use any expired food because the resident could become sick and all the food needs to be dated so kitchen staff will not use expired food for the residents. During a review of the facility's policy and procedure, Procedure for refrigerated storage dated 2018 indicated .9. Dating the packages or containers will facilitate this practice . and Storage of Food and Supplies dated 2017 indicated . 8. All food products will be used per the times specified . No food will be kept longer than the expiration date on the product. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 18 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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 Based on observation, interviews and record review, the facility failed to maintain the infection control program. The Restorative Nursing Assistant (RNA-trained to assist residents with strengthening muscles and range of motion) entered an isolation room without wearing personal protective equipment (PPE) and performing hand hygiene. For Resident 10, a half-filled urinal containing yellow urine was not removed from the meal tray while Resident 10 ate breakfast. Residents Affected - Few These failures had the potential to result in the spread of infection. Findings: During an observation on 5/24/21 at 10:47 a.m., RNA 1 entered Resident 23's isolation room without performing hand hygiene and wearing a disposable gown. During an interview on 5/24/21 at 10:47 a.m., RNA 1 stated she was sorry she did not wear the gown or perform hand hygiene. During an interview on 5/24/21 at 10:47 a.m., the Licensed Vocational Nurse 1 (LVN 1) stated RNA 1 was required to perform hand hygiene and wear a gown to enter an isolation room. Review of the care plan initiated 5/19/21 indicated Resident 23 was placed on isolation due to continued refusal of weekly tests for COVID-19 (a new coronavirus causing a respiratory illness and outbreak that is easily spread). Review of the document titled, SNF Outbreak Recommendations dated 8/11/20 indicated; Transmission based precautions (how it spreads, droplet, airborne, or contact) : Use standard plus droplet, plus contact, plus eye protection when caring for residents with suspected or confirmed COVID-19. Health care practitioner should perform hand hygiene before and after donning and doffing personal protective equipment (PPE). 2. During a dining observation on 5/25/21, at 7:40 a.m., Resident 10 was picking his food with his right hand, and in the corner of the breakfast tray, there was a urinal which was half-filled with yellow urine. During an interview with LVN 2 on 5/25/21 at 7:55 a.m., LVN 2 stated there should be no urinal on any meal tray. The urinal needs to be emptied immediately after use, disinfected, dried and kept in the drawer of Resident 10. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 19 of 20 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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, interview, and record review, the facility failed to provide 80 square feet per resident in room [ROOM NUMBER] that was occupied by two residents. This failure had the potential to result in a lack of sufficient space for providing care and storage of resident belongings. Findings: In an observation on 5/26/21 at 10:45 a.m., room [ROOM NUMBER] was occupied by two residents and had one unoccupied bed. The total square footage of room [ROOM NUMBER] was 225 square feet, allowing 75 square feet per resident. The two residents in the room stated they had no concerns regarding space and staff were easily able to move in and out of the room. They also felt they had plenty of room to store their belongings. The room was observed to be clean and without clutter. The residents were provided sufficient privacy and no complaints had been filed regarding the space in room [ROOM NUMBER]. There were no negative consequences attributed to the decreased living space in room [ROOM NUMBER] and no safety concerns were noted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 20 of 20