Health inspection·April 30, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1), Resident 1 ' s rights were not protected when Seroquel (Quetiapine -medication used to treat illness that affects thoughts and behavior) dosage was increased without physician ' s orders, indication, and no informed consent. Resident 1 ' s Seroquel ' s dose was increased to 50 milligram (mg) tablets given two times a day. This failure resulted in Resident 1 ' s right being violated due to unnecessary increase of medication dose. Residents Affected - Few Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted on [DATE], with diagnoses that included schizoaffective disorder (mental health disorder that affects mood, thoughts, and behavior), and unspecified dementia. Resident 1 ' s Minimum Data Set (MDS - resident assessment tool) dated 3/22/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident ' s cognitive status regarding attention, orientation, and ability to register and recall information) score of 06, (BIMS score of 0 - 7, suggest severe cognitive impairment). During a review of Resident 1 ' s Psychoactive Drug Review and Interdisciplinary Team Meeting (PDRITM) dated 11/12/24 indicated Treatment Intervention: Seroquel Oral tablet 25 mg (Quetiapine Fumarate) Give 25 mg by mouth two times a day for schizophrenia m/b [manifested by] visual and auditory hallucinations leading to distress. Resident 1 ' s PDRITM plan indicated to continue current prescribed medication. During a concurrent interview and record review on 4/30/25 at 12:21 p.m., with Director of Nurses (DON), DON reviewed Resident 1 ' s medication administration records (MAR) for Monitor episodes of Schizoaffective Disorder M/B [manifested by]: Visual Hallucinations Q [every] shift. Enter the # of episodes during your shift, for the months of November and December 2024. DON stated there was no indication that Resident 1 had an increase in episodes of hallucinations. During a review of Resident 1 ' s Order Summary Report for December 2024 indicated Seroquel Quetiapine Fumarate Oral Tablet 50 mg. Give 50 mg tablet by mouth two times a day for anxiety m/b [manifested by] visual and auditory hallucination lading [leading] to distress with an order date of 12/5/2024. The new order did not match the indication and monitoring of schizoaffective disorder manifestation. During a concurrent interview and record review on 4/30/25 at 12:58 p.m., with Assistant Director of Nursing (ADON), ADON stated that she took the verbal order to increase Resident 1 ' s Seroquel 50 mg twice a day and entered the new order to Resident 1 ' s electronic health record. ADON stated that the physician ' s order was given to her during the PDRITM in December 2024. ADON reviewed Resident 1 ' s PDRITM dated 12/17/24, and stated there was no order to increase Seroquel. ADON reviewed Resident 1 ' s electronic health record for December 12/5/2024, and could not find the indication that the physician had ordered to increase Resident 1 ' s Seroquel dose. During a review of facility ' s MAR for the months to 12/24 through 4/25, the MAR indicated Resident 1 was given Seroquel 50 mg tablet one tablet two times per day starting 12/6/2024 through 4/2/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 2 of 3 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 04/30/2025 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s Psychotropic Medication Consent V.2024 dated 02/24/2025 for Seroquel 50 mg tablet given two times a day. The written consent was blank for Resident 1 ' s Responsible Party, and there was no physician signature. During an interview on 4/30/25 at 1:15 p.m., with ADON, ADON stated she obtained verbal consent from Resident 1 ' s RP. ADON reviewed Resident 1 ' s Psychotropic Medication Consent V.2024 dated 02/24/2025, ADON stated she did not obtain and verify the consent with RP until 2/24/25, because the Resident 1 ' s RP was on vacation when Seroquel 50 mg tablet given twice a day was started on 12/6/25. ADON opened the Resident 1 ' s health care records binder, and written notes indicated Resident 1 ' s RP was in town until 12/14/24. During an interview on 4/30/25 at 12:21 p.m., with DON, DON stated after the provider obtained the informed consent from the resident or responsible (RP) party, the facility would verify and get a written consent. DON stated written consent Psychotropic Medication Consent form would be generated from the resident ' s electronic health record, and when the facility obtained the wet signature from the resident or RP, the consent form would be scanned and filed into the resident ' s electronic health record. During a review of facility ' s Psychotropic Medication Use policy statement indicated Residents do not receive psychotropic medication that are not clinically indicated and necessary to treat a specific condition documented in the medical record . Assessment and Evaluation of the Resident. 1. When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. The evaluation includes the resident ' s: a. physical, behavioral, mental, and psychosocial status; b. comorbid conditions; c. expressions or indications of distress; d. change in functional status; e. resident complaints, behaviors, and symptoms; and f. the state PASARR evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056052 If continuation sheet Page 3 of 3