Health inspection·October 5, 2024

F 0580 mg/dL or higher. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/04/2024 at 1:39 PM, Licensed Vocational Nurse (LVN) #3 stated he did not have to call the physician very often about residents' blood sugar levels but would contact the physician if a resident's blood sugar was over 400 mg/dL. Residents Affected - Few During an interview on 10/04/2024 at 3:40 PM, Registered Nurse (RN) #17 stated staff should contact the resident's physician if a resident had a blood sugar over 400 mg/dL to 500 mg/dL. RN #17 stated they did not always call each time a resident had high blood sugar levels, because some resident's tended to have higher levels. During an interview on 10/04/2024 at 3:53 PM, RN #18 stated she was the evening shift supervisor. RN #18 stated if a resident's blood sugar was above 300 mg/dL most physicians wanted to be notified. During an interview on 10/05/2024 at 9:27 AM, the Director of Nursing (DON) stated she did not know at what point the physician should be notified regarding resident's blood sugar levels but indicated the orders should specify. During an interview on 10/05/2024 at 10:51 AM, the Administrator stated there should be an established level for when to contact the physician regarding residents' blood sugar levels, and if a resident's blood sugar met that level, staff should notify the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 2 of 33 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 10/05/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, facility document review, and facility policy review, the facility failed to ensure each resident had a safe and homelike environment by ensuring rooms were free of damage for 2 (Resident #112 and Resident #82) of 24 sampled residents. Findings included: A facility policy titled, Safe and Homelike Environment, dated 06/01/2023, revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. An undated facility policy titled, Maintenance Inspection, revealed, 1. The Director of Maintenance Services or designee will perform routine inspections of the physical plant using the maintenance checklist. The policy revealed, 3. All opportunities will be corrected immediately by maintenance personnel. 1. An admission Record revealed the facility admitted Resident #112 on 05/06/2024. According to the admission Record, the resident had a medical history that included a diagnosis of depression. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2024, revealed Resident #112 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. An observation on 10/01/2024 at 10:29 AM, revealed a tennis ball sized hole in the bathroom door in Resident #112's room. The facility's Maintenance Request forms for the timeframe from 05/21/2024 through 09/23/2024, revealed no maintenance request for Resident #112's room. During an interview on 10/01/2024 at 10:30 AM, Certified Nurse Assistant (CNA) #14 stated that she had first seen the hole in the door in Resident #112's room in July 2024. CNA #14 revealed that she had not notified the maintenance staff of the hole in the door. She stated that she should have written a maintenance request. During an interview on 10/02/2024 at 2:56 PM, the Administrator revealed that the maintenance request records were started in May 2024, he stated there was no process to document maintenance requests prior to then. During an interview on 10/04/2024 at 2:08 PM, the Administrator revealed that he had been the acting maintenance director since August 2024. He stated that it was his responsibility to ensure the building was clean and there was a homelike environment for the residents. He stated that things that needed to be fixed must be documented in the maintenance log. The Administrator stated that he was not aware of any maintenance requests for Resident #112's room. The Administrator stated that he expected all the resident rooms to be in good repair. He stated that he expected damage to be reported to him and for the damage to be fixed in a timely manner. During an interview on 10/04/2024 at 2:27 PM, Licensed Vocational Nurse (LVN) #7 revealed that if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 3 of 33 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 10/05/2024 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 0584 any resident rooms had holes in the walls, there should be a maintenance request to fix the damage. Level of Harm - Minimal harm or potential for actual harm An observation on 10/04/2024 at 2:37 PM, revealed the bathroom door in Resident #112's room remained with a tennis ball sized hole in it. Residents Affected - Few An observation on 10/05/2024 at 8:53 AM, revealed the bathroom door in Resident #112's room remained with a hole in it. During a concurrent interview, Resident #112 stated that the hole in the door had been there since they had moved to that room. During an interview on 10/05/2024 at 9:23 AM, the Director of Nursing (DON) revealed that when the nursing staff entered residents' rooms, they should document any room damage in the maintenance binder. The DON stated that the maintenance staff checked the binder daily. Per the DON, the residents should have a homelike environment and stated that having a hole in a wall did not create a homelike environment. 2. A facility policy titled, Electrical Cord Safey Policy, dated 06/01/2024, revealed It is our policy to provide a safe and healthful environment. There is an increasing need for electrical equipment in our facility. The intent of this policy is to provide staff with information about our facility's method for ensuring safety as related to electrical wiring and equipment. An admission Record revealed the facility admitted Resident #82 on 09/10/2024. According to the admission Record, the resident had a medical history that included diagnoses of difficulty in walking and muscle weakness. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2024, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. During an observation in Resident #82's room on 09/30/2024 at 11:03 AM, the plate cover for the resident's call light appeared to be coming off the wall. An observation of Resident #82's room on 10/02/2024 at 2:45 PM, revealed the cover for the call light electrical box located on the wall behind the resident's bed was crooked and not fully attached, allowing wires to be exposed. During a concurrent interview, Resident #82 stated that in the past, staff had come in and said that their call light was always on and saw that the cover was off. Resident #82 stated that the call light issue was resolved; however, the electrical box had not been repaired. The facility's Maintenance Request forms for the timeframe from 05/21/2024 through 09/23/2024, revealed there were no documented requests to repair the electrical box in Resident #82's room. During an interview on 10/04/2024 at 1:55 PM, Janitor #8 stated he had not seen any rooms with outlet covers askew or coming off. He stated maintenance was responsible for repairs, but they did not have a facility maintenance director at that time. During an interview on 10/04/2024 at 2:08 PM, the Administrator stated he had been the acting maintenance director since August 2024. He stated no one had reported an issue with Resident #82's room. The Administrator stated his expectation was that the facility be up to code on the requirements for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 4 of 33 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 10/05/2024 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 0584 electrical wiring and if there were any issues they would call an electrician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 5 of 33 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 10/05/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected whether 1 (Resident #12) of 3 sampled residents reviewed for Preadmission Screening and Resident Review (PASRR) requirements was considered by the state Level II process to have a serious mental illness, intellectual disability, or a related condition. Residents Affected - Few Findings included: A facility policy titled, Conducting an Accurate Resident Assessment, dated 09/01/2024, revealed, The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. The policy revealed, 6. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment. Whether the MDS assessments are manually completed, or computer generated following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, dated October 2023, revealed section A1500: Preadmission Screening and Resident Review (PASRR) included Coding Instructions that specified to - Code 0, no: and skip to A1550, Conditions Related to ID [intellectual disabilities]/DD [developmental disabilities] Status, if any of the following apply: - PASRR Level I screening did not result in a referral for Level II screening, or - Level II screening determined that the resident does not have a serious MI [mental illness] and/or ID/DD or related conditions, or - PASRR screening is not required because the resident was admitted from a hospital after requiring acute inpatient care, is receiving services for the condition for which they received care in the hospital, and the attending physician has certified before admission that the resident is likely to require less than 30 days of nursing home care. -Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness, and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. An admission Record indicated the facility originally admitted Resident #12 on 05/22/2014 and most recently admitted the resident on 04/26/2024. According to the admission Record, the resident had a medical history that included a diagnosis of schizophrenia. A PASRR Level II determination report, dated 07/11/2022, revealed Resident #12 required nursing facility services due to a medical and/or mental health condition. The determination report indicated specialized services were recommended to supplement nursing facility care to address mental health needs. However, Resident #12's annual MDS, with an Assessment Reference Date (ARD) of 06/26/2024, revealed section A1500 was coded as 0, indicating the resident was not considered by the state level II PASRR process to have serious mental illness, intellectual disability, or a related condition. During an interview on 10/03/2024 at 9:51 AM, MDS Licensed Vocational Nurse (LVN) #25 stated that when completing MDS assessments, she reviewed hospital discharge summaries, physician's orders, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 6 of 33 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 10/05/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few therapy notes, social services notes, dietary notes, and activity notes. She stated that since Resident #12 had a Level II determination letter, their MDS should have been coded as yes to indicate the resident was considered by the state level II PASRR process to have serious mental illness, intellectual disability, or a related condition. She stated she was not sure why it was missed. During an interview on 10/05/2024 at 9:18 AM, the Director of Nursing (DON) stated MDS assessments needed to be accurate, and the MDS staff were responsible for ensuring the accuracy of the MDS assessments. During an interview on 10/05/2024 at 10:51 AM, the Administrator stated the accuracy of MDS assessments was the responsibility of the MDS staff. He stated MDS assessments needed to be accurate to ensure residents received the appropriate level of care and services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 7 of 33 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 10/05/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and facility document and policy review, the facility failed to ensure 1 (Resident #39) of 3 residents reviewed for preadmission screening and resident review (PASARR) requirements was referred to the state-designated authority for a Level II PASARR evaluation following a positive Level I PASARR screening. Residents Affected - Few Findings included: A facility policy titled Resident Assessment-Coordination with PASARR Program, implemented 09/01/2023, revealed 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I- initial pre-screening that is completed prior to admission i. Negative Level I Screen- permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level II Screen- necessitates a PASARR Level II evaluation. B. PASRR Level II- a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the induvial has MD [mental disability], ID [intellectual disability], or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. The policy also specified, 5. The Social Services Director and/or MDS [Minimum Data Set] Coordinator shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. An admission Record revealed the facility admitted Resident #39 on 06/14/2024. According to the admission Record, the resident had a medical history that included a diagnosis of bipolar type schizoaffective disorder. An admission MDS, with an Assessment Reference Date (ARD) of 06/17/2024, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #39 had an active diagnosis of schizophrenia. Resident #39's Level I PASARR screening, dated 06/14/2024, revealed the resident had a serious diagnosed mental disorder, specifically schizoaffective disorder. The Level I PASARR screening was positive for a suspected mental illness, and a Level II PASARR evaluation was required. Resident #39's medical record revealed no documented evidence that a Level II PASARR evaluation was completed. During an interview on 10/04/2024 at 11:10 AM, MDS Licensed Vocational Nurse (MDS LVN) #25 stated Resident #39 was not referred to the PASARR office in June 2024 when their Level I PASARR screening was positive. MDS LVN #25 stated a request for a Level II PASARR evaluation was not completed until the surveyor asked about it during the survey. During an interview on 10/05/2024 at 9:17 AM, the Director of Nursing (DON) stated that when a resident had a positive Level I PASARR screening, MDS staff should coordinate with the PASARR office to ensure the evaluation was completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 8 of 33 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 10/05/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/05/2024 at 11:13 AM, the Administrator stated MDS staff were responsible for contacting the PASARR office within a timely manner to ensure Level II PASARR evaluations were completed when indicated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 9 of 33 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 10/05/2024 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure medication orders specified the intended dosages for 1 (Resident #32) of 4 residents whose physician's orders were reconciled during the medication administration task. Additionally, the facility failed to ensure nursing staff contacted the physician to obtain order clarifications for Resident #32's incomplete orders. Residents Affected - Few Findings included: A facility policy titled, Medication Administration, dated 03/01/2023, specified, 10. Review MAR [medication administration record] to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc. [et cetera, and other similar things]) with MAR to verify resident name, medication name, form, dose, route, and time. The policy also indicated, 20. Correct any discrepancies and report to nurse manager, MD [medical doctor] and/or DON [Director of Nursing]. An admission Record indicated the facility admitted Resident #32 on 03/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of essential (primary) hypertension, chronic systolic (congestive) heart failure, and alcohol-induced acute pancreatitis without necrosis (cell injury resulting in premature death of body tissue) or infection. Resident #32's Order Summary Report, listing active orders as of 10/03/2024, contained orders dated 07/19/2024 for folic acid, vitamin A, vitamin B6, and vitamin D3 with instructions to give one tablet of each by mouth one time a day for supplement; however, the orders did not specify the dosages of each medication to be given. During an observation of medication pass on 10/02/2024 at 8:46 AM, Licensed Vocational Nurse (LVN) #3 prepared and administered medications for Resident #32, including one tablet of folic acid 1,000 micrograms (mcg), one tablet of vitamin B6 25 milligrams (mg), one tablet of vitamin D3 1,000 international units (IU), and one capsule of vitamin A 3,000 mcg. During an interview on 10/02/2024 at 4:07 PM, LVN #3 stated he used the facility's stock bottles for Resident #32's supplements and confirmed the resident's orders did not specify the ordered dosages. LVN #3 stated he should have contacted the physician to get clarification on the orders. During an interview on 10/04/2024 at 2:41 PM, the Infection Prevention LVN (IP LVN) stated if a medication order did not include the dosage, nursing staff should contact the physician for clarification. During an interview on 10/05/2024 at 8:24 AM, LVN #6 stated if a medication order did not specify the dosage to be given, the nurse needed to contact the physician to clarify the order prior to administering the medication. During an interview on 10/05/2024 at 9:18 AM, the DON stated physician's orders should include the resident's name, the medication, the dose, the route, and the time. The DON further stated nurses needed to check medication orders and contact the physician to clarify the intended dosage, if needed. During an interview on 10/05/2024 at 10:51 AM, the Administrator stated nurses should be following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 10 of 33 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 10/05/2024 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 0658 physician's orders and should obtain clarification if needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 11 of 33 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 10/05/2024 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility document and policy review, the facility failed to ensure 1 (Resident #39) of 4 residents reviewed for advance directives had a physician's order that was consistent with the resident's Physician Orders for Life Sustaining Treatment (POLST) form, which indicated the resident elected do not resuscitate (DNR)/no cardiopulmonary resuscitation (CPR). Findings included: A facility policy titled, Communication of Code Status, dated [DATE], revealed, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. The policy revealed, 3. Communication of code status include resident orders and POLST form as applicable. According to the policy, 6. The resident's code status will be reviewed quarterly or as needed and any changes will be documented in the medical record and noted in orders as indicated. An admission Record revealed the facility admitted Resident #39 on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of neuropathy, type 2 diabetes, epilepsy, bipolar type schizoaffective disorder, dysphagia, and cognitive communication deficit. Per the admission Record, Resident #39 was their own responsible party and had an advance directive that indicated DNR. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. A Physician Orders for Life-Sustaining Treatment (POLST), form signed by Resident #39 on [DATE], revealed the resident had elected Do not Attempt Resuscitation/DNR. The POLST revealed the physician signed the form on [DATE]. Resident #39's Order Summary Report, with active orders as of [DATE], contained an order dated [DATE], for Full Code. During an interview on [DATE] at 9:33 AM, Licensed Vocational Nurse (LVN) #12 stated when residents were admitted to the facility, nursing staff addressed the resident's code status. She stated all residents' POLST forms and physician orders should match. LVN #12 stated if the resident's code status changed, the nurse must document in the 24-hour report book. According to LVN #12, nursing staff were responsible for ensuring the resident's correct code status was documented. During an interview on [DATE] at 9:40 AM, LVN #13 stated staff were required to review the POLST form or the resident's admission record for the residents' code status. LVN #13 stated the code status documentation should match. During an interview on [DATE] at 10:13 AM, the Director of Nursing (DON) stated that nursing staff should look at the POLST form to determine a resident's code status. The DON stated the resident or responsible party, and the physician should sign the POLST form and the physician's order should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 12 of 33 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 10/05/2024 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few match the POLST order. Per the DON, if there were changes to the POLST form, they should complete a new physician's order. During an interview on [DATE] at 9:21 AM, the DON stated she expected the resident's POLST form and physician order for code status to match. She stated if the physician's order was not clear, the staff should clarify the code status with the physician and the resident. During an interview with the Administrator on [DATE] at 11:45 AM, he stated not having an accurate code status could result in proper action not being taken and resident choices not being upheld. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 13 of 33 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 10/05/2024 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, record review, and facility policy review, the facility failed to: 1) complete a smoking assessment for Resident #79, 2) provide supervision for Resident #91, a resident who was assessed to require supervision while smoking, and 3) ensure a safety intervention for smoking was implemented for Resident #10. These failures affected 3 (Residents #10, #79, #91) of 5 sampled residents reviewed for smoking. The facility further failed to ensure staff did not leave medications at the bedside for 2 (Resident #58 and Resident #82) of 24 sampled residents. Findings included: A facility policy titled, Resident Smoking Assessment Policy, with an implementation date of 11/01/2023, revealed, Policy It is the policy of this facility to provide a safe and healthy smoke free environment for residents. Policy Explanation and Compliance Guidelines: 1. 1. All residents will be asked about tobacco use during the admission process. 2. Residents who smoke will be further assessed, using a smoking assessment. Residents will be assessed upon admission and as needed. 3. Residents will be further assessed to determine whether or not interventions are needed to help them cope with the 'Smoke Free' policy. 1. An admission Record revealed the facility admitted Resident #79 on 05/22/2024. According to the admission Record, the resident had a medical history that included schizophrenia, toxic encephalopathy, muscle weakness, and cognitive communication deficit. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/25/2024, revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #79's medical record revealed no evidence to indicate the resident was assessment by the facility to determine the resident's ability to safely smoke. Resident #79's Progress Note dated 07/04/2024 at 10:57 AM, revealed the resident was seen smoking. During an interview on 10/02/2024 at 4:25 PM, the Medical Director stated residents should be assessed to smoke to ensure they were safe to smoke and what level of supervision was required for the resident to smoke safely. During a concurrent observation and interview on 10/03/2024 at 8:41 AM, Resident #79 was noted in the activity/communal area with seven to eight burn holes in their pants in the genital area. Resident #79 stated they smoked. During an interview on 10/03/2024 at 8:50 AM, Resident #79 stated that the burn holes in their pants occurred four weeks ago while they smoked alone on the facility patio. The resident stated they last smoked on 10/02/2024. During an interview on 10/03/2024 at 8:45 AM, Certified Nurse Assistant (CNA) #21 stated Resident #79 smoked cigarettes. CNA #21 stated she had not seen smoking materials in the resident's room, but had witnessed Resident #79 smoke outside once before. According to CNA #21, the holes and burn marks in Resident #79's pants were caused when the resident dropped a lit cigarette onto their pants. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 14 of 33 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 10/05/2024 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 - Some During an interview on 10/03/2024 at 9:02 AM, the Director of Nursing (DON) stated she was not aware Resident #79 smoked. During an interview on 10/04/2024 at 4:02 PM, Registered Nurse (RN) #18 stated that when residents admitted to the facility, she completed the initial nursing assessments for the residents. RN #18 stated she did not ask the resident if they smoked. During an interview on 10/05/2024 at 9:23 AM, the DON stated that if a resident was a smoker, facility staff would complete an assessment, then that information would be added to the care plan and communicated to the nursing staff. The DON stated during the admission process, the nurse should review resident records to determine if a resident smoked. 2. An admission Record revealed the facility admitted Resident #91 on 07/26/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, bipolar type, polyneuropathy, chronic obstructive pulmonary disease, depression, muscle weakness, and cognitive communication deficit. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/29/2024, revealed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #91's Nursing Admission/readmission Assessment, dated 07/26/2024, revealed the resident wished to smoke. The assessment revealed, Supervised smoking needed. During an observation on 10/02/2024 at 1:31 PM, Resident #91 was noted to be smoking in the facility's courtyard and there were no staff present to supervise the resident. During an interview on 10/02/2024 at 2:10 PM, Licensed Vocational Nurse #12 stated Resident #91 had a history of smoking and was provided a nicotine patch to aid the resident in quitting. During an interview on 10/02/2024 at 2:31 PM, Resident #91 stated they smoked outside in the front and back of the facility. 4. A facility policy titled, Medication Storage, dated 03/01/2023, specified, c. During a medication pass, medication must be under the direct observation of the person administering medications or locked in the medication storage area/cart. A facility policy titled, Medication Administration, dated 03/01/2023, specified, 15. Observe resident consumption of medication. On 10/05/2024 at 9:18 AM, the Director of Nursing (DON) stated that she was unable to find a facility policy for self-administering medications. An admission Record indicated the facility admitted Resident #58 on 08/30/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic systolic (congestive) heart failure and unspecified cellulitis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/04/2024, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 15 of 33 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 10/05/2024 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 had intact cognition. Level of Harm - Minimal harm or potential for actual harm An observation on 09/30/2024 at 11:29 AM revealed Resident #58 had a cup containing pills on the over-the-bed table next to their bed. During a concurrent interview, Resident #58 stated the nurses left medications at their bedside often. Residents Affected - Some An observation on 10/01/2024 at 3:02 PM revealed Resident #58 had three large white pills on a blanket over their abdomen. During a concurrent interview Resident #58 stated they were larger pills, and it took longer for the resident to swallow them. Resident #58 stated they thought one of the pills was an antibiotic and the other two were potassium pills. Resident #58 stated that they had not requested to self-administer medications and had not been assessed to do so. Review of Resident #58's health record revealed no assessment to self-administer medications. Resident #58's Progress Notes revealed a note, dated 10/01/2024 at 4:15 PM, that indicated the writer observed the resident unfold a tissue that showed three white pills, and the resident stated they were left by the nurse for the resident to take. The note indicated the resident voiced concerns regarding medication administration, medication availability, and response to concerns. 5. An admission Record indicated the facility most recently re-admitted Resident #82 on 09/10/2024. According to the admission Record, the resident had a medical history that included diagnoses of encephalopathy (disease that affected the brain), urinary tract infection, sepsis (infection of the blood stream), bacteremia (presence of bacteria in the blood), type 2 diabetes mellitus, essential (primary) hypertension, major depressive disorder, and benign prostatic hyperplasia (BPH). An admission MDS, with an ARD of 09/13/2024, revealed Resident #82 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. An observation on 09/30/2024 at 11:03 AM revealed Resident #82 had two cups of pills on the over-the-bed table in front of them. During an interview at the time of the observation, the resident stated the nurses left the pills until they were ready to take them. The resident stated they were unsure what medications they took. Review of Resident #82's health record revealed no assessment to self-administer medications. During an interview on 10/04/2024 at 2:28 PM, Licensed Vocational Nurse (LVN) #3 stated medications were not to be left at the bedside. He stated he was unsure about the facility's self-administration assessment and was not aware if Resident #58 or Resident #82 had assessments completed to determine if they were safe to self-administer their own medications. He stated that he did not feel it would be safe for either resident to self-administer medications. During an interview on 10/04/2024 at 2:41 PM, the Infection Preventionist Licensed Vocational Nurse stated medications were never to be left at the bedside, even if a resident was able to self-administer. She stated that if a resident requested to self-administer their medications, then an assessment needed to be completed, which had to be reviewed and approved by the interdisciplinary team (IDT). She stated she was not aware of Resident #58 or Resident #82 having self-administration assessments and stated that their medications should not be left at the bedside. During an interview on 10/05/2024 at 8:24 AM, LVN #6 stated medications should not be left at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 16 of 33 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 10/05/2024 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 bedside. She stated she had to make sure a resident took their medications before she left the room. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/05/2024 at 9:18 AM, the Director of Nursing (DON) stated medications were not allowed to be left at the bedside, and a resident should be assessed prior to self-administering their own medications. She stated they did not have any residents in the facility who were to self-administer medications. She stated that, if they did, the medications would be kept in a locked box. Residents Affected - Some During an interview on 10/05/2024 at 10:51 AM, the Administrator stated medications should not be left at a resident's bedside, and if a resident wanted to administer their own medications, an assessment needed to be done and a physician's order needed to be obtained. He stated all medications should be kept with a nurse. 3. An admission Record revealed the facility admitted Resident #10 on 12/08/2023. According to the admission record, the resident had a medical history that included diagnoses of other specified disorders of the brain, cardiac arrest, metabolic encephalopathy, schizoaffective disorder, delirium due to known physiological condition, major depressive disorder, and unspecified mood disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/202412/14/2023, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #10's Smoking Safety assessment, dated 01/26/2024, the safety factors and concerns related to the resident smoking were burns skin, clothing, furniture or other, dropped ashes on self, impaired gait and balance, insufficient fine motor skills needed to securely hold cigarette, was on medication that affected alertness and function, and total or limited range of motion in arms or hands Resident #10's care plan included a focus area initiated 01/26/2024, that indicated the resident was a smoker. Interventions indicated the resident required a smoking apron while smoking (initiated 01/26/2024). During an observation on 09/30/2024 at 4:05 PM, the surveyor noted Resident #10 was outside smoking with Hospitality Aide (HA) #23. The resident was observed not to have a smoking apron on. During an interview on 10/02/2024 at 2:15 PM, HA #23 stated she had been Resident #10's HA since July 2024. HA #23 stated quite often Resident #10 dropped cigarette ashes on themself. HA #23 stated no one ever told her that the resident needed a smoking apron. During an interview on 10/02/2024 at 11:55 AM, HA #22 stated she had not seen any smoking aprons and she did not know of any resident that required an apron. During an interview on 10/02/2024 at 11:14 AM, the Social Services Director (SSD) stated she had not seen any smoking aprons. During a follow-up interview on 10/02/2024 at 3:36 PM, the SSD stated she was told that none of the residents required a smoking apron, only supervision. During an interview on 10/02/2024 at 3:32 PM, the Director of Nursing stated the facility did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 17 of 33 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 10/05/2024 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 have anyone who needed a smoking apron. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 18 of 33 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 10/05/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and facility policy review, the facility failed to ensure medications were labeled and stored properly in medication carts located on 2 (South 2 Unit and North 1 Unit) of 4 units in the facility. Specifically, the South 2 Unit medication cart contained loose pills, and a topical medication and nebulizer solution were not stored separately from medications to be given by mouth, in accordance with the facility's policy. The North 1 Unit medication cart contained a bottle of guaifenesin oral solution (cough medicine) with an illegible expiration date. Findings included: A facility policy titled, Medication Administration, dated 03/01/2023, specified, 1. Keep medication cart clean, organized, and stocked with adequate supplies. The policy also indicated, 12. Identify expiration date. If expired, notify nurse manager. A facility policy titled, Medication Storage, dated 03/01/2023, specified, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufactures recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The policy also indicated, 3. External Products: Disinfectants and drugs for external use are stored separately from internal and injectable medications. 4. Internal Products: Medications to be administered by mouth are stored separately from other formulations (i.e. [id est, such as] eye drops, ear drops, injectables). An observation of the medication cart on the South 2 Unit with Registered Nurse (RN) #4 on 10/01/2024 at 3:37 PM revealed four loose pills behind the medication cards in the top drawer and one loose pill in the second drawer. The bottom left drawer contained a box of diclofenac topical gel (a topical nonsteroidal anti-inflammatory gel used for pain relief), nebulizer medications, and antidiarrheal medications. During a concurrent observation of the medication cart on the North 1 Unit and interview with Licensed Vocational Nurse (LVN) #7 on 10/04/2024 at 10:28 AM revealed a bottle of guaifenesin oral solution with the expiration date smudged off and illegible. LVN #7 confirmed the expiration date was not visible. During an interview on 10/04/2024 at 10:34 AM, LVN #7 stated it was each charge nurse's responsibility to ensure the medication cart was clean and organized for the oncoming shift, but the nurse managers were responsible for going through the carts to ensure there were no expired medications. She stated she was unsure how often it was done. During an interview on 10/04/2024 at 11:04 AM, RN #10, who also served as the nurse manager for the North Units, stated the charge nurse was responsible for ensuring the medication cart was clean and organized, and it was the responsibility of the nurse managers to check the cart periodically for expired medications and to ensure it was organized appropriately. RN #10 stated if an expiration date on a medication could not be seen, then the medication should be discarded and a new supply obtained. During an interview on 10/04/2024 at 2:28 PM, LVN #3 stated the charge nurse was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 19 of 33 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 10/05/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the cleanliness and organization of the medication carts and for checking for expired medications. He stated oral medications should not be stored with topical medications. LVN #3 stated if a medication had an expiration date that was not legible, then it should be discarded. During an interview on 10/04/2024 at 2:41 PM, Infection Prevention LVN (IP LVN) stated the cleanliness and organization of the medication carts was the responsibility of the charge nurses, and the charge nurses were also responsible for checking for expired medications. She stated oral medications should not be stored with topical medications. IP LVN stated if a date on a medication could not be seen, then the medication should be discarded. During an interview on 10/05/2024 at 8:24 AM, LVN #6 stated the nurses working on the medication carts were responsible for ensuring they were clean and organized, and the department head checked the medication cart every day at the end of their shift. LVN #6 further stated if an expiration date was rubbed off a medication, the medication should be discarded. During an interview on 10/05/2024 at 9:18 AM, the Director of Nursing (DON) stated the nurses were responsible for the medication carts, and oral medications should be kept away from topical medications. She stated if an expiration date was not able to be seen, then staff should discard it and get new medication. During an interview on 10/05/2024 at 10:51 AM, the Administrator stated the medication carts were the responsibility of the nurses working the cart, and the nurses should ensure expired medications were removed daily. He stated he was unsure what should occur if an expiration date was not visible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 20 of 33 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 10/05/2024 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 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, record review, and facility policy review, the facility failed to ensure food served to residents had an appetizing taste and failed to ensure pureed bread was prepared in accordance with the facility's recipe and in a manner to conserve nutritive value. These findings had the potential to affect all 116 residents receiving meals from the dietary department, including 18 residents with orders for pureed diets. Residents Affected - Many Findings included: 1. A facility policy titled, Food Preparation Guidelines, implemented 03/01/2024, specified, 3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: a. Providing meals that are varied in color and texture. b. Using spices or herbs to season food in accordance with recipes. c. Serving hot foods/drinks hot and cold foods drinks cold. d. Addressing resident complaints about foods/drinks. e. Honoring resident preferences, as possible, regarding foods and drinks. During a Resident Council Meeting on 10/01/2024 at 12:51 PM with four residents in attendance, Resident #55 stated the food did not look palatable and lacked variety. Resident #55 also described the food as bland. According to an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/21/2024, Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. During the meeting, Resident #43 also described the food as disgusting and horrible and said the food had no flavor or seasoning. According to a quarterly MDS, with an ARD of 07/08/2024, Resident #43 had a BIMS score of 14, indicating the resident had intact cognition. Resident #38 reported their lunch on 10/01/2024 did not have a taste. According to a quarterly MDS, with an ARD of 07/01/2024, Resident #38 had a BIMS score of 14, indicating the resident had intact cognition. During an observation of the lunch meal service on 10/01/2024, a test tray was requested at 1:03 PM. At 1:15 PM, the test tray was plated and left the kitchen. On 10/01/2024 at 1:31 PM, the surveyor tasted the test tray, and the peas and corn were both flavorless, overcooked, and dried out. The chicken was overpoweringly greasy, which dominated any other flavors. The chocolate pudding desert did not taste of chocolate, but it had a flavor of artificial sweetener. During an interview on 10/02/2024 at 1:13 PM, the Dietary Supervisor (DS) stated she ate the facility's prepared lunch meal on a daily basis. The DS described the lunch meal served on 10/01/2024 as bland and stated the chicken was tough. On 10/02/2024 at 12:50 PM, an additional test tray was requested. The test tray was plated at 1:00 PM and left the kitchen for transport to the unit. On 10/02/2024 at 1:17 PM, the surveyor tasted the test tray, and the noodles were chewy. During an interview on 10/05/2024 at 10:01 AM, the Director of Nursing (DON) stated she had never tasted the food at the facility. The DON said it was the DS's responsibility to ensure the food was palatable. During an interview on 10/05/2024 at 10:50 AM, the Administrator stated it was the Registered Dietitian's (RD's) and DS's responsibility to ensure the food was palatable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 21 of 33 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 10/05/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2. A facility policy titled, Food Preparation Guidelines, implemented 03/01/2024, specified, 1. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. 2. Foods shall be prepared by methods that conserve nutritive value, flavor, and appearance. This includes, but is not limited to: a. Storing food in a manner to minimize exposure to light and air. b. Preparing foods as directed. c. Cooking foods in an appropriate amount of water (avoid large volumes). d. Minimizing holding time prior to meal service. A recipe titled, Pureed Bread Products, revised 08/20/2018, revealed the recipe called for bread product; broth, milk, or juice; and thickener. The recipe did not call for water or margarine. During an observation of pureed food preparation on 10/02/2024 at 10:22 AM, staff did not follow the recipe for pureed bread. To make the bread, staff used one loaf of sliced bread, a half-cup of margarine, and one quart of water. During an observation of pureed food preparation on 10/02/2024 at 3:01 PM, [NAME] #11 prepared pureed bread by using two loaves of sliced bread, a half-cup of margarine, and two quarts of water. During an interview on 10/02/2024 at 3:55 PM, [NAME] #11 stated staff should review recipes before preparing food and said if they forgot, they could ask the supervisor or review the recipe again. During a follow-up interview on 10/02/2024 at 4:20 PM, [NAME] #11 stated she did not realize using water when preparing pureed bread was a mistake until she reviewed the recipe. [NAME] #11 indicated she always thought the recipe called for water and did not know if using water, instead of broth, milk, or juice as specified by the recipe, would affect nutritive value. During an interview on 10/03/2024 at 9:46 AM, the Dietary Supervisor (DS) confirmed that according to the recipe for pureed bread, staff should use broth, milk, or juice. The DS stated she did not know how using water, instead of what the recipe called for, would affect the nutritive value of the pureed bread. During an interview on 10/03/2024 at 10:22 AM, the Registered Dietitian (RD) stated she expected staff to follow the recipes completely. According to the RD, staff should have reviewed the recipe, gotten everything ready, and then began preparing the food. The RD said preparing the pureed bread with water, instead of how the recipe instructed, affected the nutritive value since there was a small amount of calories or protein omitted by not following the recipe. During an interview on 10/05/2024 at 10:01 AM, the Director of Nursing (DON) stated she had never tasted the food at the facility. The DON said it was the DS's responsibility to ensure the food was palatable and of sufficient nutritive value. The DO further stated that since water had no calories, using it in the pureed recipes would have diluted the nutritional value of the food. During an interview on 10/05/2024 at 10:50 AM, the Administrator stated the RD set the menus and recipes, and it was important that staff follow the recipes to ensure nutritive value. The Administrator said it was the RD's and DS's responsibility to ensure the food was of sufficient nutritive value. The Administrator agreed that substituting water in place of milk, broth, or juice as specified in the recipe, would alter the nutritive value. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 22 of 33 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 10/05/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, record review, and facility policy review, the facility failed to ensure foods brought in by visitors were stored in a sanitary manner. Specifically, the facility failed to ensure 1 of 1 refrigerator used on the units for residents' food items was clean. Additionally, the facility failed to ensure resident food items brought to the facility by visitors were labeled with a date prior to storage in the resident refrigerator. These failures had the potential to affect all 116 residents who resided in the facility at the time of the survey. Findings included: A facility policy titled, Food Brought in From Outside Sources, dated 2023, indicated, 3. All food brought in should be checked by the charge nurse or the Director of Food and Nutrition Services. It must be placed in a tightly sealed container with the resident's name and date on it. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) #6 on 10/02/2024 at 12:38 PM, the resident refrigerator was observed with brown stains and brown liquid in the bottom of the refrigerator. Inside the refrigerator was an undated container of half a cake, an undated bag of Chinese takeaway, an undated takeaway container of an unspecified food, and an undated fast-food bag. LVN #6 confirmed the food items were not dated. LVN #6 said food was supposed to be dated when staff placed it into the refrigerator but indicated they had some residents' family members that placed food into the refrigerator themselves. During an observation on 10/03/2024 at 9:39 AM, the resident refrigerator had an undated sign posted on it that read, Dear staff, Please Date and Label The resident's food. Throw away after 3 days. Thank you, IP [Infection Prevention] Nurse. During an interview on 10/03/2024 at 9:46 AM, the Dietary Supervisor (DS) stated the resident refrigerator on the unit was maintained in coordination with the nursing staff. According to the DS, only the staff, not the residents or their families, were permitted to put food in the unit refrigerator. The DS said housekeeping staff also helped maintain the unit refrigerator and indicated the refrigerator was cleaned every three days and items that were not dated were discarded immediately. During an interview on 10/03/2024 at 1:44 PM, the Infection Prevention Licensed Vocational Nurse (IP LVN) stated she oversaw the unit refrigerator. The IP LVN stated she had informed staff that resident food was supposed to be thrown out every three days, or if it was undated/unlabeled. According to the IP LVN, the refrigerator was not cleaned or checked routinely, only when the IP LVN remembered to tell the janitorial staff to clean it and discard any needed items. During an interview on 10/05/2024 at 10:01 AM, the Director of Nursing (DON) stated when visitors brought in food, they should check with the nurse, and then whoever received the food should ensure the food was labeled with the resident's name and a date. The DON said family members should not have access to the refrigerator. The DON further stated she expected the IP LVN to let housekeeping staff know if the refrigerator needed to be cleaned. During an interview on 10/05/2024 at 10:50 AM, the Administrator stated food brought in by visitors must be labeled and dated and discarded after three days. The Administrator said that whoever received the food was responsible for labeling and dating the food items. The Administrator said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 23 of 33 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 10/05/2024 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 0812 janitorial staff were responsible for cleaning the refrigerator, ideally every day, and the Administrator did not know why the refrigerator was observed dirty with undated food items inside of it. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 24 of 33 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 10/05/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility policy review, the facility failed to ensure safe and sanitary disposal of refuse. Specifically, the facility failed to ensure the dumpster was closed to prevent the attraction of vermin. This had the potential to affect all 116 of 116 residents who resided in the facility at the time of the survey. Residents Affected - Many Findings included: An undated facility policy titled, Disposal of Garbage and Refuse indicated, 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect / rodent attractions are minimized. During an observation on 09/30/2024 at 8:30 AM, the facility's garbage dumpster was visible from the street, and the lid of the dumpster was open. During an observation on 10/01/2024 at 11:00 AM, the lid of the dumpster was open, and trash was visible. During an interview on 10/03/2024 at 9:46 AM, the Dietary Supervisor (DS) stated the dumpster was supposed to be closed. During an interview on 10/05/2024 at 10:01 AM, the Director of Nursing (DON) stated the janitorial staff were responsible for maintaining the dumpster. The DON said all trash should be inside the dumpster, and the lid should be closed, which was important for infection control reasons. During an interview on 10/05/2024 at 10:50 AM, the Administrator stated dumpster lids should be closed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 25 of 33 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 10/05/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview, record review, and facility policy review, the facility failed to maintain a complete and accurate medical record for 1 (Resident #22) of 24 sampled residents. Specifically, the facility failed to document accurate skin assessment information for Resident #22. Findings included: A facility policy titled, Documentation in Medical Record, dated 03/01/2023, specified, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The policy also indicated, 2. Principles of documentation include but are not limited to: b. Documentation shall be accurate, relevant, and complete, containing sufficient detains about the resident's care and/or responses to care. An admission Record revealed the facility admitted Resident #22 on 08/29/2020. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia, major depressive disorder, muscle wasting and atrophy, dysphagia, protein-calorie malnutrition, and adult failure to thrive. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/2024, revealed Resident #22 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a Staff Assessment of Mental Status (SAMS). Resident #22's care plan, included a focus area dated 06/05/2024, that indicated the resident had impaired skin integrity to the right, lateral foot related to peripheral vascular disease. Interventions directed staff to document an assessment of the skin weekly (initiated 06/05/2024). Resident #22's surgical and wound care Progress Note Details report dated 09/23/2024, indicated the resident had a Stage 4 pressure injury/ulcer to the right, lateral foot fifth metatarsal. The report revealed the pressure ulcer measured 1.5 centimeters (cm) in length by (x) 1.6 cm in width by 0.3 cm in depth. According to the note, the wound was covered with 60 percent (%) slough and was deteriorating. Resident #22's Order Summary Report, for active orders as of 10/03/2024, contained an order dated 09/30/2024, to cleanse the right lateral foot PVD [peripheral vascular disease)] wound with normal saline, pat dry, apply calcium alginate with silver and cover with a foam dressing every shift. Resident #22's Nursing Weekly Summary Review, dated 09/23/2024 and authored by Registered Nurse (RN) #2, indicated the resident had clear skin. During a telephone interview on 10/04/2024 at 11:44 PM, RN #2 stated he did not recall Resident #22. He stated documenting that Resident #22 had clear skin may have been a mistake. Resident #22's Nursing Weekly Summary Review, dated 09/29/2024 and authored by Licensed Vocational Nurse (LVN) #3, indicated LVN #3 documented that the resident had clear skin. During an interview on 10/02/2024 at 12:07 PM, LVN #3 stated he made a mistake when he indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 26 of 33 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 10/05/2024 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 0842 Resident #22 had clear skin, and he should have marked that the resident had a preexisting skin concern. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/05/2024 at 10:01 AM, the Director of Nursing (DON) stated medical records and nursing assessments should reflect the resident's status. Residents Affected - Few During an interview on 10/05/2024 at 10:50 AM, the Administrator stated medical records should have been complete and accurate. The Administrator stated he did not know why the nursing staff filled out the assessments incorrectly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 27 of 33 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 10/05/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 1 (Resident #22) of 2 residents reviewed for pressure injury/ulcer. Residents Affected - Few Findings included: A facility policy titled, Enhanced Barrier Precautions Policy, implemented 04/01/2024, specified, 2. Initiation of Enhanced Barrier Precautions: b. Enhanced barrier precautions will be considered for residents with any of the following: i. Wounds (e.g. [exempli gratia, for example], chronic wounds such as pressure ulcers, diabetic foot ulcers, surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC [peripherally inserted central catheter] lines, midline catheters) even if the resident is not known to be infected or colonized with an MDRO [multidrug resistant organisms]. The policy revealed, 3. Implementation of Enhanced Barrier Precautions: a. Make gown and gloves available immediately near or outside of the resident's room. The policy revealed, 4. High-contact resident care activities include: h. Wound care. An admission Record revealed the facility admitted Resident #22 on 08/29/2020. According to the admission Record, the resident had a medical history that included unspecified dementia, local infection of the skin and subcutaneous tissue, and muscle wasting and atrophy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/2024, revealed Resident #22 had severe impairment in cognitive skills for daily decision making and had a short-term and long-term memory problem per a Staff Assessment of Mental Status (SAMS). Resident #22's care plan, included a focus area dated 09/01/2024, that indicated the resident was on EBP to reduce MDRO transmission. Interventions directed staff to follow EBP (gloves and gown) during high-contact care activities and to place a sign for EBP near the entrance of the resident's room. Resident #22's Order Summary Report, with active orders as of 10/03/2024, included an order, dated 09/30/2024, to cleanse the right lateral foot PVD [peripheral vascular disease] wound with normal saline, pat dry, apply calcium alginate with silver and cover with a foam dressing every shift. During an observation on 10/02/2024 at 11:20 AM, Licensed Vocational Nurse (LVN) #19 performed wound care for Resident #22. There was no signage for enhanced barrier precautions or personal protective equipment (PPE) outside of the resident's room. LVN #19 did not use a gown or follow EBP during wound care. During an interview on 10/02/2024 at 11:38 AM, LVN #19 stated staff should implement enhanced barrier precautions for wound care, but Resident #22's family felt it demeaned the resident and requested it not be used. During an interview on 10/03/2024 at 11:48 AM, the Infection Preventionist (IP) LVN stated enhanced barrier precautions were required for residents with wounds, feeding tubes, tracheostomies, and indwelling urinary catheters. The IP LVN stated that the intention was to protect those areas and openings as much as possible by preventing infections. The IP LVN stated Resident #22 should have EBP in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 28 of 33 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 10/05/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few place, and was surprised the sign was not posted. She stated that her expectation was that staff followed enhanced barrier precautions. During an interview on 10/04/2024 at 9:52 AM, the IP LVN stated Resident #22's responsible party refused enhanced barrier precautions because they felt the use of a gown demeaned the resident. She stated that LVN #19 had just communicated this to her that day. The IP LVN stated LVN #19 should have communicated the refusal when it happened and documented the refusal in the record. The IP LVN stated she could not find where the refusal was documented. During an interview on 10/05/2024 at 10:01 AM, the Director of Nursing (DON) stated enhanced barrier precautions were meant to protect residents with wounds and indwelling devices from infections. The DON stated staff were expected to wear personal protective equipment when performing direct care with residents. The DON stated the IP LVN was responsible for identifying which residents required EBP. The DON stated the nursing staff was also expected to wear a gown, and gloves as ordered for enhanced barrier precautions. The DON stated the facility staff made a mistake by not implementing EBP for Resident #22 during the wound treatment. During an interview on 10/05/2024 at 10:50 AM, the Administrator stated enhanced barrier precautions were used for residents with wounds and certain indwelling devices. The Administrator stated if staff provided direct care to those residents' staff should have been wearing a gown and gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 29 of 33 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 10/05/2024 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview, facility document review, and facility policy review, the facility failed to consistently complete infection surveillance checklists as indicated in the facility's antibiotic stewardship program for residents identified with infections that received prescribed antibiotic therapy. This deficient practice had the potential to affect all residents who resided in the facility. Residents Affected - Many Findings included: A facility policy titled, Infection Prevention and Control Program, implemented 07/01/2023, revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy indicated, 6. Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. A facility policy titled, Antibiotic Stewardship Program, implemented 05/01/2024, revealed, It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of this program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The policy revealed, 2. The program includes antibiotic use protocols and a system to monitor antibiotic use. The policy revealed, a. Antibiotic use protocols: included, iii. The facility uses McGeer criteria [a set of guidelines for identifying infections] to define infections. A document titled, Infection Preventionist: Tasks/Tools/Training, created in 2023, revealed daily tasks included to, Review all new antibiotic orders, add antibiotic stewardship note and complete McGeer checklist. Document MD [medical doctor] notification and response for all infections (meets and does not meet criteria). The document included copies of the Revised McGeer Criteria for Infection Surveillance Checklist for urinary tract infections, respiratory tract infections, skin and soft tissue infections, and gastrointestinal infections. The facility's Infection Control Data Logs for the timeframe from January 2024 through September 2024, provided by the Infection Prevention (IP) Licensed Vocational Nurse (LVN), revealed resident names with types of infections, locations (units in the facility), antibiotic utilization, but did not indicate if the infections met the McGeer criteria except for one infection, in February 2024. Further review revealed the information provided by the IP LVN did not include any evidence of the McGeer criteria checklist being completed for any of the infections. During an interview on 10/03/2024 at 1:44 PM, the IP LVN stated she did the McGeer criteria in my head. The IP LVN said she was a new IP and was still learning. She stated that she wanted to do it correctly, but she had not had much guidance. During an interview on 10/05/2024 at 9:27 AM, the Director of Nursing (DON) stated her expectation was for the IP LVN to review any resident on an antibiotic following the McGeer criteria; and if they did not fit the criteria, the IP LVN should contact the physician to see whether the physician wanted the antibiotic to be continued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 30 of 33 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 10/05/2024 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 0881 During an interview on 10/05/2024 at 10:51 AM, the Administrator stated he expected the IP LVN to complete the McGeer criteria and contact the physician if the criteria was not met. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 31 of 33 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 10/05/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and facility policy review, the facility failed to ensure the responsible party/conservator for 1 (Resident #113) of 5 residents reviewed for vaccinations were educated and provided the opportunity to consent for a pneumococcal vaccination. Residents Affected - Few Findings included: A facility policy titled, Pneumococcal Vaccine (Series), implemented 06/14/2023, revealed, It is our policy to offer residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC [Centers for Disease Control and Prevention] guidelines and recommendations. The policy revealed, 3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. a. The individual receiving the immunization, or the resident's representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine. The policy further revealed, 4. The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record. An admission Record indicated the facility admitted Resident #113 on 05/21/2024. According to the admission Record, the resident had a medical history that included a diagnosis of schizophrenia. The admission Record revealed Resident #113 had a conservator. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/27/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the pneumococcal vaccine was offered to the resident and was declined. An Order Summary Report, with active orders as of 10/04/2024, revealed an order dated 05/21/2024, which indicated the resident may have a flu/pneumococcal vaccine. An admission Agreement and Consent to Treatment letter regarding Resident #113, dated 05/22/2024, revealed The above-noted person [Resident #113] has been placed under conservatorship. Resident #113's Amended Order Appointing Conservator of the Person General, filed 05/20/2024, revealed, 5. Conservatee [Resident #113] does not retain the right to consent to treatment, including psychotropic medication specifically related to remedying or preventing recurrence of [the resident's] grave disability; and 6. Conservatee does not retain the right to refuse or consent to routine medical treatment unrelated to his or her grave disability. A Pneumococcal Vaccine Consent Form dated 05/21/2024, revealed there was no resident name or date of birth on the form; however, the facility provided the form as Resident #113's. Per the form, the resident did not give consent for the vaccine and refused to sign the form. Resident #113's Progress Notes, dated 05/22/2024 at 3:17 PM, indicated staff offered the resident a pneumonia vaccine and the resident said no and walked away. The notes revealed the resident refused to sign the declination/refusal form. Further review revealed there was no documented evidence the facility contacted the resident's conservator for consent for the vaccine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 32 of 33 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 10/05/2024 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #113's interdisciplinary team (IDT) Progress Notes, dated 05/23/2024 at 3:50 PM, revealed the resident was unable to understand and make healthcare decisions, had disorganized thoughts, and was suspicious of medications. The notes revealed the resident had refused the pneumonia vaccine. During an interview on 10/03/2024 at 3:43 PM, Infection Prevention Licensed Vocational Nurse (IP LVN) stated she usually called a resident's conservator for consent for vaccinations and believed she had contacted Resident #113's conservator. She stated she understood the resident should not be signing the consent forms. However, the IP LVN stated that when she told Resident #113 that she was going to give them a shot, the resident said no and walked away. During an interview on 10/05/2024 at 9:27 AM, the Director of Nursing (DON) stated if a resident had a conservator, staff should contact the conservator for consent for treatment. During an interview on 10/05/2024 at 10:51 AM, the Administrator stated he expected staff to approach the conservator for consent before approaching for the resident for administration of the vaccination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 33 of 33