Health inspection·March 21, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some By further observation on 3/18/19 at 12:44 p.m., CNA 1 was observed sitting on a chair while feeding lunch to Resident 82. Without explaining anything to Resident 82, CNA 1 got up to grab another chair from another dining table. CNA 1 then came and sat on the same previous chair, and started feeding Resident 82. By further observation while feeding Resident 82, CNA 1 got up again and wheeled Resident 31 out of the dining area. CNA 1 then picked up Resident 31's lunch tray to put it away. CNA 1 then came back and started feeding Resident 82 again. During an interview on 3/18/19 at 12:58 p.m., CNA 1 did not comment on getting up and going away from Resident 82, two times in the middle of assisting with meals. During an interview on 3/18/19 at 1:02 p.m., Director of Staff Development (DSD) stated Staff needs to show respect and full attention while assisting the residents. DSD also stated CNA 1 should have asked another staff to wheel Resident 31 out of the dining area. During a concurrent interview and record review on 3/20/19 at 9:50 a.m., DSD confirmed that CNA 1 was recently trained on Dignity for Residents on 2/19/19. Review of facility's policy and procedure titled Privacy/Dignity revised 10/24/17 showed Always ensure dignity of resident is respected during care and during conversation with residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 2 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for three of three residents (Residents 36, 98 and 172) who received Medicare benefits, the facility failed to inform residents of charges for services that would not be covered under Medicare or the facility's per diem rates should residents opted to stay in the facility after Medicare services were discontinued when: Residents Affected - Few 1. For Resident 36, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) Form issued was not completely filled out. 2. For Resident 98, SNFABN form did not have the resident or resident representative's signature. 3. For Resident 172, SNFABN form was not completely filled out and did not have resident's or resident representative's signature. This failure had the potential to result in uninformed healthcare decisions. Findings: 1. Review of the clinical record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (abnormal levels of blood sugar) and left leg amputation. The Order Summary Report for March 2019 indicated a physician's order dated 1/2/19 for Resident 36 to be discharged home. Review of Resident 36's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice issued to original Medicare beneficiaries before the skilled facility provides service that is usually paid for by Medicare, but may not be covered because it is not medically necessary or when the resident would receive custodial care.) dated and signed by Resident 36 on 12/16/18. The notice indicated Beginning 12/16/18, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The notice did not indicate the care, reason Medicare may not pay for the care and estimated cost of the service/care (that Resident 36 may have to pay out of pocket if Medicare did not pay for it). 2. Review of the clinical record indicated Resident 98 was admitted to the facility on [DATE] with diagnoses included pneumonitis (infection of the lungs), hemiplegia and hemiparesis (paralysis/weakness of one side of the body) and muscle weakness. The Order Summary Report for March 2019 indicated Resident 98 received Occupational Therapy (OT, therapy based on engagement in meaningful life activities such as self-care, work or social interaction) Physical Therapy (PT, therapy for the preservation or restoration of movement and physical function like walking) and Speech Therapy (ST, addresses communication and speech-related challenges to improve verbal, non-verbal and social communication). 3. Review of the clinical record indicated Resident 172 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, heart failure, and intracerebral hemorrhage (bleeding in the brain). The Order Summary Report printed on 3/19/19 indicated Occupational Therapy was ordered for Resident 172, but was discharged from OT on 11/8/18. The report also indicated an order dated 11/16/18 for Resident 172 to be discharged to home. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 3 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Resident 172's SNFABN did not indicated care, reason why Medicare will not pay for the care and estimated cost of the care. The notice also did not indicate any signature and it was not dated. During interview and concurrent review of the SNFABNs issued to Residents 36, 98 and 172 with Administrator (ADM) and Minimum Data Set Coordinator (MDSC) on 3/19/19 at 11:19 p.m., both ADM and MDSC stated the forms issued to the residents did not indicate the charges that residents were expected to pay out of pocket should they decide to stay at the facility and avail of the services and care. ADM stated the forms should indicate the charges and the reason why Medicare will not pay, and should have the signature of the person the notice was issued to. ADM also stated the form should be completely filled out so that residents know how much they were supposed to pay. Event ID: Facility ID: 055885 If continuation sheet Page 4 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a care plan for pain for one of 46 sampled residents (Resident 74), which had the potential to cause Resident 74 to have unmet pain relief needs. Findings: Review of the admission record for Resident 74 indicated that he was admitted on [DATE] with multiple diagnoses including chronic pain. During an interview with Resident 74 on 3/18/19 at 10:51 a.m., he stated he was in a lot of pain most of the time. He stated he can get pain medication every six hours, but it was not enough. He stated he could also have Tylenol as needed, but that did not help. During an interview and concurrent record review with Director of Nursing (DON) on 3/21/19 at 10:05 a.m. of Resident 74's care plan, she stated there was no care plan for pain. She stated Resident 74 should have a care plan for pain since he was on pain medications and was assessed for pain. The facility policy and procedure titled,Care Plan, Baseline and Comprehensive, revised 11/2017, indicated, A comprehensive person-centered care plan consistent with residents rights will include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 5 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, for two of two (Residents 37 and 76) sampled residents who were dependent on dialysis (a treatment where a machine cleans and filters the blood of toxins when the kidneys are not healthy enough to do it adequately, will be used interchangeably with hemodialysis), the facility failed to ensure services were provided in accordance with professional practice and comprehensive person-centered plan of care when phosphate binders (medications that binds with dietary phosphorus in the gastrointestinal tract) were not administered as ordered by the physician. Residents Affected - Some This failure had resulted in increased phosphorus level in Resident 37 and had potential to result in increased phosphorus level for Resident 76. Findings: 1. Review of the clinical record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (abnormal levels of blood sugar) and end stage kidney failure and required hemodialysis. The Order Summary Report as of 3/1/19 indicated an order dated 12/23/18 for Resident 37 to receive sevelamer carbonate 800 mg (a phosphate binder) one tablet by mouth with meals three times daily. The Order Summary Report also indicated Resident 37 had hemodialysis every three times weekly on Monday, Wednesday, and Friday from 10 a.m. until 2 p.m During an interview with Resident 37 on 3/19/19 at 8:49 a.m., Resident 37 stated he brought his own lunch to dialysis center. Resident 37 stated dialysis staff did not administer any medication during lunch. During an interview and concurrent review of Resident 37's Medication Administration Record (MAR) for March 2019 with Licensed Vocational Nurse (LVN) 4 on 3/19/19 at 10:53 a.m., LVN 4 stated, on dialysis days, Resident 37 left for dialysis at 9:45 a.m. and did not return to the facility until 3 p.m. so Resident 37 was given sack lunch to eat at the dialysis center. LVN 4 stated Resident 37 was not given sevelamer carbonate along with the sack lunch. LVN 4 also stated she thought dialysis center licensed staff administered sevelamer while Resident 37 was at the dialysis center. Review of Resident 37's MAR indicated the following: -In January 2019, calcium acetate (another phosphate binder) 667 mg. by mouth with meals was ordered on 12/23/18. The MAR indicated calcium acetate was not administered 15 out of 90 times for reason that Resident 37 was off the unit. Calcium acetate was discontinued on 1/30/19. Sevelamer carbonate was not administered 15 out of 90 times for the same reason that Resident 37 was off the unit. -In February 2019, 12 out of 90 doses were not administered to Resident 37. -In March 2019, 9 out of 58 doses were not administered to Resident 37. During a telephone interview with Registered Nurse (RN) 3 on 3/20/19 at 8:18 a.m., RN 3 stated Resident 37 did not have sevelamer acetate in his binder or with his sack lunch. RN 3 also stated if the facility wanted the medication administered at the dialysis center, the medication should have been sent with Resident 37's communication binder. RN 3 also stated it was not the dialysis center's responsibility to administer the medication since Resident 37 was alert and able to follow instructions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 6 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 37's laboratory results dated [DATE] indicated phosphorus level of 4.5 mg/dL, a laboratory result collected on 1/21/19 indicated Resident 37's phosphorus level as 4.5 mg/dL. The laboratory result dated 2/18/19 indicated Resident 37's phosphorus level was 5.7 mg/dL (goal range: 3.5-5.5). During a telephone interview with Registered Dietician (RD) 2 on 3/20/19 at 1:45 p.m., RD 2 stated she did not know Resident 37 missed his lunch dose of sevelamer on dialysis days. RD 2 stated missed doses of sevelamer acetate could result in elevated phosphorus level. 2. Review of the clinical record indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and was dependent on dialysis. Resident 76's Order Summary Report dated 3/20/19 indicated Resident 7 went to dialysis center every Monday, Wednesday and Friday from 6 a.m. until 10 a.m. The report also indicated an order dated 1/18/19 for Resident 76 to receive calcium acetate capsule 667 mg by mouth with meals. During an observation and concurrent interview with Resident 76 and Family Member (FM) 1 on 3/18/19 at 10:38 a.m., both Resident 76 and FM 1 stated they had just returned from dialysis center and had just finished eating breakfast that staff had left at the bedside for Resident 76. Resident 76's breakfast tray, which was almost empty, was on the overbed table. Both Resident 76 and FM 1 also stated Resident 76 was getting ready to go to the rehabilitation gym for exercises. Resident 76 stated he has not taken any medications yet since returning from dialysis center. During an interview and review of Resident 76's MAR for March 2019 with Registered Nurse (RN) 4 on 3/19/19 at 9:37 a.m., RN 4 stated she administered phosphate binder to Resident 76 at 9:07 a.m RN 4 also stated she administered the medication 20-30 minutes after Resident 76 had eaten his meals. RN 4 stated, because Resident 76 left facility at 5 a.m for dialysis, sevelamer acetate that was administered with breakfast was not given on dialysis days. RN 4 stated she marked the MAR with 11 which was code for off the unit for when residents were not at the facility during medication pass. Further review of the MARs indicated the following: - In January 2019, three of 40 doses were not administered. - In February 2019, six out of 84 doses were not administered. - In March 2019, eight out 52 doses were not administered. During a telephone interview with RD 2 on 3/20/19 at 1:45 p.m., RD 2 stated phosphate binders should be given just before the resident eats, administering the medication 10-15 minutes after the resident completed the meal is not very effective. Review of the manufacturer's prescribing information indicated oral dosage forms must be administered with meals to be effective. [Reference:https://online.[NAME].com/lco/action/doc/retrieve/docid/patch_f/6501#f_administration-and-storage-issues]. During review of Resident 76's clinical record with Licensed Vocational Nurse (LVN) 3 on 3/20/19 at 11:05 a.m., LVN 3 stated the laboratory results for Resident 76 was not in the chart. LVN 3 stated she would have to call the dialysis center to obtain the results. LVN 3 did not answer when asked who was responsible to make sure the laboratory results were available in Resident 76's chart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 7 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's policy and procedure titled Dialysis, Coordination of Care & Assessment of Resident last revised 1/2018 indicated that while the resident is at the facility, the facility has direct responsibility for assessment of the resident that including monitoring laboratory studies ordered and performed. According to the National kidney Foundation, normally, kidneys can remove phosphorus from the blood but if the kidneys are not well enough, they cannot remove phosphorus very well. High levels of phosphorus can cause damage to the body and pulls calcium out of the bones making them weak. High phosphorus and calcium levels also lead to dangerous deposits in the blood vessels, eyes, and heart. [Reference:https://www.kidney.org/atoz/content/phosphorus]. Event ID: Facility ID: 055885 If continuation sheet Page 8 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 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** 3. Review of the clinical record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (paralysis/weakness on one side of the body) following a stroke. Review of Resident 13's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 12/17/18 indicated Resident 13 was not able to verbalize needs and had short term and long term memory impairment. The assessment also indicated Resident 13 required extensive staff assistance daily tasks that included transfers, moving in bed, dressing, toilet use and personal hygiene. Resident 13 was not able to eat without total help from staff. During an observation and concurrent interview with Registered Nurse (RN) 8 on 3/18/19 at 11:23 a.m., Resident 13 was in bed and tried to extend his arm in front of his chest. Resident 13's was not able to open his right hand that was closed in a tight fist. RN 8 stated Resident 13's hand had been contracted (from the word contracture, an abnormal or permanent shortening of the muscle that results in distortion of a joint) for awhile now but RN 8 was not able to stated for how long. RN 8 attempted to help Resident 13 spread his right fingers and Resident 13 moaned and grimaced. Resident 13 did not have any hand rolls in his right hand. During a telephone interview with Family Member (FM) 2 on 3/19/19 at 12:40 p.m., FM 1 stated not being happy that Resident 13 seemed to have pain on his right hand when Resident 13 attempted to open or when somebody tried to open his right hand. FM 1 stated Resident 13 cried in pain whenever FM 1 tried to open his right hand. FM 1 stated it would have helped if the facility provided exercises because it had gotten very stiff. During joint interviews and concurrent review of the clinical record with Minimum Data Set Coordinator (MDSC) and Restorative Nursing Assistant (RNA) 1 on 3/20/19 at 2:17 p.m., RNA 1 confirmed there was an order dated 3/3/15 for application of a splint on Resident 13's right hand for 4 hours five times weekly or as tolerated. Resident 13's MDS assessment dated [DATE] indicated Resident 13 had functional limitations on both sides of upper and lower extremities. MDSC stated there was no care plan developed to address Resident 13's limited range of motion problem. Review of the facility's policy and procedure titled Contracture Management last revised 11/2012 indicated joint mobility limitations/contractures will be identified through nursing assessment and MDS assessment. When new joint mobility or increased contractures are identified, rehabilitation department will be consulted for further evaluation and treatment. Intervention will be documented to meet the resident's immediate needs which may include pain relief, proper alignment, repositioning for comfort and assistance with daily life activities. Nurse will complete and revise the plan of care that included current or potential joint mobility limitations. During an interview with concurrent review of Documentation Survey Report for February 2019 and March 2019 with RNA 1 on 3/21/19 at 10:18 a.m., RNA 1 confirmed there were weeks that Resident 13 did not have RNA program as ordered. For February 2019, Resident 13 received RNA program eight times out of 20 opportunities for RNA program. In March 2019, Resident received RNA program 10 times out of 15 opportunities. RNA 1 stated she was the only RNA for the whole facility and there were days that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 9 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0688 Level of Harm - Minimal harm or potential for actual harm she had to work as a CNA on the floor. RNA 1 stated on those days that she had to work as CNA, RNA program and exercises for residents were not done. When asked if right hand range of motion exercises were attempted for Resident 13, RNA 1 stated range of motion exercises took a lot of time and that she did not have much time to spend on one resident. RNA 1 added splinting is much better option because you just have to apply the splint, leave, and move on to another resident. Residents Affected - Few Based on observation, interview, and record review the facility failed to provide Range Of Motion (ROM) exercises to three (Resident 69, 75 and 13) of 33 sampled residents for limited ROM in extremities. This failure had the potential for Resident 69, 75 and 13 to suffer from worsening of limitation in ROM in extremities. Findings: 1. Review of admission Record dated 3/21/19 showed Resident 69 was initially admitted to the facility on [DATE]. During an observation on 3/19/19 at 7:51 a.m., Resident 69 was lying in bed with left arm and left leg covered under the bed sheet. When asked if she was able to move left arm and left leg, Resident 69 nodded her head as no. Review of Initial History and Physical dated 1/22/19 showed Resident 69 had an active diagnosis of left hemiplegia (paralysis of left side). During a concurrent interview and record review on 3/21/19 at 9:29 a.m., Registered Nurse (RN 2) confirmed Resident 69 did not receive ROM exercises for left side weakness. During a concurrent interview and record review on 3/21/19 at 10:05 a.m., Rehab Program Director (Rehab Dir.) confirmed Resident 69 did not receive any therapy after 12/11/18. During an interview with facility's Restorative Nurse Aide (RNA 1) on 3/21/19 at 10:28 a.m., RNA 1 stated, I was told by Rehab Department two weeks ago to provide ROM exercises to Resident 69. I have been doing ROM exercises for Resident 69, but I have not documented because there was no orders in the computer. During a concurrent interview and record review on 3/21/19 at 10:55 a.m., Health Information Director (HIM) confirmed Resident 69's electronic health record had Task- Daily exercise, Morning Stretch assigned for the RNA and CNA. HIM also confirmed there was no documentation if the task was being completed in the past 30 days. Review of facility's policy and procedure titled Contracture Management revised 11/2012 showed Residents will be assisted to maintain normal joint mobility, prevent complications associated with joint deformity and prevent worsening of existing contractures. Document interventions implemented to meet the resident's immediate needs which may include, but not limited to: ROM . 2. Review of admission Record dated 3/20/19 showed Resident 75 was admitted to the facility on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 10 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Physician Progress notes dated 1/17/19 showed Resident 75 had Hemiplegia with Right sided weakness. During a concurrent observation and interview on 3/19/19 at 8:42 a.m., CNA 4 confirmed Resident 75's right arm and right leg were contracted since admission. CNA 4 also stated Resident 75 was not receiving therapy or ROM exercises for past couple weeks. Review of Occupation Therapy Daily Treatment Note dated 3/14/19 showed Resident 75 was discharged from therapy on the same date. During an interview on 3/19/19 at 10:04 a.m., RNA 1 stated Resident 75 was not receiving ROM exercises at that time as she did not receive RNA recommendations yet. During a follow up interview on 3/20/19 at 10:22 a.m., RNA 1 stated she had received Resident 75's RNA recommendations on 3/15/19, and did not provide ROM exercises to her for four days because nurses did not put in orders in the computer. During an interview with Director of Nursing (DON) on 3/20/19 at 10:49 a.m., DON stated Resident 75's RNA recommendations should be entered in clinical record on 3/14/19 and must not be delayed. Review of Resident 75's Task- Daily Exercise Passive ROM for 30 day look back period, showed Resident 75 did not receive ROM exercises on 3/14/19, 3/15/19, 3/16/19, 3/17/19 and 3/18/19. Review of facility's policy and procedure titled Contracture Management revised 11/2012 showed Residents will be assisted to maintain normal joint mobility, prevent complications associated with joint deformity and prevent worsening of existing contractures. Document interventions implemented to meet the resident's immediate needs which may include, but not limited to: ROM . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 11 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the admission record for Resident 26 indicated she was readmitted on [DATE] with multiple diagnoses including chronic pain. Residents Affected - Few During an interview with Resident 26 on 3/18/19 at 9:27 a.m., she stated she was taking long acting Morphine Sulfate tablets every eight hours for her pain, but she was constantly getting it late. She stated it made her very anxious, and she worried that it would not be available to alleviate her pain. A review of Resident 26's physician orders dated 5/9/17 indicated, Morphine Sulfate (MS) Tablet Extended Release 15 mg *Controlled Drug*-Give one tablet by mouth every eight hours for pain management . During an interview and concurrent record review with the Director of Nursing (DON) on 3/20/19 at 10:44 a.m. of the documented medication administration times for Resident 26 for February 2018 and March 2018, Morphine Sulfate was given more than one hour after the scheduled administration time on thirty-four occasions. The DON stated she did not know why the Morphine Sulfate had been given late. She stated it should be given within one hour of the scheduled time. That was the policy. She stated she would need to inservice the licensed nurses. The facility policy and procedure titled, Medication Administration-General Guidelines dated October 2017, indicated, Medications are administered within sixty minutes of scheduled time (one hour before and one hour after). Based on observation, interview and record review, the facility failed to manage pain for two (Resident 120 and 26) of 46 sampled residents, when: 1. Resident 120 did not receive pain medication as desired prior to therapy session. 2. Resident 26 did not receive scheduled pain medication in a timely manner. This failure had the potential for Resident 120 and 26 to suffer from complications of pain such as limited mobility, and decreased participation in therapy. Findings: 1. Review of admission Record showed Resident 120 was admitted to the facility on [DATE] with active diagnosis of fracture of neck of Right femur (hip bone) and fracture of left acetabulum (socket of hip bone). Review of Resident 120's Physicians Order Summary Report dated 3/18/19 showed Resident 120 to receive: Morphine Sulphate Solution 20 mg/ml Give 10 mg by mouth every 6 hours as needed for severe pain. During an observation and interview with Resident 120 on 3/18/19 at 9:20 a.m., Resident 120 was lying in bed. Resident 120 stated severe pain was affecting his ability to perform physical therapy over the course of time. Resident 120 also stated that he requested nursing staff to give Morphine Sulphate dose prior to therapy at 2:00 p.m., however nursing staff was not following his request. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 12 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/18/19 at 10:28 a.m., when asked how did nursing staff address Resident 120's pain levels and participation in physical therapy, Registered Nurse (RN 2) stated Resident 120 does not really have that much pain, but he says he has high pain levels. During an interview on 3/20/19 at 11:54 a.m., Director of Nursing (DON) stated Pain is always what Resident tells us, we can not assume what the pain level is. Review of Resident 120's Medication Administration Record dated 3/18/19 showed documented pain levels were ranging from 2-9 between time period of 3/4/19 till 3/18/19. Further review showed Resident 120 received MS prior to therapy only for 3 occasions. During a concurrent interview and record review on 3/20/19 at 12:45 p.m., DON confirmed Resident 120's care plan for pain management and physician order for Morphine Sulphate did not specify to give MS prior to therapy. Review of Resident 120's Occupational Therapy Note dated 3/13/19 showed toilet transfer attempted using grab bars, Resident 120 unable to complete due to pain. Review of Centers of Medicare Services (CMS's) Resident Assessment Instrument (RAI) Version 3.0 Manual 10/2017 showed Definition of Pain: Any type of physical pain or discomfort in any part of the body. It may be localized to one area or may be more generalized. It may be acute or chronic, continuous or intermittent, or occur at rest or with movement. Pain is very subjective; pain is whatever the experiencing person says it is and exists whenever he or she says it does. Review of facility's policy and procedure titled Pain Management revised 11/28/17 showed A pain management plan provides an organized mechanism for the assessment and treatment of pain includes: appropriately trained staff determined competent to assess and treat pain using standardized pain rating scales. Further review showed A plan of care is developed for patients, documented and updated as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 13 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview and document review, the facility failed to provide adequate staff to aid 11 of 11 sampled residents who needed feeding assistance during lunch time. Residents Affected - Some This deficient practice does not promote residents' physical, mental, and psychosocial well-being. Findings: During an observation on 3/18/19 at 12:10 p.m. in the dining room, eleven of eleven dependent dining residents had their meals placed in front of them and were waiting to be assisted by staff. There were two licensed vocational nurses (LVN 7 and 8) in the dining room assisting dependent residents with eating. During an observation on 3/18/19 at 12:32 p.m. in the dining room, six of eleven dependent dining residents (Residents 13, 22, 48, 105, 112, and 117) were still waiting for assistance with eating their lunch. Resident 22 attempted to drink his chocolate milk without assistance and started choking. He continued to cough for approximately three minutes. During an interview with LVN 7 on 3/18/19 at 12:39 p.m. in the dining room, she stated residents should not be waiting for assistance with eating, and she left the dining room to get more staff for assistance. During an interview with the Assistant Director of Nursing (ADON) on 3/21/19 at 11:24 a.m., she stated one of her functions was to assist dependent residents with eating their lunch. She stated she was busy on 3/18/19, and she was unable to get to the dining room to assist for approximately forty-five minutes after lunch was served. The facility assessment stated, Registered Nurses and Licensed Vocational Nurses are available around the clock to monitor, provide and deliver the clinical care and skilled nursing services. Certified Nursing Assistants are available on each shift to provide activities of daily living (ADL) assistance . The facility policy and procedure titled, Dining Program, revised 11/2012, indicated, Meals are to be served from the kitchen within fifteen minutes of the scheduled time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 14 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview and record review, facility failed to have sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services as determined by the acuity and diagnoses of resident population in accordance with the facility assessment when three of three licensed staff did not have skills competency skills check. This failure had the potential to result in poorly trained and incompetent staff providing substandard care to residents. Findings: During an interview and concurrent review of the employee files with Director of Staff Development (DSD) on 3/21/19 at 11:55 a.m., DSD stated RN 2 did not have skills check for infection control, RN 6 (hired in 2017) and LVN 4 (hired in 2016) both did not have any skills performance checklist. All three licensed staff did not have annual performance evaluations done. Review of the Facility Assessment provided by the facility at time of survey indicated facility admits and provide care that may present common diseases that included renal failure, end stage kidney disease, and infectious diseases. It also indicated special treatments and conditions that facility staff expected residents to require that included isolation for active infectious diseases. Services and care facility offered based on residents' needs included indwelling urinary catheter and identification and containment of infections. The facility assessment also indicated Once staffs have been successfully screened, background cleared, reference checked, license .verified, they are placed on orientation for a minimum of 16 hours. Competency skills evaluations are checked on hire and annually thereafter. Performance evaluations are performed annually to ensure staffs are meeting our facility standards or performance and conduct. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 15 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional principles when: 1. multiple medications were expired and were not labeled; 2. controlled substance drugs were not accounted; 3. a medication cart was left unsecured and unattended. These failures had the potential to result in decreased medication efficacy, risk of unauthorized access, use and abuse of controlled substances. Findings: 1. During a medication room inspection on [DATE] at 10:21 a.m., the following medications and biologicals were observed: a. a bottle of Ativan (also know as Lorazepam, a sedative controlled substance used to treat seizure disorders, epilepsy and to relieve anxiety) with an expiration date of [DATE] was stored with the currently used medications in the medication refrigerator; b. a bottle of Ativan with unreadable expiration date was stored with the currently used medications in the refrigerator; c. a bottle containing 100 tables of Aspirin 325 milligrams (mg) had an expiration date of February 2019 was stored in the shelf along with the currently used medications; d. an opened vial of Influenza vaccine (lot number 252229) with an expiration date of [DATE] was stored along with the currently used vaccines. In an interview with the Licensed Vocational Nurse (LVN7) on [DATE] at 10:21 a.m., LVN7 confirmed that the ativan expired and another bottle of Ativan had an unreadable expiration date. Review of the facility's policy titled, Disposal of Medications and Medication Related Supplies. dated [DATE] indicated, If the medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose. 2. During a medication cart inspections on [DATE] at 12:40 p.m., one of four medication carts (Med Cart B), inside the Controlled Substance drawer, the following were observed: a. a bottle of Promethazine (an antihistamine used to treat for allergies and motion sickness) with Codeine syrup (a narcotic controlled substance, High risk for addiction and dependence) had 150 millilitter (ml) left in the bottle. The Controlled Substance Count sheet indicated that the count should have been 190 ml. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 16 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0755 Level of Harm - Minimal harm or potential for actual harm b. a bottle of Morphine Sulfate (a narcotic controlled substance used to treat moderate to severe pain) 100 mg/5ml had 30 ml solution in the bottle. There was no Controlled Substance Count sheet available. c. a bubble pack containing 8 tablets of Lorazepam 0.5 mg tablets where left in the bubble card. The Controlled Substance log count showed that there should have been 13 tablets left. Residents Affected - Some In an interview with LVN2 on [DATE] at 12:40 p.m., LVN2 confirmed the Controlled Substance Count log discrepancies. In a separate interview on [DATE] at 12:40 p.m., the Director of Nursing (DON) stated that she was aware of the narcotic count discrepancies. The DON stated that the facility was working on an action plan to resolve the issue. In a telephone interview with the Pharmacist (RP) on [DATE] at 12:45 p.m., RP stated that he reviewed the resident's medications monthly but must have overlooked the narcotic count discrepancies. RP added that he was involved in resolving the issues with the facility. Review of the facility's policy titled, Preparation and General Guidelines - Controlled Medications, dated [DATE] indicated, At each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. Any discrepancy in controlled substance medication counts is reported to the Director of Nursing immediately. 3. In a facility tour inspection on [DATE] at 8:56 a.m., Med Cart C was observed against the wall between resident rooms [ROOM NUMBERS] with the drawers facing the hallway. Med Cart C was left unsecured and unattended. In an interview with LVN4 on [DATE] at 8:56 a.m., LVN4 confirmed that she was responsible for Med Cart C. LVN4 stated that the facility's policy was to lock and secure the medication cart at all times when not attended. Review of the facility's policy titled, Medication Administration - General Guidelines, dated [DATE] indicated, During administration of medications, the medication cart is kept closed, locked and secure. The medication cart needs to be secured and locked when unattended. 4. During the medication pass observation on [DATE] at 9:00 a.m., a bottle of Artificial tears was found on Resident 83's over the bed table. In an interview with LVN5 on [DATE] at 9:00 a.m., LVN5 stated that she was not aware that Resident 83 was keeping a bottle of Artificial Tear at the bedside. LVN5 confirmed that there was no physician's order and that there was no physician's order for Resident 83 to self-administer the eye drops. Review of the facility's policy titled, Medication Administration - General Guidelines, dated [DATE] indicated, Residents are allowed to self-administer medications when specifically authorized by the attending physician and is in accordance with procedures for self-administration of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 17 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for two of two (Residents 37 and 76) sampled residents who were dependent on dialysis, the facility failed to ensure pharmacist identified and reported irregularities in medication regimen when missed doses of phosphate binders (medications that binds with dietary phosphorus in the gastrointestinal tract) were not identified and evaluated. This failure had resulted in multiple missed doses of phosphate binders that were not addressed in a timely manner. Findings: 1. Review of the clinical record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (abnormal levels of blood sugar) and end stage kidney failure and required hemodialysis. The Order Summary Report as of 3/1/19 indicated an order dated 12/23/18 for Resident 37 to receive sevelamer carbonate 800 mg (a phosphate binder) one tablet by mouth with meals three times daily. During an interview and concurrent review of Resident 37's Medication Administration Record (MAR) for March 2019 with Licensed Vocational Nurse (LVN) 4 on 3/19/19 at 10:53 a.m., LVN 4 stated, on dialysis days, Resident 37 left for dialysis at 9:45 a.m. and did not return to the facility until 3 p.m., so Resident 37 was given sack lunch to eat at the dialysis center. LVN 4 stated Resident 37 was not given sevelamer carbonate along with the sack lunch. LVN 4 also stated she thought dialysis center licensed staff administered sevelamer while Resident 37 was at the dialysis center. Review of Resident 37's MAR indicated the following: -In January 2019, calcium acetate (another phosphate binder) 667 mg by mouth with meals was ordered on 12/23/18. The MAR indicated calcium acetate was not administered 15 out of 90 times for reason that Resident 37 was off the unit. Calcium acetate was discontinued on 1/30/19. Sevelamer carbonate was not administered 15 out of 90 times for the same reason that Resident 37 was off the unit. -In February 2019, 12 out of 90 doses were not administered to Resident 37. -In March 2019, 9 out of 58 doses were not administered to Resident 37. 2. Review of the clinical record indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and was dependent on dialysis. The report indicated an order dated 1/18/19 for Resident 76 to receive calcium acetate capsule 667 mg by mouth with meals. During an interview and review of Resident 76's MAR for March 2019 with Registered Nurse (RN) 4 on 3/19/19 at 9:37 a.m., RN 4 stated she administered phosphate binder to Resident 76 at 9:07 a.m RN 4 also stated she administered the medication 20-30 minutes after Resident 76 had eaten his meals. RN 4 stated, because Resident 76 left facility at 5 a.m for dialysis, sevelamer acetate that was administered with breakfast was not given on dialysis days. RN 4 stated she marked the MAR with 11 which was code for off the unit for when residents were not at the facility during medication pass. Further review of the MARs indicate the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 18 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0756 - In January 2019, three of 40 doses were not administered. Level of Harm - Minimal harm or potential for actual harm - In February 2019, six out of 84 doses were not administered. - In March 2019, eight out 52 doses were not administered. Residents Affected - Some During an interview with Registered Pharmacist (RP) 1 on 3/18/19 at 1:00 p.m., RP stated he missed Resident 76's chart and did not identify an irregularity about the missed doses of phosphate binder. RP stated he was supposed to check the MARs when doing Medication Regimen Reviews. During an interview and concurrent review of the clinical record with Director of Nursing (DON) on 3/21/19 at 10:30 a.m., DON stated, during monthly medication review by RP, RP was expected to check residents' laboratory values, physician's orders, MAR and identify irregularities that included: errors in dosing, time of administration, and missed medication doses. Review of Consultant Pharmacist's Medication Regimen Review/Listing of Residents With No Recommendations created between 2/1/19 and 2/20/19 indicated RP did not have any recommendations for Resident 76. DON stated, Resident 37 had a recommendation that was not related to Resident 37's phosphate binder. Review of the facility's policy and procedure titled Organizational Aspects: IA2: Consultant Pharmacist Service Provider Requirements effective October 2017 indicated, in collaboration with facility staff, consultant pharmacist helps to identify, communicate, address and resolve concerns related to the provision of pharmaceutical services that included assisting facility in identification of medication-related issues, assisting facility in defining schedules of medication administration to maximize medication's effectiveness and to maintain appropriate blood concentrations. The consultant pharmacist performs medication regimen review incorporating professional standards and communicating to the prescriber and facility potential or actual problems identified related to medication therapy orders as well as recommendations for changes in medication therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 19 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility's medication pass observation on 3/18/19 resulted in three errors out of 27 opportunities indicating a medication error rate of 11.11%. Residents Affected - Some These failures placed both Resident 36 and 83 at risk for not getting the full therapeutic effect of their prescribed medications and could result in undesired health care outcomes. Findings: 1. Review of the admission Record showed Resident 35 was admitted to the facility with multiple diagnosis which included diabetes (high blood sugar). During a med pass observation on 3/18/19 at 12:30 p.m., Registered Nurse (RN2) drew up 10 milliliters (ml) of 100 unit/ml Admelog solution (a short-acting insulin indicated to improve control in blood sugar levels) that had an opened date of 2/9/19. RN2 entered Resident 36's room and was about to give the medication. In an interview on 3/18/19 at 12:35 p.m, RN2 stated that she was aware the opened date of the vial was over 28 days. RN2 added that she called the physician because she was not able to find another vial of admelog. Review of the physician's order, dated 2/7/19 indicated, Admelog solution, 100 unit/ml Inject 10 units subcutaneously before meals related to Type 2 Diabetes . Review of the facility's policy titled, Preparation and General Guidelines - Vials and Ampoules of Injectable Medications, dated April 2008 indicated, The date opened and the initials of the first person to use the vial are recorded on multi-dose vials. In a telephone interview with the Pharmacist (RP) on 3/20/19 at 10:00 a.m., RP stated that the multi-dose vial should be discarded 28 days after it is opened. According to the Joint Commission Accreditation of Healthcare Organizations publication titled, Standard Interpretation - The Misuse of Vials, A Followup to Sentinel Event, dated 9/11/14, Multi-dose vial expire 28 days after it is opened or when the manufacturer's expiration date is reached whichever is sooner. [Reference: https://www.jointcommission.org/assets/1/6/Webinar_on_misuse_of_vials.pdf] 2. Review of admission Record showed Resident 83 was admitted to the facility on [DATE] with multiple diagnoses which included diabetes, Myocardial Infarction (MI, Heart Attack), Atherosclerotic Heart Disease (a disease in which plaque builds up inside the arteries). Review of the physician's order dated 6/30/18, indicated, Benztropine Mesylate tablet 1 milligram (mg) give 1 tablet by mouth two times a day to prevent drug induced EPS (extrapyramidal disorders - side effects that may result from taking anti-psychotic medications. Further review of the physician's order dated, 1/18/18 indicated, Pletal Tablet 100 mg Give 1 tablet by mouth two times a day for MI. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 20 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a medication pass observation on 3/19/19 at 8:11 a.m., the Licensed Vocational Nurse (LVN5) prepared medication intended for Resident 83 to be given at 9:00 a.m. LVN5 was not able to find two medications in the cart (Benztropine Mesylate and Pletal) for Resident 83. In an interview with LVN5 on 3/19/19 at 8:11 a.m., LVN5 stated that the staff was supposed to reorder the medications five days in advance to ensure availability. LVN5 added that she will contact the pharmacy so the missing medications can be administered. Review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, dated April 2018 indicated, Medications and related products are received from the dispensing pharmacy on a timely basis . Reorder medication five days in advance of need to assure an adequate supply is on hand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 21 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure seven (Resident 115, 83, 44, 104, 73, 64, 56) out of 113 residents received food that was at an appetizing temperature. Residents Affected - Some This failure had the potential to affect all the residents who received their meals from the kitchen. Findings: In an interview on 3/18/19 at 9:20 a.m., Resident 115 stated, Food is cold and I do not like that. During resident council meeting on 3/19/19 at 10:56 a.m., Resident 83, 44, 104, 73, 64 and 56 stated food was served cold at the facility. During observation and concurrent interview on 3/19/19 at 12:58 p.m., a Test Tray was prepared for Regular and Puree consistency meal. While accompanied by facility's Dietary Supervisor (DM), the following observations were made: a. A Regular tray contained Chicken, Red Pinto Beans, [NAME] Beans and Orange Juice. Chicken- lukewarm, at 138 degrees Fahrenheit (°F) Red Pinto Beans- lukewarm, at 131 °F Green Beans- cold, at 116 °F Orange Juice- at 50 °F b. A Puree tray contained Chicken, Red Pinto Beans, and Spinach. Chicken- lukewarm, at 132 °F Red Pinto Beans- lukewarm, at 140 °F Spinach- cold, 132 °F By further observation after the completion of temperature check of test tray meals, DS stated food was cold and he needed to figure out how to cook it properly so it was not served cold. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 22 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review, the facility failed to offer therapeutic bedtime snacks to six (Residents 44, 56, 64, 73, 83 and 104) of 46 sampled residents. This failure had resulted in Residents 44, 56, 64, 73, 83 and 104 feeling very hungry due to long periods of time in between an early dinner and having late breakfast the following day. Additionally, for Resident 44 and 83, who had a diagnosis of Diabetes Mellitus, this failure placed them at risk for Hypoglycemia (low blood sugar level which could result in a potentially dangerous health outcome up to and including death). Findings: In a resident group interview on 3/19/19 at 10:00 a.m., Residents 44, 56, 64, 73, 83 and 104 stated they were not offered snacks at night. Residents 44, 56, 64, 73, 83 and 104 added that dinner was served daily around 5:00 p.m. and breakfast was served past 7:30 a.m. the following day. Resident 73 and 104 stated that sometimes breakfast was served late and they felt very hungry not having had anything since 5:00 p.m. the previous evening. Residents 44, 56, 64, 73, 83 and 104 further stated that they were unaware that the facility was suppose to offer snacks to all residents. Resident 44 stated that she requested a snack around 9:00 p.m. one evening and staff told her that she had just finished dinner and that when the kitchen closes at 7:00 p.m. there was no more food. In a telephone interview with the Certified Nursing Assistant (CNA 3) on 3/19/19 at 9:09 p.m., CNA3 stated that she only distributes snacks to specific residents whose names appear on labeled food item. CNA3 added that she does not give or offer snacks to everyone unless they asked for one. CNA3 confirmed that dinner was served between 4:45 to 5:30 p.m. In a separate telephone interview with the Licensed Vocational Nurse (LVN6) on 3/19/19 9:10 p.m., LVN6 stated, she only distributes snacks to residents whose names appeared on labeled sandwiches. In an interview on 3/19/19 at 10:50 a.m., Dietary Supervisor (DS) stated that the kitchen prepared snacks only to the residents on the list for bedtime snacks. Review of the List for Bedtime snacks, undated, showed that thirty snacks were prepared for residents at bedtime. Residents 44, 56, 64, 73, 83 and 104 were not on the list to receive bedtime snacks. In an observation on 3/20/19 at 7:51 a.m., the first breakfast cart came out of the kitchen at 7:45 a.m. In an interview with the Dietician (RD) on 3/20/19 at 8:50 a.m., RD stated that the residents with diabetes should receive bedside snacks. Review of the facility's Policy and Procedure titled, Nourishment and H.S. (bed time) Snacks, dated November 2012, indicated, Bed time snacks will be offered to all residents unless contraindicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 23 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 - Some 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, interviews, and document review, the facility failed to store, distribute and serve food in accordance with professional standards for food service safety when: 1. A bag of frozen diced egg in walk in refrigerator was open, not dated and not labeled. 2. Six out of Six chopping boards were worn out with deep cuts and brown colored stains. 3. Employees personal belongings were stored in emergency food storage area inside the Kitchen. 4. Three compartment sink did not have an air gap. 5. Dietary Aide (DA 1) did not cover beard in the food service area. 6. Nursing Station 2 Refrigerator (Ref 1) had residents' food that was open, but not dated and not labeled. discharged residents' food was kept in Ref 1. 7. Nursing Station 1 Refrigerator (Ref 2)'s thermometer was broken, frozen food was not frozen solid. discharged residents' food was kept in Ref 2. This failure placed the residents at risk for food borne illnesses. Findings: 1. During an initial tour of the Kitchen accompanied by Dietary Supervisor (DS) on 3/18/19 at 8:36 a.m., A clear bag of frozen diced egg in kitchen's walk in Refrigerator was open, not dated and not labeled. DS took the bag away and stated,oh we have to date it. 2. During kitchen's initial tour accompanied by DS on 3/18/19 at 8:40 a.m., six out of six chopping boards were worn out with deep cuts and brown stains. A white chopping board was on the steam table with slices of bread on it. When asked how often the chopping boards were used, DS stated Chopping boards were used every day. DS also stated we have to replace them once they are worn out, I do not have specific time after how long it should be replaced. 3. During an observation of Emergency food storage area in kitchen on 3/18/19 at 8:54 a.m., a pink colored 24 ounces' bottle with clear liquid was observed on food storage shelf. DS stated it's employee's water bottle. By further observation, a cell phone with pink color leather texture cover was observed right next to the water bottle. DS stated, It should not be here. When asked if facility has a policy for storage of personal belongings, DS stated, We do not have a policy for that. By further observation of emergency food storage area in kitchen on 3/18/19 at 9:00 a.m., following clothing items were observed behind the door on a wall mounted clothing rack with hooks. a. A black colored male jacket. b. A pink, blue and cream colored scarf with stripes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 24 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 c. A white colored female cardigan. Level of Harm - Minimal harm or potential for actual harm d. A black colored sweatshirt with commercial logo in the front. e. A blue colored bag pack with commercial logo in the front. Residents Affected - Some f. A blue and black check printed sweatshirt. During an interview with DS on 3/18/19 at 9:00 a.m., DS stated the clothing belonged to the kitchen staff, they did not have space in employee locker. DS also stated employee's personal belongings were not transmitting any infections, so it was okay to keep it there. During another interview on 3/18/19 at 12:05 p.m., DS stated he was not aware if staff was storing their personal items inside the kitchen. And that it was for the first time that he noticed staff's personal items in food storage area. During an interview with Director of Staff Development (DSD) who was also Infection Prevention Nurse on 3/20/19 at 9:50 a.m., DSD stated,Staff's personal items should be in lockers or shelves in the break room. They should not be stored inside the kitchen. During a follow up interview on 3/21/19 at 9:52 a.m., DSD stated facility did not have a policy for storing personal items. DSD also stated she was taught by previous DSD that way to store personal items only in staff's lockers and shelves in break room. 4. During kitchen's initial tour accompanied by DS on 3/18/19 at 9:10 a.m., three compartment sink was noted with no air-gap (a gap created to prevent back flow of contaminated water) at the drain line. DS did not comment on having a need of air gap. During a follow up observation and interview on 3/18/19 at 1:55 p.m., Maintenance Supervisor (MS) stated the sink had 90 degrees gooseneck (elbow) installed in the drain pipe. MS also stated the sink did not need an air gap and gooseneck was sufficient to prevent the back flow. During an interview on 3/18/19 at 1:56 p.m., DS stated,this is an old [AGE] years old grandfathers kitchen, so we do not have to have an air gap. We do not have a policy on that. DS also stated if facility was to build a new sink, only then air gap was a requirement. During another interview on 3/21/19 at 10:52 a.m., Administrator (Adm) stated, I do not think we need an air gap because there is gooseneck. During unusual situations drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow (USDA Food Code Annex 2013, Section 5-202.13). 5. During an observation on 3/19/19 at 12:09 p.m., DA 1 was observed with uncovered beard in kitchen's food service area. DA 1 stated he forgot to cover the beard. DS stated DA 1 was supposed to cover his beard. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 25 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 Review of facility's policy and procedure titled Dress Code revised 01/2013 showed Beards and mustaches which are not closely cropped and neatly trimmed should be covered. 6. During an observation of Ref. 1 accompanied by Registered Nurse (RN 1) on 3/19/19 at 11:34 a.m., following items were found in Ref. 1. Residents Affected - Some a. A bottle of Ranch dressing 1.06 Liters (L), open, marked with Resident 25's room number. b. Coffee mate French vanilla drink 946 milliliters (ml), open, marked with Resident 326's room number. c. Trader Joe's Coconut water 1 L, open, marked with Resident 49's room number. Manufacturer label showed use within three days. d. Sun sweet prune juice 946 ml, open, marked with Resident 59's room number. Manufacturer label showed use with 7-10 days. During an interview with RN 1 on 3/19/19 at 11:34 a.m., RN 1 stated above items must be labeled and dated with an open date. During a follow up observation of Ref 1 items and interview with Assistant Director of Nursing (ADON) on 3/19/19 at 2:07 p.m., ADON took the items away and stated she would contact the family representative if above items could be thrown away. ADON also stated Resident 326 was not at the facility anymore. Review of Transfer/Discharge Report dated 3/20/19 showed Resident 326 was discharged from the facility on 3/4/19, indicating Resident 326's food was in Ref 1 for more than two weeks. Review of facility's policy and procedure titled Personal food storage revised 4/2017 showed All opened food will be labeled with resident's name, date and place in storage. Food should not be stored for more than 72 hours. 7. During an observation of Ref. 2 accompanied by RN 5 on 3/19/19 at 11:45 a.m., RN 5 stated thermometer in Ref. 2 was no readable. RN 5 stated, looks like its mercury is broken, it looks like its reading 50 degrees. RN 5 took the thermometer and put it back in Ref. 2. Following items were noted in Ref. 2: a. Ice cream, brown colored, soft, stored in a white colored Styrofoam container, with no label, hand written dated 3/7/19 - in Freezer compartment. b. Ben [NAME] Vanilla 473 ml dated 3/12/19, soft in texture- in Freezer compartment. RN 5 stated above items belonged to Resident 327, who was discharged from the facility. Review of Transfer/Discharge Report dated 3/20/19 showed Resident 327 was discharged from the facility on 3/14/19. Review of facility's policy and procedure titled Personal food storage revised 4/2017 showed All (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 26 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 - Some opened food will be labeled with resident's name, date and placed in storage. Food should not be stored for more than 72 hours. During a follow up observation of Ref. 2 and interview on 3/19/19 at 1:31 p.m., LVN 3 stated, I cannot read the thermometer, its broken, it was working this morning. LVN 3 took the thermometer out and brought it at Nursing station 1. By further observation and interview with LVN 3, LVN 3 took away both ice cream containers and threw them in the garbage can at Nursing station 1. During an interview on 3/19/19 at 1:33 p.m. at Nursing Station 1, DON stated the thermometer was broken and must be replaced. Review of facility's policy and procedure Storing Refrigerated foods revised 01/2013 showed Refrigerators are used to maintain foods at internal temperature of 41 degrees Fahrenheit or lower. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 27 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of admission Record dated 3/20/19 showed Resident 14 was admitted to the facility on [DATE] with diagnosis of Diabetic foot ulcer and Acquired absence of Right toe(s). Residents Affected - Some Review of Resident 14's Physician Order Summary Report dated 3/20/19 showed an order stating Right 3rd toe amputation site wound: Clean with normal saline, pat dry, Apply Santyl to wound bed, pack with hydrogel impregnated 1/4 packing strip every day shift. During an observation on 3/19/19 at 9:24 a.m., Licensed Vocational Nurse (LVN 2) was observed during wound treatment for Resident 14's Right 3rd toe amputation site wound. LVN 2 prepared the wound treatment supplies at Resident 14's bedside. While wearing Right hand glove, one glove fell on the floor at Resident 14's bedside. LVN 2 put on another glove on right hand and picked up the glove from the floor. LVN 2 removed the right hand glove and without washing her hand she put on another glove. LVN 2 then pulled the privacy curtain and without washing hands and without changing gloves she used a pair of scissors to cut the bandage on Resident 14's Right 3rd toe and put the scissors back on the bedside table. LVN 2 then removed the soiled dressing with red-yellow thick matter on it. LVN 2 stated it was slough (dead tissue) on the bandage. LVN 2 then removed soiled gloves and, without washing her hands, put on new gloves. LVN 2 cleaned Resident 14's Right 3rd toe amputation site with normal saline and pat dried. LVN 2 then used the same pair of scissors at bedside table to cut Hydrogel impregnated gauze and applied it on the wound. During an interview on 3/19/19 at 9:45 a.m., LVN 2 stated she washed her hands only if gloved hands were really soiled and Resident 14's soiled dressing only had slough. LVN 2 also stated she does not perform hand hygiene in between changing gloves. During an interview on 3/19/19 at 11:00 a.m., Assistant Director of Nursing (ADON) stated Staff should wash their hands after touching anything soiled, speacially after removing soiled wound dressing. ADON also stated hand washing was important after touching curtains as we do not know what is on the curtain. During a follow up interview on 3/21/19 at 7:41 a.m., LVN 2 stated she forgot to sanitize the scissors after removing soiled dressing from Resident 14's Right 3rd toe amputation site. LVN 2 also stated she should not touch the privacy curtain during wound treatment procedures. Review of facility's policy and procedure titled Hand Hygiene P&P revised 1/10/19 showed Employees are required to wash their hands thoroughly after touching objects that may be soiled and after removing gloves. 4. Review of admission Record dated 3/20/19 showed Resident 82 was admitted to the facility on [DATE]. Review of admission Record dated 3/20/19 showed Resident 31 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 28 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During dining observation on 3/18/19 at 12:44 p.m., Resident 82 and Resident 31 were sitting at the same dining table for lunch in the main dining area. During an observation on 3/18/19 at 12:44 p.m., CNA 1 was observed sitting on chair while feeding lunch to Resident 82. CNA 1 got up from the chair and grabbed another chair from another dining table. Without washing her hands, CNA 1 came and sat on the same previous chair, and started feeding Resident 82. By further observation while feeding Resident 82, CNA 1 got up again and wheeled Resident 31 out of the dining area. CNA 1 then picked up resident 31's tray to put it away. CNA 1 then came back and without performing hand hygiene, started feeding Resident 82 again. During an interview on 3/18/19 at 12:58 p.m., CNA 1 stated she forgot to wash hands after touching the chair and after touching the wheelchair and meal tray for Resident 31. During an interview with Director of Staff Development (DSD) who was also facility's Infection Prevention Nurse on 3/18/19 at 1:02 p.m., DSD stated CNA 1 was supposed to wash hands after touching the chair and after touching another resident's wheelchair and meal tray to prevent chances of infection. Review of facility's policy and procedure titled Hand Hygiene P&P revised 1/10/19 showed Employees are required to wash their hands thouroghly after touching objects that may be soiled 2. In an observation and concurrent interview on 3/20/19 at 8:30 a.m., the housekeeping aide (HA) was observed removing clean laundry out of the washer, dropping a clean washcloth on the floor, picking up the washcloth and placing it onto the laundry cart containing clean linen. She stated she should have put it into the soiled linen container in the soiled area of the laundry room. The facility policy and procedure titled, Description of Steps in the Laundry Process, dated 10/7/16 indicated, No clean linen may touch floor . If it does, the clean linen is then considered to be soiled . Soiled linen must never come in contact with clean linen. Based on observation, interview and record review, the facility failed to ensure infection control procedures were followed when: 1. For Resident 99, Licensed Vocational Nurse (LVN) 4 changed Resident 99's urinary drainage bag (collects urine, connects to a tubing that is placed in the bladder to drain urine) with a newly opened kit with an uncovered tubing that touched Resident 99's bedside linens. Resident 99's urinary drainage bag was on the floor. 2. Housekeeping Aide (HA) picked up a linen off the floor and placed it on a clean cart with clean linens. 3. For Resident 14, Licensed Vocational Nurse (LVN) 2 did not perform hand hygiene after touching the privacy curtain before wound treatment and after removing soiled gloves. LVN 2 did not sanitize the scissors after it was used to cut a soiled dressing and before cutting ready-to use hydrogel gauze (a type of gauze used for wound dressings and treatments). 4. For Resident 82, Certified Nurse Assistant (CNA) 1 did not perform hand hygiene before assisting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 29 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 Resident 82 with meals after CNA 1 touched a chair and pushed Resident 31's wheelchair out of the room. Level of Harm - Minimal harm or potential for actual harm These failures had the potential to result in spread of infection. Findings: Residents Affected - Some 1. Review of the clinical record indicated Resident 99 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, acute kidney failure. Resident 99 had a foley catheter (a hollow flexible tube inserted into the bladder through the urethra) in place. During observation and concurrent interview with Licensed Vocational Nurse (LVN) 4 on 3/18/19 at 9:14 a.m., Resident 99's urinary drainage bag was on the floor and it was full. LVN 4 stated the urinary bag should not be on the floor because of the risk of the catheter being pulled out. During an observation and concurrent interview with LVN 4 on 3/18/19 at 9:26 a.m., LVN 4 returned to Resident 99's room with a drainage bag that did not have a cover. The tip of the tubing that was to be connected to the catheter was uncovered and was touching Resident 99's bed linens. LVN 4 stated she needed to change Resident 99's drainage bag because it touched the floor. LVN 4 asked Assistant Director of Nursing (ADON) to show her how to change the drainage bag because she has not done it before. ADON and LVN 4 both donned gloves and were about to change the bag by pulling out the old one and inserting the tip of the tubing that had repeatedly touched the bed linens. When asked if they were going to continue despite the tubing being potentially contaminated, ADON told LVN 4 to get another unopened urinary drainage kit. During an interview with Director of Staff Development (DSD) on 3/20/19 at 12:30 p.m., DSD stated when changing a urinary drainage bag, a licensed staff should do the following: 1. drain urine from the bag into a container or urinal, 2. kink the catheter, 3. old drainage bag is pulled out and goes into a garbage bag that should be on the floor, 4. open the urinary drainage bag kit, 5. remove the cover from the tubing and connect the tubing to the end of the catheter. DSD stated the cover of the drainage bag tubing should only be removed right before it is connected to the catheter and should not be touching the bed linens or any items at the bedside to avoid contaminating the urinary catheter and potentially allowing bacteria or microorganism to enter the urinary tract. Review of the facility's policy and procedure titled Urinary Catheters Change Indwelling Urinary Catheters last revised 11/2012 did not indicate procedures in changing the urinary drainage bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 30 of 31 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure that two of two dryers were in safe operating condition when the lint screens were observed full of lint. Residents Affected - Some This deficient practice has the potential to cause overheating of the dryer and fire related consequences. Findings: During an observation and concurrent interview on 3/20/19 at 8:30 a.m. in the laundry room, the lint screens on both dryers were observed full of lint with excess lint in the bottom compartments of the dryers. The housekeeping supervisor (HS) stated the lint screens should be cleaned every two hours and documented on the lint clean out log. The housekeeping aide (HA) stated she did not clean the lint screens on her shift and did not document on the lint clean out log. Review of the Dryer Lint Clean Out Schedule, revised 10/7/16, indicated no initials for cleaning lint screens on 3/20/19 at 6:00 a.m. and 8:00 a.m. The facility policy and procedure titled, Description of Steps in the Laundry Process dated 10/7/16, indicated, These lint screens must be brushed and cleaned after every load or every hour. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 31 of 31