Health inspection·August 14, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 16's medical records showed a POLST dated 11/11/24, under information and signatures, under information and signatures, it showed no information on the presence of an advanced directive. 4. During a review of Resident 26's admission Record, dated 8/14/25, indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a sickness characterized by weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 26's MDS dated [DATE] under Section C, it indicated a score of 15, meaning Resident 21 was cognitively intact. During a review of Resident 26's POLST form, dated 10/27/23, under information and signatures, it showed no information on the presence of an advanced directive. 5. During a review of Resident 28's admission Record, dated 8/14/25, indicated Resident 28 was admitted to the facility on [DATE] with diagnoses that included heart disease. During a review of Resident 28's MDS dated [DATE] under Section C, it indicated a score of 15, meaning Resident 28 was cognitively intact. During a review of Resident 28's POLST form, dated 6/2/25, under information and signatures, it showed no information on the presence of an advanced directive. 6. During a review of Resident 37's admission Record, dated 8/14/25, indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included heart failure. During a review of Resident 37's MDS dated [DATE] under Section C, it indicated a score of 13, meaning Resident 37 was cognitively intact. During a review of Resident 37's POLST form, dated 7/29/25, under information and signatures, it showed no information on the presence of an advanced directive. During a concurrent interview and record review on 8/13/25, at 9:22 a.m., with the Social Service Director (SSD), SSD reviewed Residents 7,11,16,26,28 and 37's medical records and stated there were no documentation that advance directives were discussed and followed up with the residents and their responsible parties. During an interview on 8/14/25, at 12:14 p.m., with the Director of Nursing (DON), DON stated that the facility residents' advance directives were supposed to be followed up by the SSD. Further stated the importance of advanced directives was to help ensure that the resident's 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, Revised September 2022, indicated, .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy .1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.a. The resident or representative is given the option to accept or decline assistance.b. Nursing staff will document in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 2 of 16 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 08/14/2025 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 0578 medical record the offer to assist and the residents decision to accept or decline assistance . Level of Harm - Minimal harm or potential for actual harm The CMS Interpretive Guidance states that facilities are required to obtain a written record of resident advance directives upon admission and maintained in the medical record. Importantly, residents have a right to refuse to create an advance directive so the advance directive or the refusal to create an advance directive must be documented. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 3 of 16 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 08/14/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record review and interviews, the facility failed to ensure Resident 51's wallet was protected from loss.This deficient practice had the potential to result in Resident 51 not having access to their items in their wallet and/or feelings of living in a safe, homelike environment.During a review of Resident 51's admission Record, dated 8/14/25, indicated, Resident 51 was admitted to the facility on [DATE] with diagnoses that included cachexia (weakness of the body due to severe chronic illness), hypokalemia (low potassium), dysphagia (trouble swallowing) and acute kidney failure (kidney don't work) and that he was his own responsible party. During a review of Resident 51's Inventory List, dated 5/3/25, the Inventory List indicated, Resident 51 had 1 wallet listed among the items. During an interview on 8/12/25 at 10:55 a.m. with Resident 51, Resident 51 stated that my wallet has been missing for about 2 weeks and I told them about it but it goes in one ear out the other and nobody cares about it so now I no wallet which had my money and my ID (identification) so what am I supposed to do?. During a concurrent interview and record review on 8/12/25 at 1:09 p.m. with Registered Nurse (RN) 3, Resident 51's Inventory List, dated 5/3/25 was reviewed. the Inventory List indicated, Resident 51 had 1 wallet listed among the items. RN 3 stated she was not aware about the missing wallet but does see the resident did came in with one, also if it was missing they fill out a form and notify the Social Worker, but she will discuss with Resident 51. During a review of the facility's policy and procedure (P&P) titled Investigating Incidents of Theft and/or Misappropriation of Resident Property, [undated], indicated, 3. Our facility will exercise reasonable care to protect the resident from loss or theft including b. Providing measures to safeguard resident valuables from easy public access.d. Promptly responding to and investigating complaints of theft or misappropriation of property. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 4 of 16 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 08/14/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the interdisciplinary team (IDT, a group of individuals representing different departments of the facility) initiated a care conference meeting for one of 24 sampled residents for seven months. As a result, Resident 69‘s responsible party was not able to participate in planning his care.Findings:During a review of Resident 69's admission Record, dated 8/14/25, indicated, Resident 69 was admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities).Review of Resident 69's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 6/23/25 under Section C, indicated Resident 69's short and long-term memory was impaired, and had severely impaired decision-making capacity. During a concurrent interview and record review on 8/13/25 at 3:41 p.m., with the Minimum Data Set Coordinator (MDSC), stated Resident 69's last care conference was held on December 2024. Also stated the care conference should be done quarterly (every four months). Further stated that the purpose of the care conference was to update the resident's responsible party of the resident's current plan of care, give update for any changes in care and for the responsible party to give an input in the resident's care plan. Stated if there was no care conference done for the resident, then the resident had no voice in his plan of care. During an interview on 8/14/25, at 3:58 p.m., with the Director of Nursing (DON), DON stated that Resident 69's care conference should have been done quarterly. Stated the importance of the care conference was to plan the care of the resident, discuss any change in medications, change in resident's condition and any changes in the plan of care. During a review of the facility's policy and procedure (P&P) titled Care Planning- Interdisciplinary Team, Revised March2022, indicated, The interdisciplinary team is responsible for the development of resident care plans.4. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Event ID: Facility ID: 055338 If continuation sheet Page 5 of 16 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 08/14/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure presents a threat to residents reaching their highest practicable level of well-being and had the potential to endanger the health and safety of residents. Findings: During a concurrent interview and record review on 8/12/25 at 9:00 a.m., with the Accounts Payable/Payroll (APP),the facility's licensed staffing schedules for the month of January 2024 through March 2024 were reviewed, the staffing schedule indicated there were no RNs scheduled to work eight hours a day during the following dates: 1. For the month of January 2024: 1/1/24; 1/6/24; 1/7/24; 1/13/24; 1/14/24; 1/20/24; 1/21/24; 1/26/24; 1/27/24 and 1/28/24. 2. For the month of February 2024: 2/3/24; 2/4/24; 2/10/24; 2/11/24; 2/17/24; 2/18/24 and 2/24/24.3. For the month of March 2024: 3/2/24; 3/9/24; 3/10/24; 3/16/24; 3/17/24; 3/23/24; 3/24/24; 3/30/24 and 3/31/24. During a concurrent interview and record review on 8/12/25 at 9:00 a.m., with the PC,the facility's licensed staffing schedules for the month of April 2024 through June 2024 indicated there were no RNs scheduled to work eight hours a day during the following dates: 1. For the month of April 2024: 4/19/24. 2. For the month of May 2024: 5/16/24.3. For the month of June 2024: 6/07/24 and 6/13/24. During an interview on 8/14/25, at 12:20 p.m., with the Director of Nurses (DON), stated the risk of not having an RN in the facility for eight hours a day was the quality of care the residents received would be affected. DON further stated, the residents needed an RN to assess them if there was a change in the residents' condition. During a review of the facility's policy and procedure (P&P) titled Departmental Supervision, Nursing, revised August 2022, the P&P indicated; . 2. A registered nurse provides at least eight (8) consecutive hours every 24 hours, seven (7 days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident . Event ID: Facility ID: 055338 If continuation sheet Page 6 of 16 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 08/14/2025 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 - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure Medications are accurately and safely acquired, received, dispensed, stored, and administered for two of four Residents, Resident 16 and Resident 28 during medication administration, not following their facility's policy and procedure and standards of practice:1. When Licensed nurse left Resident 16s medications (1 tab of Ferrous sulfate [to prevent and treat low iron anemia] 325 milligrams (mg) and 1 tablet of multivitamin) unattended on top the medication cart when administering medication to Resident 16. 2. When Licensed Nurse left Resident 28's medications (1 tablet of Aspirin [used to treat mild pain, arthritis, it also lowers the risk of heart attack, stroke, or blood clot] 81 mg chewable) unattended on top of the medication cart. This failure has the potential for other Residents to have access and ingest medication that was not intended for them, Residents getting wrong medication, wrong dose, risk for allergic reaction, risk injury, and hospitalization. Findings: 1. During an observation and an interview on 8/12/2025 at 09:17 A.M., with Registered Nurse (RN) 1, RN 1 took out Resident's 28 chewable Aspirin 81 mg from the original brand medication cup, placed in a medication cup, RN1 then left the medication unattended on top of the medication cart and walked away, out through the double doors to the front lobby/facility entrance. When interview RN 1 stated the drug in the medication cup was Resident's 28's Aspirin 81 mg and she was supposed to put it back in the medication cart before she walked away. RN 1 further stated this is for safety, if anyone had picked up the medication, especially for those residents who are not alert, they will swallow it and that is not a good thing. During a review of Resident 28's Facesheet, the Facesheet indicated Resident 28 is [AGE] years old, was admitted to the facility in 2025 with diagnosis of Diastolic Congestive Heart Failure (a chronic in which the heart does not pump blood as well as it should), Primary Hypertension (high blood pressure) and Atherosclerotic Heart Disease (a disease of the arteries characterized by deposition of plaques of fatty material on their inner walls) of Coronary Artery. 2. During an observation and an interview on 8/13/2025 at 08:53 A.M. with Registered Nurse (RN) 2, RN 2 left Resident 16's Multivitamin and Ferrous Sulfate unattended on top of the medication cart and went into Resident 58's room to assist the Podiatrist. When interviewed, RN 2 stated the two pills are ferrous sulfate and multi-vitamin and that they were for Resident 16. RN 2 stated she was in Resident 58's room, assisting the Podiatrist, that the Podiatrist was explaining something about Resident 58's Podiatry care. RN 2 stated the medications should have been placed back in the medication cart and not left unattended on the medication cart to prevent other Residents from picking it up and swallowing it. RN 2 stated it's for Resident safety. During a record review of Resident 16's Face sheet, the Face sheet indicated Resident 16 is [AGE] years old, was admitted to the facility in 2024 with diagnosis of Fracture of Femur (a complete or partial break in a bone) following insertion of orthopedic implant (medical devices used to replace, support, and stabilize bones that have been damaged), joint prothesis left leg in 2024 and Osteoporosis. During an interview on 8/13/2025 at 09:36 A.M. with Director of Nursing (DON), ADON stated Licensed Nurses should never leave medications unattended and on top of the medication cart for Resident's safety or drug overdose, and to prevent allergic reaction. ADON stated any Resident, or anybody can pick up those medication and swallow them. During a review of Facility Policy and Procedure (P & P), titled Administering Medications, dated April 2019, the P & P indicated, Policy heading. Medication are administered in a safe and timely manner, and as prescribed. 5. Medication administration time are determined by resident need and benefits, not staff convenience. Factors that are considered include. a. enhancing optimal therapeutic effect of the medication. b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 7 of 16 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 08/14/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete preventing potential medication or food interaction. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administering before giving the medication. 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the med cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Event ID: Facility ID: 055338 If continuation sheet Page 8 of 16 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 08/14/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interviews, and Record Reviews the facility failed to ensure Medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with: the prescriber's order; manufacturer's specifications (not recommendations) or accepted professional standards and principles which apply to professionals providing services) rates are 5 percent or lesser for three out of five residents (Resident 1, 16, and 68) during medication administration:1. When Licensed Nurse administered Alendronate medication (a medication used to prevent and treat osteoporosis [a condition in which the bones become thin and weak and break easily] in men and women) for Resident 16, was Administered to resident 16, not following Physicians orders or medication bubble pack labeling instructions and professional standards of practice.2. When Licensed Nurse administered Amlodipine medication (medication used to treat high blood pressure and certain types of chest pain) to Resident 1and Resident 68 with incomplete medication labeling instruction, not following Physician's instructions and professional standards of practice.This failure had the potential for Resident 1, 16, and 68 not getting the desire outcome of their medication and effectiveness, significant med error, hospitalization, and even injury or death.Findings: 1. During an observation on 8/13/2025 at 08:53 AM with Registered Nurse (RN) 2, RN 2 administered Resident 16's Alendronate medication without following the medication packaging instructions, Physician's order and the MAR. RN 2 did not give a full glass of water after or prior to administering Resident 16's Alendronate medication. RN 2 gave 30 millimeters (ml) of orange juice instead. During an interview on 8/13/25 at 09:10 AM with 2, RN 2 stated that Resident had already had breakfast that morning prior to administering his Alendronate medication and breakfast was served around 0700 on 8/13/2025. During a record review of Resident 16's Face sheet, the Face sheet indicated Resident 16 is [AGE] years old, was admitted to the facility in 2024 with diagnosis of Fracture of Femur (a complete or partial break in a bone) following insertion of orthopedic implant (medical devices used to replace, support, and stabilize bones that have been damaged), joint prothesis left leg in 2024 and Osteoporosis. During a review of Resident 16's Physician Order Summary, the Physician Order Summary indicated, Fosamax oral tablet 70 mg (Alendronate Sodium) give 1 tablet by mouth one time a day every 7 day(s) for osteoporosis in the morning with full glass of water at least 30 minutes before first meal, ordered date 7/15/2025, with start date 7/16/2025 and no end date. During a review on 8/14/2025 at 0940 AM with ADON, of Resident 16's Medication Administration Record (MAR) dated August 2025, Resident 16's Alendronate medication 70 mg was scheduled on the MAR to be given at 0900 A.M. for the entire month. RN 2 documented Resident 16's Alendronate medication at 0900 A.M. There were documented initials at 09:00 A.M., on Residents 16's MAR for 8/6/2025 and 8/13/2025 Alendronate medication administration. Resident 16's MAR indicated, Fosamax oral tablet 70 mg, give one tab by mouth one time a day every 7 days for osteoporosis in the morning with full glass of water at least 30 minutes before first meal, ordered 7/15/2025 at 22:37 p.m. During an interview on 8/14/2025 at 09:36 AM with Assistant Director of Nursing (ADON), ADON stated nursing staff must follow whatever direction is on the medication label and instructions given by pharmacy on the Medication Administration Record (MAR). ADON further stated Fosamax is given by night shift nurses at 0600 A.M., 30 minutes prior to their first meal or any food or drink, and the residents should stay upright at least 30 minutes before the meal. ADON stated not following the specific Physicians orders and packaging labeling will have a negative outcome, will result in poor absorption of medication and it would give less concentration in the blood. ADON further stated Resident conditions will not get better and he has recently just had a bone fracture. 2. During an observation on 8/12/2025 at 08:39 AM with Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 9 of 16 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 08/14/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Registered Nurse (RN) 1. Resident 68's Amlodipine 2.5 milligrams (mg) medication pack instructions parameters for Heart Rate (HR) had omission (missing) the number 60. RN 1 administered Resident 68's Amlodipine 2.5 mg medication without clarifying or reconciling the medication packaging label instructions to the Physician's order. During an observation on 8/12/2025 at 09:05 AM with RN 1. Resident 1's Amlodipine 2.5 mg medication pack instructions parameters for HR were missing the number 60. RN 1 administered Resident 1's Amlodipine 2.5 mg medication without clarifying or reconciling the medication packaging label instructions to the Physician's order. During an interview on 8/13/2025 at 09:18 AM with RN 1, RN 1 stated the bubble pack was missing the 60 for HR parameters. RN used a black sharpie and added number 60 on both Resident 68's and Resident 1's Amlodipine 2.5 mg medication bubble packs without clarifying or reconciling the bubble pack to the physician's order. RN 1 stated the bubble packs should have been updated and crossed or double check with two License nurses prior to administering and updating the bubble pack. RN 1 stated not doing this will put the residents at risk for medication error and not following what the Physician had ordered. During an interview on 8/13/2025 at 09:26 AM with Registered Nurses (RN) 3, RN 3 stated if a medication is missing an instruction or the HR parameters is not visible, nurses should call the pharmacy or check MAR for medication instruction clarification. During a record review of Resident 1's Face sheet, the Face sheet indicated Resident 1 is [AGE] years old, was admitted to the facility in 2024 with Primary Hypertension (high blood pressure) and Chronic Embolism (sudden blocking of an artery) and Thrombosis (blood clot forming a vein or artery, which can be life threatening) of left femoral vein. During a record review of Resident 68's Face sheet, the Face sheet indicated Resident 68 is [AGE] years old, was admitted to the facility in 2025 with diagnosis Essential Primary Hypertension (high blood pressure), Presence of Cardiac Pacemaker (a small electronic implanted in the chest to regulate a slow or irregular heart rate), device, and Atrioventricular block complete (a heart rhythm disorder that causes the heart to beat more slowly than it should, caused by communication problem within the heart electrical conduction system). During a review of Resident 1's Physician's Order Summary, the Physician Order Summary indicated, Amlodipine Besylate oral tablet 2.5 mg (Amlodipine Besylate) give 3 tablets by mouth one time a day for HTN hold for SBP less than100 or HR less than 60, order 6/28/2025, start date 06/29/2025, no end date. During a review of Resident 1's MAR, the MAR indicated, schedule for August 2025, amlodipine oral tablet 2.5 mg give 3 tablets by mouth one time a day for HTN hold for SBP less than 110 or HR less than 60, order date 09/28/2025 12:02. During an interview on 8/12/2025 at 09:18 AM with Director of Nursing (DON), DON stated if medication packing need clarification or is missing instructions, nursing staff should return the medication pack to the pharmacy for safety of the residents as safety for the licensed nurses as well. DON also stated this is to prevent allergic reactions or any other medication error. During an interview on 8/14/2025 at 09:36 AM with Assistant Director of Nursing (ADON) stated nursing staff must follow whatever direction is on the medication label instructions given by pharmacy on the Medication Administration Record (MAR).ADON stated for the HR parameters, the nurses should follow the physician's order because it's a physician's order and blood pressure meds cause the resident's HR (pulse) to drop. If the labeling is wrong or incomplete on a medication package, nursingstaff must return the medication pack back to the Pharmacy because it's not correct labeling or medication instructions. During a review of Facility Policy and Procedure (P & P), titled Administering Medications, dated April 2019, the P & P indicated, Policy heading. Medication are administered in a safe and timely manner, and as prescribed. 4. Medication are administered in accordance with prescriber orders, including any required time frames.5. Medication administration time are determined by resident need and benefits, not staff convenience. Factors that are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 10 of 16 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 08/14/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete considered include. a. enhancing optimal therapeutic effect of the medication. b. preventing potential medication or food interaction. honoring resident choices and preferences, consistent with his or her care plan. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administering before giving the medication. Event ID: Facility ID: 055338 If continuation sheet Page 11 of 16 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 08/14/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure residents were served palatable, flavorful food and properly cooked vegetables.This deficient practice placed the residents at risk of decreased nutrient intake possibly leading to weight loss and/or nutritional medical complications who received food from the kitchen.1. During observation on 8/13/25 at 12:47 p.m., in the facility conference room, two test trays containing one regular and another puree (blending or mashing regular food into a smooth, pudding-like consistency, eliminating lumps and making it easier to swallow) were presented. 2. During a concurrent observation and interview on 8/13/25 at 12:47 p.m with the Assistant Dietary Manager (ASDM) and Dietary Manager (DM) a regular and puree texture meal was sampled immediately following the delivery of the last resident tray. The regular tray contained citrus barbeque and mixed vegetables. The puree tray contained citrus barbeque and mixed vegetables. Temperatures of the food were measured with the surveyor's calibrated thermometer. The pureed citrus barbeque chicken was 147.6 Fahrenheit ( F), and the pureed mixed vegetables was 165.4 F. The regular citrus barbeque chicken was 151 F, and the regular mixed vegetables was 141.2 F. The regular mixed vegetables was overcooked, lacked color and was bland. The pureed citrus barbeque chicken lacked color, was not palatable and the mixed vegetables was bland. felt barely warm in the mouth and the pureed zucchini felt barely warm in the mouth and tasted bland. ASDM and DM stated pureed food was not palatable and the regular food mixed vegetables lacked color and looks overcooked. ASDM also stated that they steam the vegetables and doesn't normally look like that. 3. During review of the facility's policy and procedure (P&P) titled. Meal Service: Tray Assembly, dated 2023, indicated, Residents will receive their food at appropriate temperatures and appetizing appearance. 4. During a review of the article, Quality and Nutrient Loss in the Cooking Vegetable and Its Implications for Food and Nutrition Security in Ethiopia: A Review, dated 4/2023 on the website https://www.dovepress.com/quality-and-nutrient-loss-in-the-cooking-vegetable-and-its-implication-peer-reviewed-fulltext-art the article indicated, Overcooked vegetables will not make you ooh and aah because they lose their visual appeal, become mushy, and lose much of their natural flavor.71 Cooking destroys some of the nutritional value of vegetables; for example, vitamin C is destroyed by heat, so the longer you cook, especially at high temperatures, the less vitamin C will remain. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 12 of 16 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 08/14/2025 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 interview, record review and observation, the facility did not ensure that food was stored, prepared, and served in a safe and sanitary manner when the following was noted:1. Food preparation utensils and equipment were not cleaned and/or maintained in good condition.2. A 2 slice and conveyor toaster were not maintained in clean condition.3. One knife blade tip was bent.4. Microwave has brown stain and chipped turntable.5. Cup/Food container lids was in drawer without original packaging.6. An industrial can opener was not maintained in clean condition.7. Tray line pans and sheet pans were not air dried and were stacked wet.8. Pots and pans were not air dried and stacked wet.10. The oven was not maintained in clean condition.11. Nine expired food items.These failures placed 76 residents who received food from the kitchen at potential risk for food borne illnesses and/or illness related to use of contaminated utensils and expired food. 1. During a concurrent observation and interview on 8/11/25 at 9:47 a.m. with Assistant Dietary Manager (ASDM), in the kitchen, the following expired food items were observed: Freezer 3: Parmesan Cheese EXPIRATION: 5/2025 Over main stove: bottle of Teriyaki Sauce EXPIRATION: 7/30/2025 Fridge 4: 3 containers Plain Greek non-fat yogurt EXPIRATION: 5/14/2025 Fridge 4: 1 container Low-fat Cottage Cheese EXPIRATION: 7/2025 Fridge 4: 3 cans Whipped Cream EXPIRATION: 4/24/2025ASDM stated that usually do rotation of foods when delivery of foods come on Tuesday and Thursday and were not sure why these are still here but will take care of it.During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2023, the P&P indicated, .3.Older items should be rotated to use the FIFO (First in- First out). According to the 2022 Federal Food Code, Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. 2. During a concurrent observation and interview on 8/13/25 at 3:31 p.m. with ASDM, in the kitchen, multiple cup/food container lids were not found in kitchen draw loose and not in original packaging or in closed containers. ASDM stated that the lids were used for the resident coffee, hot tea or meal item, but, will take care of it. During a review of the facility's P&P titled, Sanitation and Infection Control , dated 2001, the P&P indicated, .2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas. 3. During a concurrent observation in the kitchen and interview on 8/13/25 at 3:40 p.m. with ASDM, in the kitchen, the following were observed: Tray line: o 1 Tray line lid with bent edgeso 6 flat Tray line pans with rust and dentso 6 long Tray line pans with rust and dentso 5 square Tray line pans with rust and baked on food particleso 2 rectangular Tray line pans with multiple dentso 4 Tray line covers dented on all corners 2 whisks with wood handle that is faded with open areas 1 knife with bent tip 1 metal masher with wood handle that is faded with open areas 1 red stained plastic spoon 6 loaf pans with baked on food particles 3 cutting boards with multiple cuts and deep grooves 4 fry pans with multiple scratches to the non-stick coating 8 pots dented with baked on food particles and scratches 1 pot missing plastic handle cover 1 metal bowl dented 3 large muffin pans dented and with multiple rusted areas 2 medium muffin pans dented and with multiple rusted areas ASDM stated that most of these items get a lot use and when run stuff through the dishwasher, the wood gets affected. ASDM stated that will take them and have them replaced. During a review of the facility's P&P titled, Meal Service, dated 2023, the P&P indicated, .7. Plates and serving equipment; plates, cups, silverware, special feeding devices, that are chipped According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulation. 4. During a concurrent observation in the kitchen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 13 of 16 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 08/14/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete and interview on 8/13/25 at 3:57 p.m. with ASDM, in the kitchen, the following were observed: 6 loaf pans were stacked wet 4 metal mixing bowls were stacked wet 5 muffin pans were stacked wet 2 cutting boards were stacked wet 6 long pans were stacked wet ASDM stated that don't have much space to dry stuff but will do in-service to let staff know. According to the 2022 Federal Food Code, after cleaning and sanitizing, equipment and utensils are to be air-dried or used. According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulation. 5. During a concurrent observation and interview on 8/13/25 at 4:27 p.m. with ASDM, in the kitchen, the inside of the microwave had dark brown spots and stains to vents. Also, glass turn table had moderate chip to outer edge. ASDM stated that they clean it regularly and may have get a new one. During a review of the facility's P&P titled, Sanitation and Infection Control, dated 2001, the P&P indicated, .2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas. According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. According to the 2022 Federal Foode Code, The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. 6. During a concurrent observation and interview on 8/13/25 at 4:36 p.m. with ASDM, in the kitchen, an industrial stove and oven showed moderate build-up of grease to the 4 burners and burner plates/foil. In addition, knobs had moderate build-up grease and dust behind it and both ovens had heavy buildup of grease and burnt on food. There was foil on one side of oven with moderate grease and burnt on food. Oven glass to both have moderate to heavy grease build up. Also, the secondary oven had rust to the hinges and inside. ASMD stated that expectation is that it is cleaned after they cook and it's cleaned once a week; the last time was cleaned was this past Sunday. ASDM also stated that the second oven is used sometimes but not all the time.According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulation. 7. During a concurrent observation and interview on 8/13/25 at 4:50 p.m. with ASDM, in the kitchen, the following were observed: Conveyor toaster with moderate build up of crumbs and burnt food particles; top of toaster ha peeling black paint and knobs had moderate buildup of grease 2 slice toaster inside had moderate buildup of crumbs and burnt particles ASDM stated that may not be able to clean and might have to purchase new ones.According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulation. Event ID: Facility ID: 055338 If continuation sheet Page 14 of 16 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 08/14/2025 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, interview and record review, the facility failed to maintain an effective infection control program when the laundry department did not have a separate space for clean and unclean hampers. This failure placed the residents at increased rate of healthcare- associated infections. Findings: Residents Affected - Some During a concurrent observation and interview on 8/14/25 at 10:00 a.m., with Laundry Worker (LW) 1, in the soiled linen room, LW 1 sanitized a dirty hamper and placed the then sanitized hamper together with the dirty hampers in the soiled linen room. LW1 acknowledged that after she emptied the used linens and clothes from the dirty hampers to the washing machine, she sanitized and returned the hampers to the soiled linen room, mixed with the dirty hampers because there was no space to store the clean and sanitized hampers. Stated the clean hampers were then brought to the facility hallways to collect residents' used linens and clothes. During an interview on 8/14/25 at 10:15 a.m., with the Laundry Supervisor (LS) 1, LS 1 confirmed that the clean hampers were stored together with the dirty hampers in the soiled linen room, stated the risk of mixing the clean and dirty hampers was spread of infection. During an interview on 8/14/25 at 12:14 p.m., with Director of Nursing (DON), stated the risk of storing the clean and dirty hampers together in the soiled utility room was the spread of infection amongst the staff and the residents. During a review of facility's policy and procedure(P&P) titled, Laundry and Bedding, Soiled, revised September 2022 P&P indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection and prevention control . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055338 If continuation sheet Page 15 of 16 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 08/14/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide residents with at least 80 square feet (sq. ft.) per resident for rooms occupied by multiple residents in 6 (Rooms 5, 23, 26, 28, 29, and 30) of 45 resident rooms in the facility. The failure had the potential for reduced space for staff to deliver care and lack of sufficient space for storage of residents' belongings. Findings: Based on an observation on 8/13/25, at 8:13 a.m., with the Facility's Maintenance Director (FMD), the following rooms and corresponding square footage (sq. ft.) were identified: Rooms 5, 23, 26, 28, 29, and 30 were observed as follows: room [ROOM NUMBER] had two beds and measured 145 sq ft, equaling 72.5 sq ft per resident. room [ROOM NUMBER] had three beds and measured 230 sq ft, equaling 76.7 sq ft per resident. room [ROOM NUMBER] had two beds and measured three beds and measured 220 sq ft, equaling 73.3 sq ft per resident. room [ROOM NUMBER] had three beds and measured 220 sq ft, equaling 73.3 sq ft per resident. room [ROOM NUMBER] had three beds and measured 225.5 sq ft, equaling 75.2 sq ft per resident; and room [ROOM NUMBER] had three beds and measured 220 sq ft, equaling 73.3 sq ft per resident. During random observations of care and services from 8/11/25 to 8/14/25, residents and staff never complained about the room size and staff have enough room to do their job. There was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents' care, and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings and no negative consequences attributed to the decreased space and/or safety concerns in the identified rooms. Granting of the room size waiver recommended. Event ID: Facility ID: 055338 If continuation sheet Page 16 of 16