Health inspection·December 3, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a meal observation on 11/30/2021 at 12:40 p.m., in Resident 16's room, Resident 16 lay in bed with the head of the bed elevated while Certified Nursing Assistant 5 (CNA 5) stood next to the bed and leaned over Resident 16 to feed her lunch. During a meal observation on 12/1/2021 at 7:35 a.m., in Resident 16's room, CNA 5 stood next to the bed and leaned over Resident 16 to feed her breakfast. During an interview on 12/1/2021 at 7:45 a.m., with CNA 5, CNA 5 stated staff were supposed to sit while feeding residents but there was no chair in the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 2 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 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. Based on observation, interview, and record review the facility failed to provide a clean, safe, home-like environment for: Residents Affected - Some 1. One of 11 sampled residents (Resident 17), when Resident 17's bed moved whenever Resident 17 stood up or sat down on the bed. Resident 17's room had a light fixture with a non-functioning bulb, the floor on one side of his bed was not cleaned, and there was a pile of empty garbage bags on the floor near the head of his bed. 2. Residents who used the shower room, when the shower room floor had an unlabeled hairbrush, with hair in the bristles, and a shelf in the shower room had the following items: a face mask, used gloves, four empty bottles of lotion, one bottle of conditioner, and an empty box of disposable razors. These failures resulted in: 1. Resident 17 feeling unsafe when transferring in or out of bed due to bed movement on the floor, having difficulty reading from inadequate lighting, and feeling staff did not care enough about him to adequately clean and tidy his room. 2. Residents who used the shower potentially having emotional distress from an unclean, cluttered environment. Findings: 1. A review of Resident 17's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 10/26/2021, indicated Resident 17 had a diagnosis of heart failure (heart is unable to pump adequate blood for the body's needs). The MDS indicated Resident 17 understood others and was able to be understood. The MDS indicated Resident 17 had adequate vision and was able to read fine details including regular print in newspapers/books. The MDS indicated Resident 17 required extensive assistance from at least two people for transfer between surfaces and bed mobility, was unsteady during transfer and walking with assistive devices, and used either a walker or wheelchair for locomotion. During a concurrent observation and interview on 11/30/21, at 12:44 PM, in Resident 17's room, Resident 17 sat on the side of his bed, using a tablet computer placed on the overbed table in front of him. A paperback book was lying on the overbed table. Resident 17's bed had casters (wheels mounted to an apparatus or piece of equipment to make that apparatus moveable) on the legs. The bed was located approximately 15 inches from a wall with a window, opposite from the door entry. A pile of translucent garbage bags, which appeared empty, were located on the window-side corner of the room, near the head of Resident 17's bed. The light fixture on the wall at the head of Resident 17's bed had one burned out bulb. Resident 17 stated the light bulb had been burned out for about a week which made the room darker and harder for him to read. Resident 17 stated he told Maintenance 1 (MTN) 1 that the bulb was burned out, but the bulb had not been changed yet. Resident 17 said the garbage bags were not his but had been there since he was admitted . Resident 17 adjusted his position while he sat on the bed and the bed moved back and forth. Resident 17 then stood up, and sat back down, using an assistive device (a walker); the bed moved back and forth when he stood up and sat down. Resident 17 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 3 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 stated his bed moved every time he got up or sat down on the bed which made him feel unsafe, especially since walking was hard for him and he used a walker. Resident 17 stated the Housekeeper (HSKP) never mopped the floor on the window-side of the bed. Resident 17 stated, the lack of mopping and the pile of garbage bags left him feeling the room was not clean and that nursing and housekeeping staff did care enough to pay attention to details. Residents Affected - Some During a concurrent observation and interview on 12/1/21, at 11:07 AM, with Resident 17, in Resident 17's room, the light at the head of Resident 17's bed still had a burned out bulb and the garbage bags were in the same position on the floor in the corner. Resident 17 stated his bed still moved when he got up or sat down on it, and the window-side of the floor next to his bed not been mopped. During a concurrent observation and interview on 12/2/21, at 10:28 AM, with Resident 17, in Resident 17's room, the light at the head of Resident 17's bed still had a burned out bulb and the garbage bags were in the same position on the floor in the corner. Resident 17 stated his bed still moved when he got up or sat down on it, and the window-side of the floor next to his bed not been mopped. During an interview on 12/2/21, at 1:40 p.m., with Housekeeper (HSKP), which translation by MTN 1, HSKP stated, she mopped Resident 17's room. HSKP stated she had not mopped the floor on the window-side of Resident 17's bed. HSKP stated she never noticed the pile of garbage bags on the floor in the window-side corner of the room. During an interview on 12/3/21, at 10:15 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated she was assigned to Resident 17 yesterday and today. CNA 4 stated she was unaware Resident 17's bed moved when he stood up or sat down on the bed. CNA 4 stated she always kept the bed's casters locked to prevent the bed from moving. CNA 4 stated it was not safe for the bed to move because Resident 17 could fall. CNA 4 stated she was unaware of the pile of garbage bags in the corner of the room and that one light bulb at the head of the bed was burned out. During an interview on 12/3/21, at 11:27 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was unaware the light was burned out in Resident 17's room and was unaware Resident 17's bed moved when Resident 17 stood up or sat down on the bed. LVN 2 stated needed repairs should be reported to licensed staff who could inform MTN 1, or to MTN 1 directly. During an interview on 12/3/21, at 11:21 a.m., with Director of Nursing (DON), DON stated Resident 17's bed casters should have been locked, as bed movement could cause Resident 17 to fall and be injured. DON stated MTN 1 had inspected Resident 17's bed after notification of the bed movement and noticed one of the casters was missing a wheel lock. DON stated Resident 17's safety and comfort would be increased by repair of the caster lock, a new light bulb, removal of the garbage bags, and mopping of the entire floor. 2. During an observation on 11/30/2021 at 10:29 a.m., in the shower room, a small shelf had the following items: a face mask, used gloves, four empty bottles of lotion, one bottle of conditioner, and an empty box of disposable razors. An unlabeled hairbrush, with hair in the bristles, was lying on the shower floor. During a concurrent observation and interview on 11/30/2021 at 10:45 a.m., with Licensed Vocational Nurse 1 (LVN 1), in the shower room, LVN 1 confirmed the used hairbrush was on the shower floor and the shelf contained used gloves, a face mask, empty bottles of lotion, a bottle of conditioner, and an empty box of disposable razors. LVN 1 stated staff were not supposed to the items in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 4 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 bathroom, but should discard the used gloves, face mask, empty bottles and boxes in the garbage can. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 5 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide fingernail trimming and/or facial hair removal for three of 11 sampled residents (Residents 9, 19 and 5) who were unable to perform personal grooming. Residents Affected - Few These failures resulted in Residents 9, 19, and 5 appearing ungroomed, and had the potential for a reasonable person to feel a diminished sense of self-esteem; the ragged nails also had the potential to cause injury from scratches or skin tears. Findings: 1. A review of Resident 19's admission Record, undated, indicated Resident 19 was admitted in June 2021 with a diagnosis of dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality). A review of Resident 19's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 10/29/2021, indicated Resident 19 was sometimes able to be understood, and sometimes understood others. The MDS indicated Resident 19 required total physical assistance from at least one person for personal hygiene (activities such as shaving, hair brushing, hand washing, etc.). During an observation on 11/30/2021 at 10:45 a.m., Resident 19 lay in bed with her arms on top of the bed linens. Resident 19's fingernails extended beyond the length of her fingertips and had dark brown substances beneath the fingernail tips. Resident 19 had visible white hairs on her chin. 2. A review of Resident 9's admission Record, undated, indicated Resident 9 was admitted in 2015 with a diagnosis of dementia with behavioral disturbance. A review of Resident 9's MDS dated [DATE], indicated Resident 9 was sometimes able to be understood, and sometimes understood others. The MDS indicated Resident 19 required extensive physical assistance from at least one person for personal hygiene. During an observation on 11/30/21 at 11:25 a.m., Resident 9 sat on the edge of her bed. Resident 9's fingernails extended beyond the length of her fingertips had jagged edges with dark substances beneath the fingernail tips. Resident 9 had visible white facial hairs above her upper lip and chin. During a concurrent observation and interview on 12/1/21 at 10:30 a.m., in Resident 9's room, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 9's fingernails should be trimmed and cleaned because they were long and dirty. CNA 2 stated Resident 9's upper lip and chin hairs needed to be shaved. During a concurrent observation and interview on 12/1/21 at 11:45 a.m., in Resident 19's room, the Activity Director (AD) assisted Resident 19 with eating her lunch. The AD stated Resident 19 needed her fingernails trimmed and cleaned and her chin hairs shaved. During an interview on 12/1/21 at 1:00 p.m., with the Director of Nursing (DON), the DON stated she expected the nursing staff to provide fingernail care to the residents with daily cleaning and trimming as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 6 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. A review of Resident 5's admission Record, undated, indicated Resident 5 was admitted to the facility with a diagnosis of dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities). A review of Resident 5's MDS dated [DATE], indicated Resident 5 was rarely able to be understood, and sometimes understood others. The MDS indicated Resident 5 required total assistance from at least one person for personal grooming. During an observation on 11/30/2021 at 12:35 p.m., in Resident 5's room, Resident 5 lay in bed with his hands crossed on his stomach. Resident 5's fingernails extended beyond his fingertips and were raggedly chipped with a black substance underneath the fingernail tips. During an observation on 12/2/2021 at 1:35 p.m., Resident 5's fingernails remained untrimmed with a black substance underneath the fingernail tips. During an observation and concurrent interview on 12/3/2021 at 8:35 a.m., in Resident 5's room, with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 5's nails needed cleaning and trimming, which was a task for the assigned certified nursing assistant. During an interview on 12/3/2021 at 12:05 p.m., with the Director of Nursing (DON), the DON stated staff are supposed to check and provide needed services for the resident's fingernails during daily personal care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 7 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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. Based on observation, interview and record review, the facility failed to: 1. Ensure one of (Resident 179) of 11 sampled residents received four medications as ordered by the physician. 2. Ensure expired medications were not available for resident use when one expired intravenous antibiotic (ertapenem) and one expired influenza vaccine were stored in the medication room refrigerator. These failures had the potential for: 1. Resident 179 to not receive medications as needed for therapeutic effect, or adverse effects if medications were administered too closely together. 2. A residents to receive expired, less effective medications. Findings: 1. A review of Resident 179's admission Record, undated, indicated an admission date of 11/29/2021 with diagnoses of heart failure (heart is unable to pump enough blood for the body's needs) and dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities). A review of Resident 179's Medication Administration Record (MAR) dated November 2021, indicated Resident 179 had the following medications ordered for administration at 9 a.m.: one tablet of amlodipine for high blood pressure, one tablet of bumetanide for heart failure, one tablet aspirin for stroke prevention, two tablets bismuth for prophylactic treatment of infection with the bacteria Heliobacter Pylori (a stomach infection). During an observation and concurrent interview on 11/30/2021 at 10:08 a.m., in Resident 179's room, was an overbed table at Resident 179's bedside. On top of the overbed table was a medication cup containing three white tablets and 4 pink tablet halves. Resident 179 stated the cups contained his medications and he did not want to take them. During an interview on 11/30/2021 at 10:20 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 179 had not wanted to take his 9 a.m. medications when she had offered them earlier, so she had left them on the overbed table for Resident 179 to take later. LVN 1 stated Resident 179 had not been evaluated for his ability to safely self-administer medications as he had just been admitted the previous day. A review of the facility policy and procedure (PNP) titled, Medication Administration General Guidelines, dated 2007, indicated, Medications are to be administered at the time they are prepared. The person who prepares the dose for administration is the person who administers the dose Medications are administered within 60 minutes of scheduled time .Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 8 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 regulations . Level of Harm - Minimal harm or potential for actual harm 2. During an observation and concurrent interview on 11/30/2021 at 11:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), of the medication room refrigerator contents, LVN 1 confirmed the medication room refrigerator had one vial of influenza vaccine, opened date of 9/29/2021; and one ertapenem (antibiotic) intravenous infusion bag (medication delivered by infusion through a tube inserted directly into a vein), expiration date of 11/14/2021 at 5 p.m. LVN 1 stated the influenza vaccine expired 28 days after the vial was opened on 9/29/21, and all expired medication should be discarded. Residents Affected - Some During an interview on 12/1/2021 at 1:05 p.m., with the Director of Nurses (DON), the DON stated she was responsible for discarding expired medications but had been too busy to do so. A review of the facility policy and procedure (PNP) titled, Discarding and Destroying Medications, revised April 2019, indicated, Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. A review of California Code of Regulations Title 22 §72357 (l) indicated, Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 9 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure the pharmacist's medication regimen review (MRR) was promptly acted upon for one (Residents 5) of 11 sampled residents. Residents Affected - Few This failure had the potential for delayed treatment and increased risk of adverse side effects for Residents 5. Findings: A review of Resident 5's admission Record undated, indicated Resident 5 was admitted to the facility with a diagnosis of dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities). A review of the facility's Consultant Pharmacist (CP) Medication Regimen Review (MRR) dated 10/29/2021, indicated This resident has been taking Risperdal 0.5 mg since 5/18/2021. The recommendation indicated please evaluate the current dose and consider a dose reduction. During an interview and concurrent record review on 12/2/2021 at 11:05 a.m., with the Director of Nursing (DON), Resident 5's MRR dated 10/26/2021, was reviewed. The DON stated she had been so busy she had totally missed sending the pharmacist's MRR recommendations to the physician until 12/1/21, at which time the physician discontinued the medication. A review of the policy and procedure titled, Medication Regimen Review, dated May 2019, indicated, Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity If the Physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) the Administrator. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 10 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 observation, interview and record review, the facility failed to ensure one (Resident 23) of 11 sampled residents was free of significant medication errors when Licensed Vocational Nurse 2 (LVN 2) did not follow the medication instructions to shake the Dilantin suspension (a liquid preparation of medication used to prevent seizures) before administration. Residents Affected - Few This failure had the potential to result in uneven distribution of medication in the liquid and prevent administration of the ordered dose necessary to maintain Resident 23's therapeutic drug level (the concentration of medication in the blood stream necessary to prevent seizures). Findings: A review of Resident 23's admission Record, undated, indicated Resident 23 was admitted to the facility in May 2021 with a diagnosis of epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). A review of Resident 23's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 11/10/2021, indicated Resident 23 had a feeding tube (a plastic or rubber tube that is used to bypass chewing and swallowing in a patient who is not able to eat or drink safely). A review of Resident 23's Physician Order Summary Report, dated 12/8/2021, indicated an active order for 3 milliliters (ml) of 125 milligrams/5 ml Dilantin Suspension, through the gastrostomy tube (GT, a type of feeding tube surgically inserted through the abdomen into the stomach) every 8 hours, for treatment of epilepsy. During an observation on 12/1/2021 at 8:40 a.m., in Resident 23's room, with Licensed Vocational Nurse 2 (LVN 2), Resident 23 lay in bed while LVN 2 prepared medications for administration. LVN 2 picked up the Dilantin suspension container and without shaking the bottle, poured 5 ml of Dilantin Suspension into a medication cup, used a syringe to withdraw 3 ml of Dilantin suspension from the med cup, and administered the medication to Resident 23's GT. During a concurrent interview and record review on 12/1/2021 at 8:50 a.m., with LVN 2, Resident 23's Dilantin Suspension bottle label instructions were reviewed. The Dilantin Suspension bottle instructions indicated, Shake well before each use. LVN 2 stated because the Dilantin was a suspension it needed to be shaken before administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 11 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 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 sanitize the ice machine's ice bin at the time of installation. Residents Affected - Few This failure had the potential to result in resident food borne illness from contaminated ice. Findings: During a concurrent observation and interview on 11/30/21, at 12:35 p.m., with Maintenance 1 (MTN 1), an ice machine was located on a patio against the exterior wall of the facility, near the sliding glass door of the activity room. The inside of the ice machine cabinet had a reddish-brown substance on the back and side walls above the ice bin. The reddish-brown substance was removed from the walls by a paper towel. MTN 1 stated the ice from the ice machine was used in the residents' drinking water. MTN 1 stated the ice machine was three weeks old; the facility had not previously had an ice machine. MTN 1 stated the ice machine needed to be cleaned regularly to prevent contamination of the drinking water, but he had not cleaned the machine yet. MTN 1 stated he would check for the manufacturer's recommendations on how to correctly clean the ice machine. During an interview on 11/30/21, at 1:40 p.m., with Dietary Services Supervisor (DSS), DSS stated MTN 1 was responsible for cleaning of the ice machine. During an interview on 11/30/21, at 1:42 p.m., with Registered Dietician (RD), RD stated the ice machine needed to be kept clean to prevent contamination of the ice. A review of the ice machine manufacturer's manual, [Brand name] Undercounter Ice Machines, UG series, Installation, Operation and Maintenance Manual, dated 03/19, indicated, The chart below is an overview of the maintenance that the end user and service technician should perform, and the frequency. These figures are the minimum required. A review of the chart indicated the end user was responsible for sanitizing the ice bin at the time of installation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 12 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 and implement infection control measures for six of 11 residents (3, 5, 10, 19, 21, and 23) when: Residents Affected - Some 1. Certified Nursing Assistant 1 (CNA 1) did not perform hand hygiene (wash hands with soap and water or use an alcohol-based hand rub) between consecutive meal tray deliveries and set-up of meals for Residents 19, 21, and 5. 2. The blood pressure cuff was not sanitized between the consecutive use of Residents 10, 3, and 23. These failures had the potential to transmit infectious organisms and increase the risk of infection for residents. Findings: 1. During an observation on 12/01/21, at 12:20 p.m , CNA 1 carried a lunch tray into Resident 19's room. Resident 19 sat in a chair with an adjacent table. CNA 1 placed the lunch tray on the table, a cloth napkin on Resident 19's chest, took the covers off the food and drinks, and arranged the silverware on the tray. Without performing hand hygiene, CNA 1 exited Resident 19's room and walked to the tray cart, took a tray off the cart, and carried the tray into Resident 21's room. Resident 21 lay in bed, on his side, with the overbed table next to the head of the bed. CNA 1 placed the lunch tray on the overbed table, placed a cloth napkin on Resident 21's chest, took the covers off the food and drinks, and arranged the silverware on the tray. Without performing hand hygiene, CNA 1 exited Resident 21's room, walked to the tray cart, took a tray off the cart and carried it into Resident 5's room. Resident 5 lay in bed, with the head of the bed elevated and the overbed tray across his upper torso/lap. CNA 1 took the covers off the food and drinks, arranged silverware on the tray, and began assisting Resident 5 to eat. During an interview on 12/1/21, at 2:05 p.m., with CNA 1, CNA 1 stated she washed her hands before she started passing the lunch trays to residents and was sorry she had not performed hand hygiene between serving residents. During an interview on 12/2/21, at 11:03 a.m., with Director of Nursing (DON), DON stated staff were required to perform hand hygiene between residents when passing meal trays to residents, to prevent cross contamination and the spread of infection. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised August 2019, the P&P indicated staff were to perform hand hygiene before and after direct contact with residents and before and after assisting a resident with meals to prevent the spread of infections. 2. During a continuous observation of medication administration on 12/1/2021 from 8:00 a.m. to 8:25 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 placed a reusable blood pressure cuff on Resident 10's arm and checked Resident 10's blood pressure. After checking Resident 10's blood pressure, LVN 2 removed the blood pressure cuff and without cleaning, placed the cuff on top of the medication cart. At 8:18 a.m., LVN 2 placed the same blood pressure cuff on Resident 3's arm and checked Resident 3's blood pressure. After checking Resident 3's blood pressure, LVN 2 removed the blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 13 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pressure cuff and without cleaning, placed the cuff on top of the medication cart. At 8:25 a.m., LVN 2 placed the same blood pressure cuff on Resident 23's arm and checked Resident 23's blood pressure. After checking Resident 23's blood pressure, LVN 2 removed the blood pressure cuff and without cleaning, placed the cuff on top of the medication cart. During an interview on 12/1/2021 at 8:50 a.m., with LVN 2, LVN 2 stated she only sanitized the blood pressure cuff between residents when a resident was on isolation precautions (measures intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). During an interview on 12/2/2021 at 1:08 p.m., with the Director of Staff Development (DSD), the DSD stated nursing staff were expected to sanitize blood pressure cuffs used for multiple residents, with alcohol swabs or wipes between each resident's use. A review of policy and procedure (P & P) titled, Cleaning and Disinfection of Resident Care Items and Equipment, revised October 2018, indicated, Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 14 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility had one resident room (room [ROOM NUMBER]), that accommodated more than four residents. This failure had the potential to result in insufficient space to provide care to each of the five residents, and inadequate space to store their personal belongings. Findings: During observation of resident care in room [ROOM NUMBER] on 12/1/21 at 9:50 a.m., the staff had sufficient room to move around the residents' area as they provided care and changed linens. Privacy was always maintained during each procedure that the staff performed. Storage area for the personal belongings of each of the five residents was adequate, clean, and in good repair. The five residents did not have any complaints. There were no safety issues. Recommend granting room waiver. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 15 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 17 of 17 residents in the following multiple resident bedrooms (Rooms 1, 2, 4, 5, 8) with at least 80 square feet per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside. After observation and interview, there was adequate space for residents and staff to move about without obstruction. Recommend granting waiver. Findings: During an observation on 12/2/21 at 9:10 a.m., the following resident rooms and corresponding square footage (sq ft) were identified: Room # # of residents Total Sq Ft Sq ft/resident room [ROOM NUMBER] 4 residents 297 sq ft 74.37 sq ft/bed room [ROOM NUMBER] 4 residents 297 sq ft 74.37 sq ft/bed room [ROOM NUMBER] 2 residents 146.3 sq ft 73.19 sq ft/bed room [ROOM NUMBER] 2 residents 136.9 sq ft 72.86 sq ft/bed room [ROOM NUMBER] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 16 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony Care Center 553 Smalley Avenue 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 5 residents 364.3 sq ft Level of Harm - Potential for minimal harm 72.86 sq ft/bed Residents Affected - Some During an observation on 12/2/21 at 9:10 a.m., there was sufficient space for the staff to move around without violating privacy as they provided care to residents. There were no complaints from residents that there was insufficient space for their belongings. There were no negative consequences attributable to the decreased space in resident rooms 1, 2, 4, 5, and 8; nor were any safety concerns noted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 17 of 17