Health inspection·February 6, 2024

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete educated on the rights of residents and the responsibility of the facility to properly care for its residents. Respect and dignity. The resident has a right to be treated with respect and dignity, including: .c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups . Event ID: Facility ID: 056052 If continuation sheet Page 2 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect one (Resident 1) of three sampled residents from abuse when the facility roomed Resident 2, a resident with known angry outbursts and a potential for assaultive behaviors, with Resident 1, a bedridden, vulnerable resident. This failure resulted in Resident 2 physically assaulting Resident 1 within hours of being moved into a shared room with Resident 1. As a result of Resident 2's assault, Resident 1 required admission to the hospital for closure of a scalp laceration (cut) with staples (metallic staples to hold wound edges together until the wound is healed), a fractured (broken) cheek bone, and a concussion. (A brain injury that occurs when the head hits an object, or a moving object strikes the head. A concussion may lead to headaches, changes in alertness, unconsciousness/coma, memory loss, and changes in thinking.) See also F 609 and F 689. Findings: During a review of Resident 1's admission Record, undated, the admission Record indicated Resident 1 was admitted in 2021, with diagnoses which included a cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain), hemiplegia (left sided paralysis or inability to or difficulty to move one side of the body), and anxiety. The admission Record indicated Resident 1 had a Responsible Party (RP 1) for healthcare decisions. During a review of Resident 1's Minimum Data Set (MDS-a comprehensive assessment tool to guide care) dated 10/18/23, the MDS indicated Resident 1 predominantly used a non-English language, had impaired vision due to partial blindness; was sometimes able to understand what others said, and could sometimes be understood; Resident 1 had problems with short-term and long-term memory. The MDS indicated Resident 1 required staff to provide partial assistance with eating, and maximal assistance for transfers between surfaces (such as bed to wheelchair), and all other activities of daily living (oral hygiene, personal hygiene, toileting, dressing upper and lower body) The MDS indicated Resident 1 had dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a review of Resident 1's care plan, initiated 10/18/23, the care plan indicated Resident 1 had impaired cognition (the abilities to think, reason, and remember) or impaired thought processes related to dementia. The facility's goal for Resident 1 on 11/18/23 was to maintain current level of cognitive function. On 11/10/23, the facility added to Resident 1's care plan, Resident is at risk for falls and/or injuries related to history of falls dementia, incontinence, poor safety awareness. The facility's goal for Resident 1 was to minimize risk for falls. On 11/10/23, the facility added to Resident 1's care plan, Resident requires assistance with ADLs (activities of daily living) related to muscle weakness, stroke, dementia, and hemiplegia. The facility's goal was Resident 1 would not have a decline in self-care. During a review of Resident 2's admission Record, undated, the admission Record indicated the facility admitted Resident 2 in October 2023. The admission Record indicated Resident 2 had diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 3 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0600 Level of Harm - Actual harm Residents Affected - Few which included mental conditions which made it difficult to think clearly, have normal emotional responses, act normally in social situations, tell the difference between what was real and what was not real, to have firmly held beliefs which were contrary to reality, to have wide or extreme swings in mood from periods of feeling sad and depressed to periods of intense excitement and activity or irritability. The admission Record indicated Resident 2 had a conservator for healthcare decisions (a person appointed through legal proceedings to make healthcare and/or financial decisions for a person adjudged to be without mental capacity to make such decisions), and a responsible party with financial Power of Attorney (the legal power to make financial decision). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was moderately impaired in the ability to communicate and understand others. The MDS also indicated Resident 2 used a wheelchair for mobility and required only minimal assistance from staff with activities of daily living (eating, toileting, bathing, oral hygiene, personal hygiene, dressing, putting on and off footwear and transferring between surfaces). During a review of Resident 2''s care plan titled, The Resident is at Risk for Behavior Problems, initiated 10/6/23, the care plan indicated the behavioral problems were due to medical needs, amputation, mental condition, history of substance abuse, moderately impaired cognition, and traumatic brain injury. (TBI, injury to the brain resulting from force applied to the brain as in a physical hit or a bullet into the head. TBI can cause temporary or short-term problems with normal brain function, including problems with how the person thinks, understands, moves, communicates, and acts.) Care plan interventions to reach the goal of decreased episodes included staff were to intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; remove from situation and take to alternate location as needed; provide quiet environment and decreased stimuli to de-escalate behaviors. During a review of Resident 2's Psychiatric Consult Progress Report dated 10/18/23, the Progress Report indicated Resident 2 had been at an inpatient psychiatric facility for three months prior to admission at the facility for treatment of agitation and threatening behaviors. The Progress Report indicated Resident 2 was a high risk for assaultive behaviors. During a review of Resident 2's Medication Administration Record (MAR) dated December 2023, the MAR indicated Resident 2 had verbal and physical angry outbursts seven times on 12/10/23, and six times on 12/14/23. During a review of Resident 2's nursing progress notes dated 12/14/23 at 10:55 a.m., the progress notes indicated the Interdisciplinary Team (IDT, a consulting team that includes staff members from multiple disciplines such as nursing, therapy, physicians, and other advanced practitioners.) had reviewed current room allocations and decided to move Resident 2 into a new room in order to provide a quiet/low stimuli environment as Resident 2's current roommate played loud music, spoke loudly, and had a lot of visitors. The notes indicated the IDT team determined Resident 1's room would be the best choice for Resident 2's new room. During a review of Resident 2's nursing progress notes dated 12/14/23 at 1:30 p.m., the progress notes indicated Resident 2 had moved into the new room, which was shared with Resident 1. During an interview on 12/20/23, at 2:46 p.m., with Registered Nurse 1 (RN 1), RN 1 stated she had been assigned to Resident 1 and Resident 2 on the night shift which started 12/14/23 at 11 p.m. RN 1 stated she had gone into the shared room at 11:15 p.m. to do a visual check: Resident 1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 4 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0600 Level of Harm - Actual harm Residents Affected - Few sleeping, and Resident 2 had told her to turn off the light and leave the room. RN 1 stated the door to Resident 1 and 2's shared room had been closed at 11:45 p.m. RN 1 stated at midnight, she saw Resident 2 at the nursing station talking with Certified Nursing Assistant 4 (CNA 4). RN 1 stated a short time later, she was called into the room shared by Resident 1 and 2, and saw multiple staff members with Resident 1, who was on the floor bleeding from the head. RN 1 stated Resident 1 was opening and closing her eyes and speaking, but her words could not be understood. RN 1 stated she called emergency services for assistance, and paramedics and the police arrived. During an interview on 12/21/23, at 3:08 p.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated when at the nursing station on the early morning of 12/15/23, Resident 2 had come to the nursing station in a wheelchair and said someone was on the floor. CNA 4 stated she saw blood on Resident 2's left leg, and quickly went into the room shared by Resident 2 and Resident 1. CNA 2 stated upon entering the shared room, she saw Resident 1 on the floor, bleeding. CNA 2 stated she called for assistance from the assigned CNA and the licensed nurses. During a review of Resident 2's nursing progress notes dated 12/15/23, at 2:51 a.m., by RN 1, the notes indicated on 12/14/23 at around 11:15 p.m., RN 1 made rounds and saw Resident 1 asleep in the bed. The notes indicated around midnight Resident 2 was in the wheelchair outside the shared room of Resident 1 and 2, and Resident 2 told CNA 4 that Resident 1 had scratched her. The notes indicated CNA 4 noticed blood spots on Resident 2's foot, so went into the shared room of Resident 1 and 2 to check on Resident 1. The notes indicated RN 1 immediately called 911 because Resident 1 was on the floor and bleeding from the head; Resident 2 remained outside the room. The notes indicated the police took Resident 2 to the acute care hospital for psychiatric evaluation under an involuntary detention order. (5150, a legal order for involuntary detention for up to 72 hours for psychiatric evaluation to determine if an individual is a danger to themselves or others.) During a review of the Police Report, dated 12/15/2023, the Police Report indicated Police Officer (PO) was summoned and came to the facility to investigate a report of an assault between two residents. PO reported observing the following: the center of the room had the middle bed pushed aside. On a nearby bed table, PO reported seeing smears of blood on the table and on a plastic cup. On the floor, PO reported seeing a shattered plastic cup. PO said he could not determine if the cup was used as a weapon or if blood smears were caused by Resident 2 or the nurses who'd been cleaning the room prior to his arrival. PO said he could not determine if the broken cup occurred from falling on the ground or if Resident 1 had fallen onto the cup, causing it to shatter. PO reported he had reasonable suspicion to believe Resident 2 assaulted Resident 1, an [AGE] years old, with an unknown weapon, because they (Resident 1 and Resident 2) were the only two subjects in room [ROOM NUMBER]. PO reported Resident 2 suffered from a mental disorder that may have caused her to assault Resident 1. PO resported due to his inability to determine if Residetnt 2 had malicious intent towards Resident 1, he could not develop probable cause to believe Resident 2 knowingly committed the violation of assault. For this reason, PO reported he placed Resident 2 on a 72-hour psychiatric hold, pursuant to 5150 W&l (Welfare & Institution) Code. During a review of Resident 1's nursing progress notes dated 12/15/23, at 3:16 a.m., by RN 1, the notes indicated RN 1 had contacted emergency services after Resident 1 was found on the floor bleeding from a head wound, awake, nonverbal, but moaning. The notes indicated paramedics took Resident 1 by ambulance to acute care hospital. During a review of Resident 1's acute care hospital record, Trauma and Acute Care Surgery History & Physical, dated 12/15/23, the History and Physical indicated Resident 1 met criteria for trauma (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 5 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0600 Level of Harm - Actual harm Residents Affected - Few team activation, as Resident 1's condition/injury had a high probability of imminent or life-threatening deterioration of one or more vital organs/body systems. The History and Physical indicated Resident 1 had dementia, was bed bound, and was brought in by ambulance after being assaulted by another resident at the skilled nursing facility. The History and Physical indicated Resident 1 was struck on her face and head causing a fracture of her right cheek bone, a concussion, facial swelling and bruising, and lacerations to her right ear and right forehead with staples used to close the forehead laceration. The History and Physical indicated Resident 1 was admitted to the intensive care unit for continued care and treatment. During a concurrent observation and interview on 12/21/23, at 11:06 a.m., with Resident 2, in a single-occupancy room, Resident 2 lay in bed with the head of the bed elevated, awake. When questioned about the events of 12/15/23, Resident 2 stated on 12/15/23, just past midnight, she became irritated with Resident 1 because Resident 1 was yelling and screaming for the nurses. Resident 1 stated she threw her water bottle at Resident 1, the water bottle struck Resident 1 in the head, and Resident fell off the bed. Resident 2 stated she self-transferred into her wheelchair and went over to try to make Resident 1 be quiet, and Resident 1 defensively attempted to scratch Resident 2. During a telephone interview on 1/4/24, at 5:46 p.m., with Resident 1's Responsible Party (RP 1), RP 1 stated the facility contacted her on 12/15/23, at 1:18 a.m., and said Resident 1 had been taken to the emergency department at the acute care hospital. RP 1 stated she was contacted at 2:54 a.m. by police who reported Resident 1 had been assaulted and was injured with lacerations to the head. RP 1 stated she contacted a family member (RP 2) to check on Resident 1, as RP 1 was not able to go to the acute care hospital. During a phone interview on 1/4/24, at 7:53 p.m., with RP 2, RP 2 stated she had visited Resident 1 in the hospital the day after the event. RP 2 stated Resident 1 was almost unrecognizable, with her hair matted with dried blood, the right eye swollen shut, and bruising everywhere. RP 2 stated Resident 1 was moaning and would frequently sleep and then awaken crying and in pain. RP 2 stated Resident 1 made a statement that she had been sleeping when she was awakened by being hit and then kicked three times by Resident 2. RP 2 stated Resident 1 said she was afraid to go into a deep sleep. RP 2 stated Resident 1 kept repeating she did not want to return to the skilled nursing facility and that Resident 2 wanted to kill her. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 6 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review and interview, the facility delayed reporting one of two abuse incidents to the California Department of Public Health for over 11 hours. Residents Affected - Few Note: The nursing home is disputing this citation. This failure prevented oversight of the facility and delayed investigation of an assault of Resident 1 by Resident 2. See F-600 and F-689 Findings: During a review of Resident 1's Nursing Progress Notes, dated 12/15/23, at 3:16 a.m., Registered Nurse 1 (RN 1) documented on 12/14/23 at around 23:15 p.m. RN 1 made rounds and saw Resident 1 on the bed asleep. The notes indicated at 23:55 p.m., Certified Nursing Assistant (CNA 4) called RN 1 to go to the shared room of Resident 1 and Resident 2 as Resident 1 was on the floor bleeding from a head wound. The notes indicated RN 1 immediately called 911 and paramedics and police arrived. Resident 1 was sent to the acute care hospital by ambulance for treatment, and Resident 2 was taken to acute care hospital under an involuntary hold for assessment. During a review of the Police Report, case number 2023-00071046, dated 12/15/2023, the Police Report indicated Police Officer (PO) arrived at the facility at 12:23 a.m. to investigate a report of an assault between two residents. The report indicated PO observed the following: The bed table adjacent to Resident 1's bed had smears of blood on the table. On the floor next to Resident 1's bed was a shattered plastic cup on the floor, with blood smears on the cup fragments. The notes indicated PO was unable to determine if the cup was used as a weapon to hit Resident 1 or if the blood smears were caused by Resident 2 falling on the cup and breaking it. The notes indicated PO had reasonable suspicion to believe Resident 2 had assaulted Resident 1, as they were the only occupants in the room at the time of the incident. The notes indicated PO had Resident 2 removed from the facility on a 72-hour hold for psychiatric assessment. During an interview on 12/15/23 at 2:30 p.m., with the Director of Nursing (DON), the DON stated she had been called by RN 1 after midnight on 12/15/23 and told Resident 1 had been sent to the hospital for treatment of a head wound. The DON stated nursing staff told her they had called police, the physician, and Resident 1's responsible party. During a review of Resident 1's acute care hospital record, Trauma and Acute Care Surgery History & Physical, dated 12/15/23, the History and Physical indicated Resident 1 met criteria for trauma team activation, as Resident 1's condition/injury had a high probability of imminent or life-threatening deterioration of one or more vital organs/body systems. The History and Physical indicated Resident 1 had dementia, was bed bound, and was brought in by ambulance after being assaulted by another resident at the skilled nursing facility. The History and Physical indicated Resident 1 was struck on her face and head causing a fracture of her right cheek bone, a concussion, facial swelling and bruising, and lacerations to her right ear and right forehead with staples used to close the forehead laceration. The History and Physical indicated Resident 1 was admitted to the intensive care unit for continued care and treatment. During a review of the facility's faxed report of suspected abuse to the California Department of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 7 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0609 Public Health dated 12/15/23 at 11:48 a.m., the report indicated the administrator had been informed on 12/15/23 at 10 a.m., that staff were suspicious Resident 1's injuries were due to an assault by Resident 2. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 8 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (Resident 2) of three sampled residents was provided one-to-one supervision as ordered for aggressive behaviors. Note: The nursing home is disputing this citation. The failure to provide Resident 2 with continual one-to-one supervision resulted in Resident 2 being unsupervised for six minutes and had the potential to result in serious injury to other residents. The Chief Nursing Officer (CNO), the Administrator (Admin), the Administrator In Training (AIT), the Quality Assurance Consultant (QAC), and the Minimum Data Set Consultant (MDSC), were notified of the Immediate Jeopardy (IJ, a situation in which a provider's noncompliance with one or more requirements of participation have caused or is likely to cause serious injury, harm, impairment, or death to a patient/resident), on 12/21/23, at 2:55 p.m., for the facility's failure to provide one-to-one supervision to protect facility residents from abuse by Resident 2, a resident known to have physically aggressive behavior. An acceptable Action Plan was received on 12/21/23. Through observation, interviews and record reviews, an on-site survey on 12/21/23, determined the facility had removed the IJ by: implementation of one-to-one sitter policy which included duties, responsibilities and documentation requirements; immediate education of all clinical staff and sitters on the policy, process, and documentation of one-to-one supervision, including sitter break relief; implementation of monitoring tools and checklists to ensure documentation of necessary tasks/duties of one-to-one sitters are completed. The IJ was removed on 12/21/23, at 4:35 p.m., while onsite with the Chief Nursing Officer (CNO), the Administrator (Admin), the Administrator In Training (AIT), the Quality Assurance Consultant (QAC), and the MDS Consultant (MDSC), and the scope and severity was lowered to an isolated deficiency with no actual harm with the potential for more than minimal harm that is not immediate jeopardy. See tags F 600, F 609, F 940 Findings: During a review of Resident 2's admission Record, undated, the admission Record indicated the facility admitted Resident 2 in October 2023. The admission Record indicated Resident 2 had diagnoses which included mental conditions which made it difficult to think clearly, have normal emotional responses, act normally in social situations, tell the difference between what was real and what was not real, to have firmly held beliefs which were contrary to reality, to have wide or extreme swings in mood from periods of feeling sad and depressed to periods of intense excitement and activity or irritability. The admission Record indicated Resident 2 had a conservator for healthcare decisions (a person appointed through legal proceedings to make healthcare and/or financial decisions for a person adjudged to be without mental capacity to make such decisions), and a responsible party with financial Power of Attorney (the legal power to make financial decision). During a review of Resident 2's MDS (a comprehensive assessment tool to guide care) dated 10/9/23, the MDS indicated Resident 2 was moderately impaired in the ability to communicate and understand others. The MDS also indicated Resident 2 used a wheelchair for mobility and required only minimal assistance from staff with activities of daily living (eating, toileting, bathing, oral hygiene, personal hygiene, dressing, putting on and off footwear and transferring between surfaces). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 9 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. During a review of Resident 2's care plan titled, The Resident is at Risk for Behavior Problems, initiated 10/6/23, the care plan indicated the behavioral problems were due to medical needs, amputation, mental condition, history of substance abuse, moderately impaired cognition (the abilities to think, reason and remember), and traumatic brain injury. (TBI, injury to the brain resulting from force applied to the brain as in a physical hit or a bullet into the head. TBI can cause temporary or short-term problems with normal brain function, including problems with how the person thinks, understands, moves, communicates, and acts.) Care plan interventions to reach the goal of decreased episodes included: staff were to intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; remove from situation and take to alternate location as needed; provide quiet environment and decreased stimuli to de-escalate behaviors. During a review of Resident 2's Psychiatric Consult Progress Report dated 10/18/23, the Progress Report indicated Resident 2 had been at an inpatient psychiatric facility for three months prior to admission at the facility for treatment of agitation and threatening behaviors. The Progress Report indicated Resident 2 was a high risk for assaultive behaviors. During an interview 12/15/23 at 1:15 p.m., the Administrator stated police had removed Resident 2 from the facility on 12/15/23 around 2:30 a.m., on a 5150 hold. (5150, a legal order for involuntary detention for up to 72 hours for psychiatric evaluation to determine if an individual is a danger to themselves or others.) The Administrator stated staff had suspicions Resident 2 had been involved with injuries sustained by her roommate, Resident 1, who had been found on the floor around midnight, bleeding from a head wound. The Administrator stated there were no witnesses to the event, but Resident 2 had told staff there was blood on her leg because Resident 1 had tried to scratch her. The Administrator stated staff did not believe the blood was due to Resident 1 scratching Resident 2, as Resident 1 was not able to move out of bed without assistance, and Resident 2 did not have any visible wounds. During a review of Resident 2's acute care hospital record, Emergency Department Note, Discharge Plan, dated 12/15/23, the Note indicated Resident 2 had been cleared from the 5150 involuntary hold by psychiatry and was discharged back to the skilled nursing facility on 12/15/23 at 5:30 p.m. During a review of Resident 2's nursing progress notes dated 12/15/23 at 6:30 p.m., the notes indicated Resident 2 returned to the facility on [DATE] at 6:25 p.m. During a review of Resident 2's facility record, Physician's Orders, Order Details, dated 12/15/23 at 7:37 p.m., the Physician's Order indicated an order for one-to-one supervision. During a review of Resident 2's care plan titled, Resident on 1:1 (one-to-one) Supervision, dated 12/15/23, the care plan indicated the goal was for Resident 2 to have no complications related to behavior issues. The care plan included the interventions of one-to-one supervision/sitter 24/7 (24 hours per day, seven days per week) at bedside, and will monitor resident for behavior. During a concurrent observation and interview on 12/21/23, at 11:00 a.m., the entry door to Resident 2's single-occupancy room was unattended; inside the room, there were no occupants in the room except for Resident 2 who lay in bed, the head of the bed elevated, awake. When questioned about the events of 12/15/23, Resident 2 stated on 12/15/23, just past midnight, she became irritated with Resident 1 because Resident 1 was yelling and screaming for the nurses. Resident 1 stated she threw her water bottle at Resident 1, the water bottle struck Resident 1 in the head, and Resident fell off the bed. Resident 2 stated she self-transferred into her wheelchair and went over to try to make (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 10 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0689 Resident 1 be quiet, and Resident 1 defensively attempted to scratch Resident 2. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 12/21/23, at 11:06 a.m., Hospitality Aide 1 (HA 1) stood in the entry door to Resident 2's room, and stated she was Resident 2's assigned one-to-one sitter. Residents Affected - Few During an interview on 12/21/23, at 12:30 p.m., with HA 1, HA 1 stated Resident 2 did not like to have a sitter present inside Resident 2's room, so the sitter would stay outside the room near the door. HA 1 stated she had left Resident 2's room unattended on 12/21/23, at 11:06 a.m., because she needed to take a personal break for approximately seven minutes. HA 1 stated she told two certified nursing assistants (CNA 2 and CNA 3) assisting another resident inside a nearby room, that she was taking a break from monitoring Resident 2. Note: The nursing home is disputing this citation. During an interview on 12/21/23, at 2:25 p.m., with CNA 2, CNA 2 stated she was in resident room B, assisting CNA 3 with resident care at 11 a.m. that morning. CNA 2 stated she was not able to see Resident 2's room or the entry door to Resident 2's room from her location in resident room B. During an interview on 12/21/23, at 2:35 p.m., with CNA 3, CNA 3 stated she had not heard CNA 1 ask for help with supervision of Resident 2 while CNA 1 went on a break. CNA 3 stated she had been in room B with CNA 2, providing resident care and had not been able to see Resident 2's room or entry door. During an interview on 12/21/23, at 2:40 p.m., with the facility's Director of Nursing (DON), the DON stated the expectation for a one-to-one sitter was for the sitter to stay with the resident. The DON stated if the sitter needed a break, the sitter was to endorse supervision to either the assigned certified nursing assistant or a licensed nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 11 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify the potential need for one-to-one supervision of residents with mental or physical conditions requiring close supervision to prevent injury to themselves or others, and consequently failed to establish training and competency guidelines for staff members who provided one-to-one supervision of residents. This failure resulted in use of an untrained, non-nursing staff member (Hospitality Aide 1) to provide one-to-one supervision of a resident (Resident 2) at risk of harming others. Hospitality Aide 1 left Resident 2 unsupervised for six minutes, which had the potential to result in harm to the other residents in the facility. See F-600, F-609, and F-689 Findings: During a review of Resident 2's admission Record, undated, the admission Record indicated the facility admitted Resident 2 in October 2023. The admission Record indicated Resident 2 had diagnoses which included mental conditions which made it difficult to think clearly, have normal emotional responses, act normally in social situations, tell the difference between what was real and what was not real, to have firmly held beliefs which were contrary to reality, to have wide or extreme swings in mood from periods of feeling sad and depressed to periods of intense excitement and activity or irritability. The admission Record indicated Resident 2 had a conservator for healthcare decisions (a person appointed through legal proceedings to make healthcare and/or financial decisions for a person adjudged to be without mental capacity to make such decisions), and a responsible party with financial Power of Attorney (the legal power to make financial decision). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was moderately impaired in the ability to communicate and understand others. The MDS also indicated Resident 2 used a wheelchair for mobility and required only minimal assistance from staff with activities of daily living (eating, toileting, bathing, oral hygiene, personal hygiene, dressing, putting on and off footwear and transferring between surfaces). During a review of Resident 2's care plan titled, The Resident is at Risk for Behavior Problems, initiated 10/6/23, the care plan indicated the behavioral problems were due to medical needs, amputation, mental condition, history of substance abuse, moderately impaired cognition, and traumatic brain injury. (TBI, injury to the brain resulting from force applied to the brain as in a physical hit or a bullet into the head. TBI can cause temporary or short-term problems with normal brain function, including problems with how the person thinks, understands, moves, communicates, and acts.) Care plan interventions to reach the goal of decreased episodes included: staff were to intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; remove from situation and take to alternate location as needed; provide quiet environment and decreased stimuli to de-escalate behaviors. During a review of Resident 2's Psychiatric Consult Progress Report dated 10/18/23, the Progress Report indicated Resident 2 had been at an inpatient psychiatric facility for three months prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 12 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0838 Level of Harm - Minimal harm or potential for actual harm admission at the facility for treatment of agitation and threatening behaviors. The Progress Report indicated Resident 2 was a high risk for assaultive behaviors. During a review of Resident 2's facility record, Physician ' s Orders, Order Details, dated 12/15/23 at 7:37 p.m., the Physician's Order indicated an order for one-to-one supervision. Residents Affected - Few During a review of Resident 2's care plan titled, Resident on 1:1 (one-to-one) Supervision, dated 12/15/23, the care plan indicated the goal was for Resident 2 to have no complications related to behavior issues. The care plan included the interventions of one-to-one supervision/sitter 24/7 (24 hours per day, seven days per week) at bedside, and will monitor resident for behavior. During a concurrent observation and interview on 12/21/23, at 11 a.m., the entry door to Resident 2's single-occupancy room was unattended from 11a.m. to 11:06 a.m., when the sitter arrived to the door of the room. Inside the room, there were no occupants in the room except for Resident 2 who lay in bed, the head of the bed elevated, awake. When questioned about the events of 12/15/23, Resident 2 stated on 12/15/23, just past midnight, she became irritated with Resident 1 because Resident 1 was yelling and screaming for the nurses. Resident 1 stated she threw her water bottle at Resident 1, the water bottle struck Resident 1 in the head, and Resident fell off the bed. Resident 2 stated she self-transferred into her wheelchair and went over to try to make Resident 1 be quiet, and Resident 1 defensively attempted to scratch Resident 2. During an interview on 12/21/23, at 12:30 p.m., with HA 1, HA 1 stated Resident 2 did not like to have a sitter present inside Resident 2's room, so the sitter would stay outside the room near the door. HA 1 stated she had left Resident 2 ' s room unattended this morning because she needed to take a personal break for approximately seven minutes. HA 1 stated she told two certified nursing assistants (CNA 2 and CNA 3) assisting another resident inside a nearby room, that she was taking a break from monitoring Resident 2. HA 1 stated she was not a certified nursing assistant or licensed nurse but was a sitter. HA 1 stated she had not received any training for her duties as a sitter. During an interview on 12/21/23, at 2:40 p.m., with the facility's Director of Nursing (DON), the DON stated the expectation for a one-to-one sitter was for the sitter to stay with the resident. The DON stated if the sitter needed a break, the sitter was to endorse supervision to either the assigned certified nursing assistant or a licensed nurse. During an interview on 12/21/23, at 2:45 p.m., with the Director of Staff Development (DSD), the DSD stated she trained one-to-one sitters by telling sitters the resident status, what to watch for, and how to keep the resident and others safe. The DSD stated she had not provided sitter training for HA 1, and was unable to provide written training materials or course syllabus for any sitter training. During a review of the Facility Assessment, updated 11/16/23, the Facility Assessment Part 1 titled, Our Resident Profile, indicated the facility was able to provide care for residents with diagnoses that included mental conditions which made it difficult to think clearly, have normal emotional responses, act normally in social situations, tell the difference between what was real and what was not real, to have firmly held beliefs which were contrary to reality, to have wide or extreme swings in mood from periods of feeling sad and depressed to periods of intense excitement and activity or irritability, and those with behaviors that needed interventions. Facility Assessment Part 2 titled, Services and Care We Offer Based on our Residents ' Needs, the Assessment indicated provided services included, person-centered/directed care: psycho/social/spiritual support: .prevent abuse and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 13 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few neglect, identify hazards and risks for residents The Facility Assessment Part 3 titled, Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, indicated the facility would maintain one full-time Director of Social Services, and one on-call Social Services Assistant for the position in addition to nursing staff, other staff needed for behavioral healthcare and services (list other staff members positions/roles). The Facility Assessment did not indicate the facility utilized non-nursing personnel to provide one-to-one supervision. During a review of the facility's Policy & Procedure (P&P) titled, Accidents & Supervision, dated 7/1/23, the P & P indicated, Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes:1. Identifying hazards and risks.2. Evaluating and analyzing hazards and risks.3. Implementing interventions to reduce hazards and risks.4. Monitoring for the effectiveness and modifying interventions when necessary Communicating the interventions to all relative staff. b. Assign responsibility. c. Providing training as needed. e. Ensuring the interventions are put into action. h. Facility-based interventions may include but are not limited to: iii. Developing or revising policies and procedures. 5. Supervision- is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: c. Supervision may include 1:1 supervisor so long as the supervision and safety needs of the resident are being met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 14 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain a full-time qualified social worker (SW) for the 121 bed facility when the facility ' s full time SW went out on maternity leave without a replacement SW, and had no estimated return date for the current SW. Residents Affected - Few This placed residents of the facility at risk for their psychosocial needs to go unnoticed and unmet. Note: The nursing home is disputing this citation. Findings: During a review of the facility ' s Daily Census Report, dated 1/31/24, the Daily Census Report indicated there were 121 resident beds in the facility. During an interview on 1/31/24, at 7:30 a.m., with the Director of Nurses (DON), the DON stated the full-time SW had been out on maternity leave since 1/6/24, and the facility ' s Activity Director (AD) had assumed her roles and responsibilities. The DON did not know when the SW was due to return back to the facility. During an interview on 1/31/24, at 8:35 a.m., with the Activities Director (AD- acting social services designee), the AD stated she had assumed all social services needs on 1/8/24, when the full time SW went out on maternity leave. The AD stated her background and education was in accounting and bookkeeping. The AD further stated she had no formal training in social work, human services, sociology, gerontology, special education, rehabilitation counseling, psychology, and had not completed the required one year of supervised social work experience in a health care setting working directly with individuals. During an interview on 2/6/24, at 2:00 p.m., with the facility ' s Administrator (Admin), the Admin stated the SW went out on maternity leave, and he did not know when she would return. The Admin could not show he was actively recruiting an interim social worker. During a review of the Facility Assessment, dated 1/16/24, the Facility Assessment indicated the facility housed residents with psychiatric and mood disorders which required the SW to coordinate care. The Assessment indicated, In addition to nursing staff, other staff needed for behavioral healthcare and services were 1-2 full time and on call social services employees. During a review of the facility ' s Job description for Social Services Director, last revised 3/1/14, the job description indicated, Position: The Social Services Director assumes administrative authority, responsibility and accountability to provide medically-related social services which assists residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. Education: High school diploma or equivalent, for communities with less than 120 beds; B.A. (Bachelor ' s of Arts) Degree in social work or human services field, for communities with more than 120 beds. License: Current SSD (social services designee) Certificate required. Work Experience: 1 year of supervised social work experience in a healthcare setting working directly with individuals. Experience completing electronic records for all documentation and have basic computer skills, including operating online applications and basic Word and Excel skills. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 15 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to maintain an effective Pest Control Program when there were numerous fruit flies in the Rehabilitation Room (Rehab room). Residents Affected - Few This failure created a nuisance for residents receiving rehabilitation services in the rehabilitation room, and had the potential to result in transfer of diseases such as salmonella, e.coli, and listeria (bacteria known to cause food-borne illness). Note: The nursing home is disputing this citation. Findings: During a concurrent observation and interview on 12/21/23, at 3:50 p.m., with Resident 3, in the Rehab room, there was a multitude of fruit flies flying around the room. Resident 3 stood in the middle of the room and swatted at the fruit flies flying around her face. The Rehab room had a countertop next to a wall. On top of the countertop was an apple-shaped object with holes in the top. Resident 3 stated the fruit flies had been a nuisance here for weeks, and the situation had not improved over time. During a concurrent observation and interview on 12/21/23, at 4:17 p.m., with the Administrator In Training (AIT), in the Rehab room, the AIT stated there were multiple fruit flies in the rehab room. During an interview on 12/21/23, at 4:20 p.m., with the facility's Physical Therapist (PT) and Occupational Therapist (OT), the PT stated the apple shaped object on the Rehab room countertop was a fruit fly trap he had brought in because he was annoyed by the fruit flies. PT stated he had told the Maintenance Director (MDir) about the fruit flies, but nothing was done. OT stated the infestation had been going on for at least three weeks and had been getting worse during the three weeks. During a concurrent observation and interview on 12/21/23, at 4:25 p.m., with the MDir, in the Rehab room the MDir confirmed there were numerous fruit flies in the Rehab room, and he had noticed the fruit flies and fruit fly trap previously. MDir stated he would need to put in a work order for the pest control company to come and take care of the fruit flies. MDir was unable to provide documentation to demonstrate prior notification to the pest control company about the fruit fly infestation. During a review of the facility's Policy & Procedure (P&P) titled, Pest Control Program, dated 4/23/23, the Pest Control Program P&P indicated: Policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). Policy Explanation and Compliance Guidelines: .3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated. 4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 16 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. 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 one of two sietters, the facility failed to develop and implement a training program for a one-to-one sitter (1:1, one sitter assigned to only one resident) prior to the sitter being assigned supervision of Resident 2, an abusive resident known for angry outbursts and assault. Residents Affected - Few The failure to adequately train the sitter had the potential to result in inadequate supervision and placed residents of the facility at risk for injury and assault See also F 689. Findings: During a review of Resident 2's admission Record, undated, the admission Record indicated the facility admitted Resident 2 in October 2023. The admission Record indicated Resident 2 had diagnoses which included mental conditions which made it difficult to think clearly, have normal emotional responses, act normally in social situations, tell the difference between what was real and what was not real, to have firmly held beliefs which were contrary to reality, to have wide or extreme swings in mood from periods of feeling sad and depressed to periods of intense excitement and activity or irritability. The admission Record indicated Resident 2 had a conservator for healthcare decisions (a person appointed through legal proceedings to make healthcare and/or financial decisions for a person adjudged to be without mental capacity to make such decisions), and a responsible party with financial Power of Attorney (the legal power to make financial decision). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was moderately impaired in the ability to communicate and understand others. The MDS also indicated Resident 2 used a wheelchair for mobility and required only minimal assistance from staff with activities of daily living (eating, toileting, bathing, oral hygiene, personal hygiene, dressing, putting on and off footwear and transferring between surfaces). During a review of Resident 2's care plan titled, The Resident is at Risk for Behavior Problems, initiated 10/6/23, the care plan indicated the behavioral problems were due to medical needs, amputation, mental condition, history of substance abuse, moderately impaired cognition, and traumatic brain injury. (TBI, injury to the brain resulting from force applied to the brain as in a physical hit or a bullet into the head. TBI can cause temporary or short-term problems with normal brain function, including problems with how the person thinks, understands, moves, communicates, and acts.) Care plan interventions to reach the goal of decreased episodes included: staff were to intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; remove from situation and take to alternate location as needed; provide quiet environment and decreased stimuli to de-escalate behaviors. During a review of Resident 2's Psychiatric Consult Progress Report dated 10/18/23, the Progress Report indicated Resident 2 had been at an inpatient psychiatric facility for three months prior to admission at the facility for treatment of agitation and threatening behaviors. The Progress Report indicated Resident 2 was a high risk for assaultive behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 17 of 18 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 2's facility record, Physician ' s Orders, Order Details, dated 12/15/23 at 7:37 p.m., the Physician's Order indicated an order for one-to-one supervision. During a review of Resident 2's care plan titled, Resident on 1:1 (one-to-one) Supervision, dated 12/15/23, the care plan indicated the goal was for Resident 2 to have no complications related to behavior issues. The care plan included the interventions of one-to-one supervision/sitter 24/7 (24 hours per day, seven days per week) at bedside, and will monitor resident for behavior. During a concurrent observation and interview on 12/21/23, at 11 a.m., the entry door to Resident 2's single-occupancy room was unattended from 11a.m. to 11:06 a.m., when the sitter arrived to the door of the room. Inside the room, there were no occupants in the room except for Resident 2 who lay in bed, the head of the bed elevated, awake. When questioned about the events of 12/15/23, Resident 2 stated on 12/15/23, just past midnight, she became irritated with Resident 1 because Resident 1 was yelling and screaming for the nurses. Resident 1 stated she threw her water bottle at Resident 1, the water bottle struck Resident 1 in the head, and Resident fell off the bed. Resident 2 stated she self-transferred into her wheelchair and went over to try to make Resident 1 be quiet, and Resident 1 defensively attempted to scratch Resident 2. During an interview on 12/21/23, at 12:30 p.m., with HA 1, HA 1 stated Resident 2 did not like to have a sitter present inside Resident 2's room, so the sitter would stay outside the room near the door. HA 1 stated she had left Resident 2 ' s room unattended this morning because she needed to take a personal break for approximately seven minutes. HA 1 stated she told two certified nursing assistants (CNA 2 and CNA 3) assisting another resident inside a nearby room, that she was taking a break from monitoring Resident 2. HA 1 stated she was not a certified nursing assistant or licensed nurse but was a sitter. HA 1 stated she had not received any training for her duties as a sitter. During an interview on 12/21/23, at 2:40 p.m., with the facility's Director of Nursing (DON), the DON stated the expectation for a one-to-one sitter was for the sitter to stay with the resident. The DON stated if the sitter needed a break, the sitter was to endorse supervision to either the assigned certified nursing assistant or a licensed nurse. During an interview on 12/21/23, at 2:45 p.m., with the Director of Staff Development (DSD), the DSD stated she trained one-to-one sitters by telling sitters the resident status, what to watch for, and how to keep the resident and others safe. The DSD stated she had not provided sitter training for HA 1, and was unable to provide written training materials or course syllabus for any sitter training. During a review of the facility's Policy & Procedure (P&P) titled, Accidents & Supervision, dated 7/1/23, the P & P indicated, Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes:1. Identifying hazards and risks.2. Evaluating and analyzing hazards and risks.3. Implementing interventions to reduce hazards and risks.4. Monitoring for the effectiveness and modifying interventions when necessary Communicating the interventions to all relative staff. b. Assign responsibility. c. Providing training as needed. e. Ensuring the interventions are put into action. h. Facility-based interventions may include but are not limited to: iii. Developing or revising policies and procedures. 5. Supervision- is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: c. Supervision may include 1:1 supervisor so long as the supervision and safety needs of the resident are being met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 18 of 18