Health inspection·February 23, 2026

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 5) had their personal funds safeguarded when Resident 5's wallet containing $140, which had been entrusted to the facility's Social Services Director (SSD), was not secured in accordance with facility procedures. This failure resulted in Resident 5's $140 going missing, which had the potential for psychosocial outcomes including anxiety, distress, and reduced trust in the facility's ability to safeguard belongings.During a review of Resident 5's admission Record (AR) dated 2/23/26, the AR indicated Resident 5 was admitted to the facility in July 2025 with diagnoses that included diabetes mellitus (a chronic condition characterized by high levels of sugar in the blood due to the body's inability to produce or use insulin effectively), benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland that can cause urinary problems in men), and chronic gout (a long-term form of arthritis caused by the buildup of uric acid crystals in the joints, leading to pain and inflammation). The AR indicated Resident 5 was self-responsible.During a review of Resident 5's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 11/25/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13. A score of 13-15 is an indication of intact cognitive status.During a concurrent interview and record review on 2/23/26 at 11:03 a.m. with Administrator (ADM), ADM stated, on 11/21/25, Resident 5 handed over a wallet with $180 cash to SSD for safekeeping. The SSD placed the wallet in an unlocked drawer in the SSD office. In December 2025, Resident 5's family requested $140 from Resident 5's money but found only $40 remaining. ADM stated SSD no longer works at the facility.During a review of Resident 5's Social Services Progress Notes from 10/15/25 to 12/26/25, the progress notes did not indicate Resident 5 was informed about the missing $140. SSD had discussed it with Resident 5's family but not with Resident 5.During an interview on 2/23/26 at 11:22 a.m. with Resident 5, Resident 5 stated the facility still had the wallet, stated a man had visited his room and provided a number to call to regarding the missing money.During a review of the facility's policy and procedure (P&P) titled Management of Residents' Personal Funds last revised March 2021, the P&P indicated if a resident chooses to have the facility manage his personal funds, a written authorization from the resident or the resident representative is required and documented in the resident's clinical record. The facility acts as a fiduciary, holding, safeguarding, managing and accounting for the personal funds. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 2 of 4 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 02/23/2026 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 0572 Give residents a notice of rights, rules, services and charges. 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, the facility failed to provide notice of rights and services prior to or upon admission for four of five sampled residents (Resident 1, 2, 3, and 4), when admission agreements were either delayed or not provided at all.This failure had the potential to result in unnecessary emotional stress, diminished autonomy in making healthcare choices and violation of resident rights.During an interview on 2/23/26 at 11:41 a.m. with Admissions Director (AD), AD stated the admission agreement is very important as it covers information about resident rights, advanced directives, facility and Ombudsman information, arbitration agreement and details on what residents should expect. AD stated the resident or the resident's decision-maker should sign the admission agreement within 72 hours of admission.1.During a review of Resident 1's admission Record (AR) dated 2/20/26, the AR indicated Resident 1 was admitted to the facility on [DATE]. The AR also indicated Resident Representative (RR) 1 as Resident 1's Emergency Contact and that Resident 1 was self-responsible (able to make decisions for themselves). Resident 1 was transferred to the hospital after a medical emergency on 10/10/25.During a review of the State-specific admission Agreement (SAA) titled California Standard Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, the SAA indicated it was signed by RR 1 on 10/2/25, eight days after Resident 1's admission.2. During a review of Resident 2's AR dated 2/23/26, the AR indicated Resident 2 was admitted to the facility on [DATE]. The AR indicated Resident 2 was self-responsible but listed RR 2 as emergency contact. The AR also indicated Resident 2 was discharged home on [DATE].During a concurrent interview and review of the clinical records on 2/23/26 at 12:33 p.m. with Assistant Director of Nursing (ADON), ADON stated there was no signed admission agreement for Resident 2 in the clinical records.3. During a review of Resident 3's AR dated 2/20/26, the AR indicated Resident 3 was admitted to the facility on [DATE]. The AR indicated Resident 3 was self-responsible and listed RR 3 as the emergency contact, Resident 3 was discharged home on [DATE].During a telephone interview on 2/18/26 at 1 p.m. with RR 4, RR 4 stated the admission agreement was given to RR 3 only on the day Resident 3 was discharged . RR 4 also stated Resident 3 and family were unaware of the care and services were provided while at the facility.During a review of Resident 3's SAA, the SAA indicated Resident 3 was issued the admission agreement on 12/5/25, the day Resident 3 was going home.4.During a review of Resident 4's AR dated 2/20/26, the AR indicated Resident 4 was admitted to the facility on [DATE]. The AR indicated Resident 4 was self-responsible.During a review of Resident 4's SAA, the SAA indicated Resident 4 signed the admission agreement on 1/2/26, more than one month after Resident 4 was admitted .During a review of the facility's policy and procedure (P&P) titled admission Agreement last revised December 2025, the P&P indicated that each resident must have an admission agreement, signed and dated by the resident or resident representative at the time of admission and filed in the resident's clinical record. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055885 If continuation sheet Page 3 of 4 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 02/23/2026 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 3) received a summary of the baseline care plan, when neither Resident 3 nor Resident 3's Representative (RR 3) were provided with the required summary.This failure had the potential to place Resident 3 at risk for unmet needs, inconsistent care and adverse health outcomes.During a review of Resident 3's AR dated 2/20/26, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included fractured left pubis (a break in the left side of the pubic bone, which is part of the pelvis), sacrum (the triangular bone at the base of the spine), and upper end of left humerus (a break near the top of the left upper arm bone), dementia (a general term for a decline in mental ability severe enough to interfere with daily life, often involving memory loss and impaired judgment), difficulty in walking, and delirium (a sudden and severe confusion due to rapid changes in brain function, often temporary but serious). The AR indicated Resident 3 was self-responsible (able to make decisions for themselves) and listed RR 3 as the emergency contact.During a concurrent interview and record review on 2/20/26 at 11:38 a.m. with Assistant Director of Nursing (ADON), Resident 3's Interdisciplinary Care Conference (ICC) dated 11/21/25 was reviewed. ADON stated she was not sure whether a summary of the baseline care plan was provided to Resident 3 or RR 3, as the notes did not indicate this. ADON also stated a representative of Resident 3 participated in the care conference, but the record did not indicate who it was. The ICC indicated attendees that included only seven facility representatives, and the section on whether the care plan summary copy was provided was left blank.During a telephone interview on 2/18/26 at 1 p.m. with RR 4, RR 4 stated RR3 received the admission agreement only on the day Resident 3 was to be discharged . RR 4 also stated Resident 3 and family were unaware of the care and services to be provided at the facility. During a review of the facility's policy and procedure titled Care Plan-Baseline effective 8/25/21, the P&P indicated the baseline care plan includes the instructions for effective, person-centered care of the resident and be developed and implemented by the Interdisciplinary Team (IDT, a group composed of staff representing different departments of the facility) for each resident. The P&P did not indicate when or how to provide a summary of the baseline care plan to the resident or their representative. Event ID: Facility ID: 055885 If continuation sheet Page 4 of 4