Health inspection·November 16, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 22's MDS assessment, dated 8/25/23, indicated resident had severely impaired cognition and was totally dependent with one-person assist in activities of daily living (ADLs), including eating. During a concurrent observation and interview on 11/13/23, at 12:31 p.m., inside the resident's room, CNA 2 was standing next to the bed while assisting Resident 22 with lunch. CNA 2 pointed to the chair inside the room but remained standing while feeding the resident. CNA 2 stated he should sit while feeding so that he was in eye level with the resident due to risk of choking. During an interview on 11/14/23, at 1:08 p.m., with the Director of Nursing (DON), DON stated CNAs should sit when feeding the residents so that they are within eye level and easier to assess and monitor residents for choking. A review of the facility's policy and procedure (P&P) titled, Feeding the Impaired Resident, undated, indicated, Be observant during the feeding process. Watch for signs of choking or anything unusual .position a chair where it will be convenient for you and the resident . A review of the facility's P&P titled, Quality of Life - Dignity, revised date August 2009, indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall treat cognitively impaired residents with dignity and sensitivity . 3. A review of Resident 8's admission Record, indicated Resident 8 was admitted to the facility with multiple diagnoses including dementia (dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a concurrent interview and observation on 11/14/23, at 1:25 p.m., with LVN 1, in Resident 8's room, LVN 1 started to administer medication (eye drop) to Resident 8 while the door was open wide with Resident 8 visible from the hallway, and a staff member was walking in the hallway at that time. LVN 1 stated that she forgot to close the door and she should always provide privacy for the resident during medication pass which she did not do for Resident 8. 4. A review of Resident 12's admission Record, indicated Resident 12 was admitted to the facility with multiple diagnoses including brain injury. During a concurrent interview and observation on 11/14/23, at 9:00 a.m., with LVN 1, in Resident 12's room, LVN 1 started to administer medication via GT while the door was open wide with Resident 12 visible from the hallway, and a staff member was walking in the hallway at that time. LVN 1 stated she made a mistake and should have closed the curtain or the door for the privacy of Resident 12. A review of the facility's P&P titled, Quality of Life-Dignity, revised 2009, indicated, . Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 2 of 9 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 11/16/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for one of 15 sampled residents (Resident 26) with limited range of motion (ROM, a joint or body part with limited range of motion cannot move through its normal range of motion, also known as contractures), the facility failed to apply the ankle foot orthosis [AFO, boot(s) or external supportive devices used on lower legs/feet to stabilize the joints to prevent contractures] to Resident 26's left foot as ordered by the physician. This failure resulted in Resident 26's unmet care needs and had the potential to result in worsening of left foot contracture. Findings: A review of Resident 26's admission Record, printed 11/15/23, indicated resident was admitted on [DATE] with diagnoses of dementia (memory loss), contracture of left ankle, hemiplegia (unable to move one side of the body due to damage to the parts of the brain responsible for movement), and hemiparesis (muscle weakness on one side of the body). A review of Resident 26's Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/23/23, indicated resident had moderately impaired cognition. The MDS also indicated resident had impairment of the left lower extremity that required extensive assistance with bed mobility, toilet use, personal hygiene, and total physical assistance with one-person assist on transfers between surfaces. A review of Resident 26's Physician Order, dated 8/25/23, indicated, Restorative Nursing Assistant/Certified Nursing Assistant (RNA/CNA) Program: Standard wheelchair with leg rest while wearing left (L) AFO, up on wheelchair 1-3 hours (hrs)/day, 3x/week as tolerated. Every day shift every Monday (Mon), Thursday (Thu), Sunday (Sun). A review of Resident 26's Care Plan, date initiated 3/24/23, indicated, The resident has limited physical mobility related to (r/t) Contracture left ankle. The resident will remain free of complications related to immobility, including contractures .Monitor/document/report as needed (PRN) any signs/symptoms (s/sx) of immobility: contractures forming or worsening .RNA/CNA Program as ordered . A review of Resident 26's Physical Therapy Treatment Encounter Note(s), completed on 6/21/23, indicated, Skilled Instruction; Patient and Caregiver Training: Instructed patient and primary caregivers in positioning maneuvers .increase safety and reduce the risk of further medical complications that may result from impairments/conditions . A review of Resident 26's Physical Therapy Treatment Encounter Note(s), completed on 6/22/23, indicated, Skilled Instruction; Patient and Caregiver Training: educated and trained CNA to get patient up 3x/week (wk) into wheelchair (w/c) while wearing AFO to left lower extremity (LLE) . During a concurrent observation and interview on 11/15/23, at 11:40 a.m., in the dining room/activity room, with the Activity Director (AD), the AD stated Resident 26 attended activities daily, positioned in the w/c with footrests, and AD had not seen the resident wear a boot to his left contracted foot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 3 of 9 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 11/16/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/15/23, at 11:43 a.m., with CNA 2, CNA 2 stated he had been assigned as Resident 26's morning shift CNA the last three days and had taken the resident to activities daily, positioned up in the w/c with bilateral footrests, with no boot applied to the resident's left contracted foot. CNA 2 stated he knew of the resident's left foot contracture but was not aware of the left AFO. CNA 2 stated he could put a pillow on the footrest. Residents Affected - Few During a concurrent observation, interview, and record review on 11/15/23, between 12:06-12:20 p.m., with the Director of Rehabilitation (DOR), Resident 26's Physician Order was reviewed. The DOR had Resident 26's labeled personal boot in her hand and stated Resident 26 required use of the AFO to his left foot to prevent further worsening of the contracture. DOR stated she found the left ankle boot inside the resident's room in his nightstand. The facility was unable to provide policies and procedures (P&Ps) on either Limited Range of Motion or Use of Orthotics, Braces, or Splints upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 4 of 9 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 11/16/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure the prevention of complications of enteral feedings for one of one sample selected resident who has a feeding tube at the facility (Resident 12) when Licensed Vocational Nurse (LVN) 1 administered the medication and water via gastrostomy tube (GT-a tube inserted through the abdomen that brings nutrition directly to the stomach) without first checking stomach residual (amount of fluid remaining in the stomach). This failure resulted in Resident 12 vomiting after receiving the medication and water via GT, and a potential for Resident 12 to aspirate (breathe in food or liquid into the airway). Findings: A review of Resident 12's admission Record, indicated Resident 12 was admitted to the facility with multiple diagnoses including brain injury. During a concurrent interview and observation on 11/14/23, at 9:00 a.m., with LVN 1, in Resident 12's room, LVN 1 started to administer medication and water flush via GT without checking the stomach residual, and Resident 12 started vomiting immediately after receiving the medication and water. LVN 1 stated she forgot to check the stomach residual before she administered medication and water which could have prevented complications such as vomiting. A review of the facility policy and procedure titled, Medication Administration, Enternal Tubes, dated 2007, indicated, . Aspirate stomach contents with syringe. Check residual . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 5 of 9 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 11/16/2023 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 follow proper sanitation, food handling, and food storage practices when: Residents Affected - Some 1. Refrigerator 1 had two bags of iceberg lettuce that were discolored, wilted, and did not have received-by or used-by dates. 2. During tray line (serving and plating of food) service: - Pureed (a procedure to change the texture of solid food so that it is smooth with no lumps and has a texture like pudding) fish and pureed rice were watery and did not stay formed when scooped on the plate. - Scooped food on four resident plates were left uncovered after these plates were placed inside the open food cart. 3. Dietary staff switched from one kitchen task to the next without performing handwashing. 4. Dietary staff's hair was not fully secured with the hairnet. These failures had the potential to result in food contamination and resident foodborne illnesses. Findings: 1. During the concurrent initial observation and interview on 11/13/23, at 9:50 a.m., in the kitchen, with the Registered Dietitian (RD) and Dietary Supervisor (DS), Refrigerator 1 had an unlabeled clear plastic bag that contained a head of wilted and discolored iceberg lettuce. DS stated the plastic bag should have been labeled and dated of when it was received. DS also stated the lettuce had signs of spoilage and should be discarded right away. During the concurrent second day observation and interview on 11/14/23, at 11:25 a.m., in the kitchen, with the Registered Dietitian (RD) and Dietary Supervisor (DS), Refrigerator 1 had another unlabeled clear plastic bag that contained six heads of wilted and discolored iceberg lettuce. DS stated this was delivered the same time as the previous bag of lettuce observed on 11/13/23. DS stated all six heads of lettuce will also be discarded. A review of the facility's dietary guideline titled, Produce Storage Guidelines, dated 2018, indicated, May use longer if no signs of spoilage are visible .lettuce, salad greens, parsley - 7 to 10 days . 2. During an observation on 11/14/23, at 11:55 a.m., in the kitchen, [NAME] 1 preceded with the tray line service and: -Scooped pureed fish and pureed rice which were watery and did not stay formed when served on the plates. During a follow-up concurrent interview on 11/14/23, at 12:40 p.m., with [NAME] 1 and RD, [NAME] 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 6 of 9 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 11/16/2023 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 stated cooked fish was pureed with fish juice while the cooked rice was pureed with rice water. RD stated when preparing pureed foods, no specific amount of liquid was mixed with the cooked food as long as the required consistency was followed for the specific type of food pureed. RD also stated correct pureed food consistency was important for food presentation to make it look more appealing and appetizing to the residents with swallowing difficulty. Residents Affected - Some A review of the facility's dietary guideline titled, Handout for Puree In-service, dated 10/2020, indicated consistency for meats and starches should be slightly softer than whipped topping. - [NAME] 1 did not cover four of the resident plates before these plates were placed in the tray inside the open food cart. During a follow-up interview on 11/14/23, at 12:45 p.m., with the RD, RD confirmed the observation and stated all food trays need to be covered to keep the food temperature warm and to prevent cross-contamination. A review of the facility's policy and procedure (P&P) titled, Covering Food During Transport, dated 2018, indicated, .All foods will be covered on trays .All hot food will be covered to maintain the proper temperature . 3. During an observation on 11/14/23, at 12:15 p.m., [NAME] 1 moved from plating foods to grind fish and did not perform handwashing before and after food preparation. During a follow-up concurrent interview on 11/14/23, at 12:40 p.m., with [NAME] 1 and RD, RD acknowledged [NAME] 1 left the tray line food service to grind the fish, without performing handwashing in between the two tasks. A review of the facility's policy and procedure (P&P) titled, Inservice: Handwashing, dated 3/2021, indicated, .Hand washing, when done correctly and often, can help us stay healthy and avoid spreading disease. When should hand washing be done .After handling soiled equipment, utensils .During food preparation as often as necessary to prevent contamination . 4. During an observation on 11/14/23, at 11:55 a.m., [NAME] 1's hair was not fully covered with a hairnet. During a follow-up concurrent interview on 11/14/23, at 12:40 p.m., RD confirmed [NAME] 1's hair to the side of her ears were exposed and not completely covered with the hairnet. A review of the facility's policy and procedure (P&P) titled, DRESS CODE for Women and Men, dated 2018, indicated, .PROPER DRESS: Women .Hair net or hat completely covers the hair . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 7 of 9 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 11/16/2023 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 ensure prevention of infection for one of 15 sample selected residents (Resident 12), when Licensed Vocational Nurse (LVN) 1 did not disinfect the blood pressure device between resident use. Residents Affected - Few This failure had the potential of transmitting infection between the residents who are residing at the facility. Findings: A review of Resident 12's admission Record, indicated Resident 12 was admitted to the facility with multiple diagnoses including brain injury. During a concurrent observation and interview on 11/14/23, at 9:00 a.m., with LVN 1, in Resident 12's room, LVN 1 removed the blood pressure device from the medication cart and without disinfecting the device, checked Resident 12's blood pressure and put the device back inside the medication cart. LVN 1 confirmed and stated she should have disinfected the blood pressure device between residents' use for infection prevention and she forgot to do that. A review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfecting of Resident-Care items and Equipment, revised 2010, indicated, . Reusable items are cleaned and disinfected or sterilized between residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 8 of 9 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 11/16/2023 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 and interview the facility had five residents (Rt)'s rooms (room [ROOM NUMBER], 2, 4, 5 and 8) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 11/13/23, at 10:00 a.m., the following rooms and corresponding square footage per bed were identified: Room Activity Room size Floor area 1 Rt room [ROOM NUMBER].8 x 20.3 sq. ft 297 sq. ft (74.3 per bed) 2 Rt room [ROOM NUMBER] x 21.3 sq. ft 297.5 sq. ft (74.3 per bed) 4 Rt room [ROOM NUMBER].2 x 10.4 sq. ft 146.4 sq. ft (73.2 per bed) 5 Rt room [ROOM NUMBER].2 x 9.8 sq. ft 137 sq. ft (68.5 per bed) 8 Rt room [ROOM NUMBER].4 x 17.11 sq. ft 364.3 sq. ft (72.86 per bed) During random observations of care and services from 11/13/23 to 11/16/23, 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 the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the five rooms. Granting of room size waiver recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055809 If continuation sheet Page 9 of 9