Health inspection·April 15, 2022

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately follow through the Preadmission Screening and Resident Review (PASARR) assessment process (a screening tool used to prevent individuals with mental illness (MI), intellectual disability (ID) or related conditions (RC) from being inappropriately placed in a Medicaid certified nursing facility (NF) for long-term care) for two of two sampled residents (Resident 1 and Resident 35) when following was noted: 1. Resident 1 did not receive PASSR level II evaluation. 2. Resident 35's PASSR level 1 assessmentwas not completed accurately to reflect the severely impaired cognitive status (mental status). This failure placed Resident 1 and Resident 35 at risk to not receive care and services appropriate to their needs. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE]. During a review of Resident 1's 'Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/25/21, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of three of 15. Meaning, Resident 1 had severe impaired cognition. The MDS also indicated, Resident 1 had multiple diagnoses that included psychotic disorder (severe mental disorder that causes abnormal thinking and perceptions). During a review of Resident 1's PASARR Level I Screening, dated 11/17/21, the PASARR Level I Screening indicated the level I screening result was positive. The PASARR Level I Screening also indicated, Resident 1 was suspected with mental illness. During a concurrent interview and record review on 4/11/22, at 11:36 a.m., with the Assistant Director of Nursing (ADON), the ADON stated, Resident 1 was positive for PASARR Level I. ADON further stated, she did not coordinate PASARR level II Evaluation because she was not aware of the process. 2. During a review of Resident 35's admission Record dated 4/12/22 indicated Resident 35 was originally admitted to the facility on [DATE]. During a concurrent interview and record review on 4/12/22, at 1:56 p.m., with Assistant Director of Nursing (ADON), Resident 35's Preadmission Screening and Resident Review (PASSR) Level 1 Screening Document, dated 5/24/19 was reviewed. Resident 35's PASSR indicated facility answered No to Question 19b. Does the individual have serious difficulty communicating their needs, responding appropriately to direct questions, or otherwise engaging in a meaningful verbal interaction as a result of a cognitive deficit? During a concurrent interview and record review on 4/12/22, at 2:09 p.m., with Social Services Director (SSD), Resident 35's Minimum Data Set (MDS, a resident assessment tool used to guide care) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055562 If continuation sheet Page 2 of 12 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 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated 5/17/19 was reviewed. The MDS assessment indicated Resident 35's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was zero out of 15 which indicates severe mental impairment. During an interview on 4/12/22, at 2:11 p.m., the SSD stated since Resident 35's had severe cognition impairment, facility was expected to code Yes to Question 19b on the PASSAR Level I assessment completed on 5/24/19. SSD stated the documentation in PASSR level 1 assessment was incorrect. During an interview on 4/15/22, at 9:03 a.m., the Director of Nursing (DON) stated completing the PASRR Level I assessment accurately was important to identify if residents with mental disorder required Level II evaluation or not. The DON stated Level II evaluation was completed by a State Organization to ensure if the resident with a mental disorder received appropriate and individualized care. The DON stated Resident 35's PASSR assessment was overlooked for accuracy. During a review of the facility's undated Policy and Procedure (P&P) titled, admission Criteria updated 3/2019, indicated Policy Interpretation and Implementation .9. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID or RD, he or she is referred to the state PASARR representative for the level II (evaluation and determination) screening process .c. Upon completion of the Level II evaluation, state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055562 If continuation sheet Page 3 of 12 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 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review facility failed to provide a written summary of baseline care plan to one of three sampled residents (Resident 257). This failure resulted in Resident 257 not being aware of his plan of care. Findings: During a review of Resident 257's admission Record, dated 4/14/22, the admission Record indicated Resident 257 was admitted to the facility on [DATE]. The admission record indicated that Resident 257 was his own responsible party. During an interview on 4/11/22, at 10:01 a.m., Resident 257 stated he was not aware of his plan of discharge from the facility. During a concurrent interview and record review on 4/13/22, at 10:10 p.m., with Assistant Director of Nursing (ADON), Baseline care plan v1.1 dated 3/31/22 was reviewed in Resident 257's Electronic Medical Record (EMR). Resident 257's baseline care plan showed the discharge plan was part of the extensive baseline care planning process. ADON stated facility completed Resident 257's baseline care plan on 3/31/22, however it did not indicate if Resident 257 or his family representative was involved in care planning process. ADON also stated there was no evidence if facility provided a written summary of baseline care plan to Resident 257 and or his family representative. During an interview on 4/15/22, at 9:03 a.m., with the Director of Nursing (DON), the DON stated facility didn't have a system to ensure a written summary of baseline care plan was provided to residents. The DON also stated she was aware that baseline care plan must be completed within 48 hours of admission and a written summary must be provided to the residents and/or their representatives. During a review of the facility's undated Policy and Procedure (P&P) titled, Care plans- Baseline, revised on 12/2016, indicated, Policy Interpretation and Implementation .4. The resident and their representative will be provided a summary of the baseline care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055562 If continuation sheet Page 4 of 12 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 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 254) received care when following was noted: Residents Affected - Some 1. Resident 254 had long fingernails with black matter underneath on both hands. 2. Resident 254 did not receive shower/bed bath for four of five days within one week of readmission to the facility. This failure resulted in Resident 254 to feel helpless, placed him at risk for infections and hurting himself with long fingernails. Findings: 1. During a review of Resident 254's admission Record dated 4/14/22, the admission Record indicated Resident 254 was originally admitted to the facility on [DATE]. During a record review of Resident 254's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 12/6/21, the MDS assessment also indicated Resident 254's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was 15 out of 15 which indicates intact mental status. During a concurrent observation and interview on 4/11/22, at 11:15 a.m., with Certified Nursing Assistant 3 (CNA 3), Resident 254 had long fingernails and black matter underneath fingernails on on both hands. CNA 3 stated Resident 254's could scratch himself and cause skin tears with his long fingernails. During a follow up observation and interview on 4/12/22 at 11:20 a.m., Resident 254 still had long fingernails with black matter underneath on both hands. Resident 254 stated no one helped to trim his fingernails and that made him feel helpless. During an interview on 4/13/22 at 11:31 a.m., with Registered Nurse 1 (RN1), RN1 stated it was important to trim residents' fingernails as it was an essential part of grooming and there was a risk of causing skin tears from scratching. During a review of the facility's undated P&P titled, Fingernails/Toenails, Care of, revised 02/2018, the P&P indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 2) During an interview on 4/13/22 at 11:32 a.m.,with Resident 254, Resident 254 stated staff delayed the shower time till end of their shift and then never provided him showers since he got re-admitted to the facility on [DATE]. During a record review of Resident 254's MDS assessment dated [DATE], the MDS assessment indicated Resident 254 was totally dependent on staff for showers/bed bath. During a review of Resident 254's Care Plan- ADL Self-care deficit, revised on 4/7/22, the care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055562 If continuation sheet Page 5 of 12 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 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some plan indicated to provide one staff assistance to Resident 254 for upper and lower body bathing related to weakness and impaired mobility. During a concurrent interview and record review with the Director of Staff Development (DSD) on 4/15/22, at 9:55 a.m., residents' shower schedule was reviewed. The shower schedule indicated Resident 254 was scheduled to receive shower every Monday and Friday [4/8/22 and 4/11/22 since he got readmitted on [DATE]]. During an interview on 4/14/22, at 9:36 a.m., Certified Nursing Assistant (CNA 3) stated she checked shower schedule every day at beginning of shift to see which resident was scheduled for shower. CNA 3 stated residents received bed baths if they did not want showers on the scheduled days. During a concurrent interview and record review with Assistant Director of Nursing (ADON) on 4/13/22, at 10:53 a.m., Resident 254's Electronic Medical Record (EMR) for shower for the period of 4/7/22 to 4/13/22 was reviewed. The ADON stated Resident 254 did not receive showers and/or bed bath on 4/8/22, 4/9/22, 4/11/22, 4/12/22 since he got readmitted on [DATE]. During an interview on 4/15/22, at 9:03 a.m., the Director of Nursing (DON) stated staff was expected to provide bed bath on non-shower days. The DON also stated the risk of not providing showers/bed bath could result in skin issues getting overlooked and/or getting worse; and affect quality of life of residents. The DON stated not providing the care, that the residents required, was not acceptable. During a review of the facility's undated Policy and Procedure (P&P) titled, Activities of daily living (ADL), Supporting, revised on 3/2018, the P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. During a review of the facility's undated policy and procedure (P&P) titled, Bath, Shower/Tub, revised 02/2018, the P&P indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the conditions of the resident's skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055562 If continuation sheet Page 6 of 12 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 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident received the volume of oxygen as ordered by the physician for two of two sampled residents (Resident 2 and Resident 37). Residents Affected - Some This deficient practice resulted in Resident 2 and Resident 37 receiving more oxygen than required and can negatively impact both resident's the health and well-being. Findings: 1. During a review of Resident 37's admission Record, the admission Record indicated, Resident 37 was originally admitted to the facility on [DATE], and was readmitted on [DATE]. During an observation on 4/11/22, at 9:40 a.m., in Resident 37's room, Resident 37 was laying in bed receiving oxygen at three liters (L-liters, unit of measurement) per minute via nasal cannula (NC -a device to provide supplemental oxygen therapy) from an oxygen concentrator (medical device that gives extra oxygen). During a concurrent observation and interview on 4/11/22, at 9:42 a.m., with the Licensed Vocational Nurse (LVN) 1, in Resident 37's room, the oxygen concentrator was delivering three liters of oxygen per minute to Resident 37 via NC. LVN 1 confirmed the oxygen concentrator was set to deliver three liters of oxygen. During a review of Resident 37's Order Summary Report, dated 1/20/21, the Order Summary Report indicated, Give 2L per minute oxygen per nasal cannula as needed (prn) for dyspnea (difficulty breathing) . 2. During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE], and was readmitted on [DATE]. During a concurrent observation and interview on 4/11/22, at 9:53 a.m., with LVN 1, in Resident 2's room, LVN 1 confirmed the the oxygen concentrator was delivering three liters of oxygen per minute to Resident 2 via NC. During a review of Resident 2's Order Summary Report, dated 2/16/22, the Order Summary Report indicated, Give 2L per minute oxygen per nasal cannula prn for shortness of breath (SOB). During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised October 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Under preparation, 1. Verify that there is a physician's order for the procedure, review the physician's order or facility protocol for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055562 If continuation sheet Page 7 of 12 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 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow food safety requirements when the following were noted: 1. Dietary staff did not perform hand hygiene after entering the kitchen. 2. Dishwasher did not reach 120ºF (degrees Fahrenheit) each time. 3. Multiple items were unlabeled and undated in the unit refrigerator. These failures had the potential for cross contamination. Findings 1. During an observation on 4/11/22 10:24 a.m., in the kitchen, Dietary Aide (DA) was observed donning an apron and gloves, without first performing proper hand hygiene. During an interview on 4/12/22, at 2:20 p.m., with Dietary Manager (DM), DM stated everyone should stop and wash their hands before doing anything in the kitchen. DM stated it's a risk for cross contamination. 2. During a concurrent observation and interview on 4/11/22, at 9:50 a.m., with DA, observed temperature reading on thermometer used to test dishwasher temperature at 110ºF, DA stated the dishwasher should be 120ºF. DA stated the dishwasher is mostly 120º and sometimes less. DA stated they must run the dishwasher a few times to get to 120ºF. During a concurrent observation and interview on 4/11/22, at 9:50 a.m., with DM, DM stated the dishwasher was supposed to be 120ºF per manufacturer guidance. During a concurrent observation and interview on 4/11/22, at 10:28 a.m., with DM, observed temperature reading on thermometer used to test dishwasher temperature at 110ºF, DM stated the dishwasher was 110ºF, and directed DA to stop the dishwasher and get maintenance. During an interview on 4/12/22, at 2:22 p.m., with Registered Dietician (RD), RD stated the dishwasher temperature should go to 120ºF or there would be a risk that the dishes were not as clean, and it may not get enough debris off. RD stated she was aware that the dishwashing machine temperature did not reach 120ºF. RD stated she did a return demonstration on 3/15/22 and had to run the dishwasher three times to reach 120ºF. During a record review of the ES-2000 & ES-4000 Series Installation/ Operation Manual, revised 5/9/05, the manual indicated the minimum wash and rinse temperature was 120 ºF. 3. During a concurrent observation and interview on 4/12/22, at 1:52 p.m., with Infection Preventionist (IP), IP stated the unit refrigerator between rooms [ROOM NUMBERS] was used for snacks for short term residents. The following items were found in the refrigerator and were not labeled with resident's name or date: one pre-packaged store-bought lunch item, one string cheese, one opened 330 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055562 If continuation sheet Page 8 of 12 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 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 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 milliliter (ml) bottle of lemon drink, one opened 330 milliliter (ml) bottle of sparkling water, one opened 236ml milk bottle, and one opened 828ml sports drink. The following items were found in the refrigerator and were not labeled with date: one opened 828ml sports drink labeled Resident 254, and one 500ml water bottle labeled Resident 254. There was one plastic cup of uncovered cut fruit which IP stated was cantaloupe, labeled Resident 206. Residents Affected - Many During a concurrent observation and interview on 4/12/22, at 2:03 p.m., with Certified Nursing Assistant 2 (CNA), CNA 2 stated CNAs are responsible for labeling food. CNA 2 stated the sports drink, and lemon drink were for Resident 254. CNA 2 stated Resident 206 was not in the facility anymore. During a concurrent observation and interview on 4/12/22, 2:07 p.m., with IP, IP stated if food is not labeled and dated, they can go bad, mold and fungus can grow, other food can get contaminated, and it can attract bugs. IP stated residents are risk for upset stomach, and vomiting. IP stated she will throw all the opened and unlabeled food away. During an interview on 4/15/22, at 12:11 p.m. with Director of Nursing (DON), DON stated Resident 206 was discharged on 4/5/22. During a record review of the Refrigerator Cleaning Log, dated April 2022, the log indicated all food that has no date and label will be discarded. During a record review of the facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, revised October 2017, the P&P indicated, Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility prepared food . The P&P indicated, Perishable foods must be stored in re-sealable containers with tight-fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055562 If continuation sheet Page 9 of 12 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 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 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 ensure Activity Assistant (AA) performed hand hygiene in between residents while preparing and serving coffee to three of three sampled residents (Resident 52, 11 and 13). Residents Affected - Some This failure placed Resident 52, 11 and 13 at risk for cross contamination. Findings: During an observation on 4/12/22 at 9:00 a.m., Resident 52 was sitting in wheelchair in the activity room. AA repositioned Resident 52's wheelchair while she touched the wheelchair handles, and repositioned Resident 52's feet on the footrest. Without performing hand hygiene, AA then prepared and served coffee to Resident 11 and 13 while touching the inside of coffee mugs. During an interview with AA on 4/12/22, at 9:07 a.m., AA stated she missed to clean hands with a hand sanitizer in between Resident 52, 11 and 13. AA also stated performing hand hygiene was important to protect the residents from Coronavirus (a highly infectious disease, commonly known as COVID-19). During an interview with Director of Staff Development/ Infection Preventionist (DSD/IP), on 4/12/22, at 9:48 a.m., the DSD/IP stated staff was expected to perform hand hygiene anytime they touched resident's environment. DSD/IP also stated hand hygiene was important to break the chain of transmission of infections. During a review of facility's policy and procedure titled Handwashing/Hand Hygiene dated 08/2019 indicated, The facility considers hand hygiene the primary means to prevent the spread of infection .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antibacterial or nonantibacterial) and water for the following situations: b. Before and after direct contact with residents; o. Before and after eating or handling food . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055562 If continuation sheet Page 10 of 12 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 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a patient to signal his or her needs for assistance) was within reached for four of 18 sampled residents (Resident 10, 33, 40 and 3). This deficient practice had the potential to result in the delay of care and services. Residents Affected - Some Findings: 1. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE], with multiple diagnoses that included abnormal posture and abnormalities of gait and mobility (unable to move and walk in a usual way). During a review of Resident 10's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 11/2/21, the MDS indicated Resident 10 required extensive assistance with bed mobility, transfer, dressing, toilet use and hygiene. During an observation on 4/11/22, at 10:07 a.m., in Resident 10's room. Resident 10 was seen crawling on floor mattress. Resident 10 indicated he needed assistance with toilet use. Resident 10's call light was missing from the electrical outlet. During an interview on 4/11/22, at 10:11 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 confirmed, there was no call light connected. CNA 1 stated she was not aware Resident 10's call light was missing. CNA 1 further stated, Resident 10 required assistance with toilet use and needed call light within reached at all times. 2. During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses that included muscle wasting and atrophy (thinning of muscle mass causing numbness, weakness and tingling sensation). During a review of Resident 33's MDS, dated 2/22/22, the MDS indicated Resident 33 was totally dependent on staff with bed mobility, dressing, eating, toilet use and hygiene. During a concurrent observation and interview on 4/11/22, at 10:18 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 33's room. Call light was observed on the floor under Resident 33's bed. LVN 1 picked up the call light, placed it within reached on Resident 33's right side. LVN 1 stated, call light should be within reached of Resident 33 all the time. 3. During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses that included Cerebrovascular Disease (CVA - loss of blood flow to part of the brain), muscle wasting and atrophy, abnormal posture, muscle weakness and hemiplegia [paralysis (loss of ability to move) of one side of the body] and hemiparesis (minor to severe weakness or paralysis on one side of the body) affecting left non-dominant side. Durng a review of Resident 40's MDS, dated 3/13/22, the MDS indicated Resident 40 required extensive assistance with bed mobility, dressing and hygiene. The MDS also indicated, Resident 40 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055562 If continuation sheet Page 11 of 12 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 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 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 0919 totally dependent on staff with toilet use. Level of Harm - Minimal harm or potential for actual harm During an observation on 4/11/22, at 10:24 a.m., Resident 40's call light cord was wrapped on left side of bed rail and call light was on the floor. Residents Affected - Some During a concurrent observation and interview on 4/11/22, at 10:26 a.m., with the Director of Staff Development/Infection Preventionist (DSD/IP), in Resident 40's room, DSD/IP unwrapped call light cord from left bed rails, picked up call light from the floor. DSD/IP then placed call light on right side of Resident 40 and stated, Resident 40's needs must be attended and required call light within reached at all times. 4. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with multiple diagnoses that included, extrapyramidal and movement disorder (involuntary or uncontrollable movements, tremors and muscle contractions), muscle weakness and abnormal posture. During a review of Resident 3's MDS, dated 7/6/21, MDS indicated Resident 3 required extensive assistance with bed mobility. The MDS also indicated, Resident 3 was totally dependent on staff with dressing, toilet use and personal hygiene. During a concurrent observation and interview on 4/11/22, at 10:27 a.m with DSD/IP, in Resident 3's room. Call light was observed on the floor behind Resident 3's bed. DSD/IP was observed picking up the call light, then secured it on Resident 3's bed. DSD/IP stated, call light should be within reached at all times for safety of Resident 3. During an interview on 4/11/22, at 12:16 p.m., with the Director Of Nursing (DON), DON stated, facility protocol should always ensure resident's call lights are within reached so staff can tend to residents needs right away. During a record review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated October 2010, the P&P indicated, under general guidelines.4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055562 If continuation sheet Page 12 of 12