Health inspection·October 21, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one (Resident 27) of five sampled residents received the necessary care to maintain good grooming and personal hygiene. Residents Affected - Few This failure resulted in Resident 27 having long fingernails to his left contracted hand and had the potential to create discomfort, especially into the palm of his hand. Findings: A review of Resident 27's face sheet indicated Resident 27 was originally admitted to the facility in 2016 with diagnosis of Lewy Body disease (a progressive brain disorder associated with a decline in thinking, reasoning, and ability to perform everyday activities). A review of Resident 27's Minimum Data Set (MDS, an assessment tool used to guide care), dated 8/23/22, indicated Resident 27 was sometimes able to understand others and rarely/never was understood by others. The MDS indicated Resident 27 was totally dependent on activities of daily living including personal hygiene with one-person physical assist. During a concurrent observation and interview on 10/18/22, at 10:25 a.m., with Certified Nursing Assistant 1 (CNA 1) and Restorative Nursing Assistant (RNA), Resident 27's left hand maintained a passive position of his fingers curled inward toward his palm (contracted). CNA 1 opened and uncurled Resident 27's left hand to show Resident 27's fingernails were untrimmed, thumb nail 1/8 inch long, index fingernail 1/4 inch long, and middle fingernail 1/8 inch long beyond the tips of his fingers. RNA stated fingernails were clipped by CNAs once a month or as needed. RNA further stated fingernails needed to be trimmed to prevent residents from scratching or poking into the skin of residents with contracted hands. During an interview on 10/20/22, at 9:45 a.m., with the Director of Staff Development (DSD), DSD stated CNAs are to check resident fingernails during showers, especially residents with contracted hands, and trim fingernails as needed in order to prevent infection or injury. Review of the facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails, revised on October 2010, indicated, The purpose of this procedure are to clean the nail bed, or keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 2 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to accurately label two of two (Resident 2 and Resident 25) sampled resident's medications when: Residents Affected - Few 1. For Resident 2, there was inaccurate and not identical labeling between the Medication Administration Record (MAR), Physician Orders, (PO), and medication administration card to facilitate safe administration of medication; and 2. For Resident 25, the Licensed Vocational Nurse 1 (LVN 1) did not label and date newly administered transdermal patch to Resident 25's skin. This failure had the potential for Resident 2 to receive the wrong medication dose of Seroquel (a medication used to treat certain mental/mood disorders) and for licensed nurses' inability to monitor patch administration was given to the resident as ordered. Findings: 1. A review of Resident 2's Face Sheet indicated resident was admitted to the facility in 2020 with diagnosis of major depressive disorder. A review of Resident 2's previous PO, dated 2/3/22, indicated an order for Seroquel (quetiapine) tablet 25 milligram (mg) two tabs twice a day for major depressive disorder. A recent order, dated 7/8/22 indicated, Increase Seroquel to 50 mg twice a day (BID). During a medication administration observation and concurrent interview with LVN 1 on 10/19/22, at 8:06 a.m., LVN 1 held Resident 2's medication administration card that indicated, Quetiapine Fumerate/Seroquel 50 mg tab - give one tablet by mouth twice daily. Transcribed on the MAR was a PO dated 2/3/22, that indicated, Seroquel (quetiapine) tablet; 25 mg; Amount to Administer: 2 tablets; oral twice a day. LVN 1 gave 50 mg tab from the medication administration card instead of 2 tabs of 25 mg tab. LVN 1 confirmed Resident 2's medication administration card label was not identical to the order on the MAR or the PO. LVN 1 stated it was important the PO and the medication administration card was accurate with identical labeling in order to avoid mistakes in administering the correct ordered dose to the resident. During a concurrent telephone interview and record review on 10/19/22, at 10:10 a.m., with the Consultant Pharmacist (CP), CP stated Resident 2 had a PO on 1/27/22 of Seroquel 25 mg tab 1 tab once daily for 1 week then increase to twice daily. On 2/3/22, Resident 2's PO was changed to Seroquel 25 mg tab 1 tab twice daily. On 7/8/22, Resident 2's most recent PO was changed to Seroquel 50 mg 1 tab twice daily which was why the medication administration card stated as indicated. During a concurrent interview and record review on 10/19/22, at 10:14 a.m., with the Assistant Director of Nursing (ADON), ADON stated, on 7/8/22, when the physician gave a new order for Resident 2's Seroquel, ADON had instructed the licensed nurses to administer the existing stock (of Seroquel 25 mg tab give 2 tabs equivalent to 50 mg) until supply was finished. ADON stated she failed to recap Resident 2's MAR correctly after the supply was used up to make it accurate and identical with the current PO of Seroquel. ADON stated this discrepancy had placed Resident 2 at risk of either being under-dosed or overdosed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 3 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of facility's policy and procedure (P&P) titled, Medications and Medication Labels, dated 2007, indicated, .Medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws .If the prescriber's directions for use or the label is inaccurate, the nurse may place a direction change, change of order-check cart, or similar label on the container indicating there is a change in directions for use, taking care not to cover important label information. When such a direction label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the prescriber's order for current information. If directions for use change, the provider pharmacy is informed prior to the next refill of the prescription so the new container will show an accurate label . 2. A review of Resident 25's Face Sheet indicated Resident 25 was admitted to the facility in 2019 with diagnoses of left thigh pain and other chronic pain. A review of Resident 25's PO, dated 3/16/22, indicated Lidocaine Pain Relief adhesive patch 4%, 1 patch topical (apply to skin) to both thighs and left shoulder, apply in the morning, remove at bedtime. During a medication administration observation and concurrent interview with LVN 1 on 10/19/22, at 7:30 a.m., LVN 1 held Resident 2's three lidocaine patches, opened, and applied one patch to each of Resident 25's thighs and another patch to Resident 25's left shoulder without labeling and initialing the patches. LVN 1 stated it was not necessary to date and initial the patches applied to Resident 25's skin since the licensed nurse on evening shift will remove the old patches and new patches will be applied by the day shift nurse in morning. During an interview on 10/19/22, at 10:30 a.m., with the ADON, ADON stated licensed nurses are not required to label and date transdermal patches since Resident 25's PO was to apply the Lidocaine patches in the morning and remove in the evening. A review of facility's P&P titled, Transdermal Delivery Systems (Patches), dated 2007, indicated, To administer medication through the skin by continuous absorption while the patch is in place with proper placement of the patch and care of the application sites .The application site should be clean, dry, and hairless area on the body for patch placement .Label patch with date and nurse's initial . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 4 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 record review, the facility failed to ensure pharmacy services policies and procedures were followed when: 1. Two partially tablet-filled medication administration cards, without expiration dates, were left out unattended on top of the medication cart; and 2. Licensed Vocational Nurse 2 (LVN 2) left the medication cart unlocked and unattended in the hallway. This failure had the potential for loss or misuse of medications and the potential to jeopardize the residents' health and safety and could cause other complications. Findings: 1. During a medication administration observation and concurrent interview on 10/19/22, at 8:06 a.m., LVN 1 held Resident 2's medication administration card that indicated Losartan Potassium 50 mg tab with 4 tablets left in the bubble pack and Resident 25's Furosemide 20 mg tab with 20 tablets left in the pack. Both labels on the medication administration cards were without expiration dates. LVN 1 confirmed she accidentally left the two medication cards unattended on top of the medication cart as she wanted to remind herself later to follow-up with pharmacy regarding the expiration dates. LVN 1 stated she was expected to store the medication administration cards at all times when out of view. During an interview on 10/19/22, at 10:14 a.m., the Assistant Director of Nursing (ADON) stated leaving medication administration cards unattended on top of the medication cart was not a safe practice because multiple adverse effects could occur. During a concurrent telephone interview and record review on 10/19/22, at 11:47 a.m., the Consultant Pharmacist (CP) stated the pharmacist who scanned the two medication administration cards did not notice the labels were missing the expiration dates. CP stated Resident 2's Losartan had an expiration date of 8/2023 while Resident 25's Lasix (a medication to treat fluid retention and swelling caused by heart failure, liver disease, kidney disease, or other medical conditions) expiration date was 9/2023. CP stated it could have been an easy fix had the pharmacist caught the scanned medication administration cards were without expiration dates before it got delivered to the facility. During an interview on 10/21/22, at 9:40 a.m., Director of Staff Development (DSD) stated licensed nurses (LNs) should be checking the five rights (right resident, right medication, right dose, right time, right route), during medication administration, including the expiration dates. DSD also stated receiving nurse should check pharmacy-delivered medications including expiration dates as expired medications may result in diminished efficacy. A review of the facility's policy and procedure (P&P) titled, Medications and Medication Labels, dated 2007, indicated, Medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws .Each prescription medication will be labeled to include .expiration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 5 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 or end-of-use date . Level of Harm - Minimal harm or potential for actual harm A review of the facility's P&P titled, Medication Packaging, dated 2007, indicated, .Medications are provided in packaging to facilitate proper storage and administration of the medication .Any problems noted with packaging of a medication are reported immediately to the provider pharmacy. Residents Affected - Some 2. During an observation of a hallway, on 10/18/22, at 10:35 a.m., the medication cart was unlocked and unattended. During a concurrent observation and interview with the Licensed Vocational Nurse (LVN) 2 on 10/18/22, at 10:36 a.m., LVN 2 returned then proceeded to lock the medication cart. LVN 2 confirmed, he forgot to lock the medication cart and stated it was wrong to leave medication cart unlock, a resident can open it easily and take medications. During an interview with the Assistant Director of Nursing (ADON) on 10/18/22 at 10:40 a.m., ADON confirmed LVN 2 left the medication cart unlocked and unattended. ADON further stated, it is a safety concern for residents. ADON also stated, Residents can get medications from the cart and take it. A review of the facility's Policy and Procedure (P/P) titled, Security of Medication Cart dated April 2007, the P/P indicated, under policy interpretation and implementation.4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 6 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and facility document review the facility failed to: 1. Ensure the Registered Dietitian (RD) provided frequent consultation to Food and Nutrition Services Director; and 2. Employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. These failures resulted in inadequate oversight of kitchen staff to ensure staff were conducting job duties in a safe and sanitary manner, resulting in the potential for food borne illness for 38 residents who ate food from the kitchen out of a facility census of 38. Findings: 1.Review of the Agreement to Provide Consultation Services dated April 22, 2022, indicated the purpose of the agreement was to provide a qualified RDN (Registered Dietitian Nutritionist) Consultant. The RDN's sole responsibility was to be guidance and council to the Nutrition Services Department. Responsibilities of the consultant included: provide consultation to administration regarding planning and priority setting based on initial and ongoing evaluation of the food service needs; review sanitation in accordance with current regulatory standards; and maintain and provide written reports for each visit to the facility. This would include any audits performed, summary of performance, goals, and recommendations to the facility. During the Federal Re-certification Re-visit survey conducted from 10/18/22 to 10/21/22, multiple issues were identified with storing and preparing food and a safe and sanitary environment and staff competency (cross-reference F802 and F812). In an interview on 10/20/222 at 10:05 a.m., the Food and Nutrition Services Director who went by the title of Dietary Manager (DM), stated since her two months of employment at this facility, the RD did not come to her with any issues of concern for kitchen safety and sanitation. In an interview on 10/20/22 at 12:41 p.m., the RD stated she did a monthly checklist in the kitchen. The RD showed the surveyors a multi-paged checklist she used that was not yet filled out. During this interview, safety and sanitation issues found in the kitchen were discussed. The first issue discussed was food was stored above 41 degrees in the walk-in refrigerator and there were three thermometers toward the back of the refrigerator, all indicating different temperatures (cross-reference F812). When asked what consultation RD would provide to the Dietary Manager (DM) in this situation, the RD stated she would buy a new thermometer but would not check the temperature of the food to make sure it was safe. RD stated she would not have thought of taking food temperatures in the refrigerator and she never took food temperatures in the refrigerator. Another issue found for the kitchen was food was stored outside (cross-reference F812). The RD stated food should not be stored outside and was aware the facility was storing food outside but did not think to recommend to the facility to store the food inside. The next issue discussed was the dish machine logbook indicated all dish machine temperatures that were logged twice a day were too low from June 2022 to October 2022 (cross-reference F812). The RD stated she thought she looked at the dish machine in July and August. RD stated she did not check to make sure the dish machine was working properly by checking temperatures and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 7 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many chemicals herself. RD stated she only looked at the logs to show staff were documenting dish machine temperatures. RD stated she was not aware the temperature of the dish machine was logged below the appropriate temperature from June to October. Another issue found in the kitchen was staff were not following proper cleaning and sanitizing procedures for cleaning surface areas in the kitchen such as countertops used to prepare food. Rags used for cleaning were not stored in a sanitary manner, soap was not rinsed off from surface areas being cleaned, and the required sanitizing step was not done (cross-reference F812). The RD stated facilities in general used the red bucket system, which meant the buckets were filled with sanitizer to clean food contact surfaces. RD stated she did not observe to see that this facility was using red buckets and sanitizer to sanitize surfaces. Another issue found was the juice machine was not being cleaned according to manufacturer's instructions. Wet rags that were not stored properly and were used to wipe the machine down and the machine was not sanitized (cross-reference

F812). The RD stated she did not know if staff cleaned the juice machine appropriately, this was not something she looked at. Another issue in the kitchen was resident diet tray cards were taped to trays and were not removed before cleaning in the dish machine and using the tray again. The tape holding the tray cards on the trays was peeling and rough. According to the Dietary Manager (DM) this practice was in place before she started working at the facility two months ago (cross-reference F812). The RD stated she was aware the tray cards were taped to trays and did not think they should be taped to trays because bacteria and germs could get under the tape. RD said she thought this was a new practice put into place by the new DM. In addition, according to the facility's policy and procedures, in the case the dish machine was not useable to wash and sanitize dishes and equipment, manual dish washing was to be done, which is in alignment with the standard of practice. It was found that staff did not know the proper procedures for manual dishwashing (cross-reference F802). The RD stated she did not know if kitchen staff knew how to manually wash dishes in the case of the dish machine breaking down. RD said she did not think staff should manually wash dishes because manually washing dishes would not get dishes clean enough. At the end of this interview, it was asked that the RD provide documentation showing her last three monthly sanitation reports as evidence they were conducted. The RD did not provide her sanitation reports and the facility did not have copies of her sanitation reports. Review of three Nutrition Consultant Reports dated 8/30/22, 9/20/22, 10/11/22, indicated evidence the RD did clinical related tasks and meal observations when on site such as initial assessments, annual assessments, quarterly reviews, significant weight changes, wound reviews, attended weight variance meetings, and dining/meal observations. All three documents did not show the RD conducted a sanitation check in the kitchen. The box titled sanitation, where it indicated a kitchen sanitation check was done, was blank. Also, there were no notes to indicate RD did a sanitation check. 2.Review of the job description titled, FNS [Food and Nutrition Services] Director dated 2018, indicated to be qualified for this position the qualifications under State and Federal regulations must be met. The California Health and Safety Code HSC 1265.4 indicated a licensed health facility must employ a full-time, part-time, or consulting dietitian. If that dietitian is less than full-time, the facility shall employ a full-time dietetic services supervisor who meets the requirements to supervise dietetic service operations. The dietetic services supervisor shall have completed at least one of the following requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 8 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 0801 Level of Harm - Minimal harm or potential for actual harm (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. Residents Affected - Many (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision. (7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6). According to the Certifying Board for Dietary Managers (CBDM), the credentialing agency for Association of Nutrition and Foodservice Professionals (ANFP), a Certified Dietary Manager (CDM), Certified Food Protection Professional (CFPP) has the education and experience to competently perform the responsibilities of a dietary manager and has proven this by passing the nationally recognized CDM Credentialing Exam and fulfilling the requirements needed to maintain certified status. To maintain the CDM, CFPP credential, one must complete and submit 45 hours of continuing education every three years. In a concurrent interview and review of the DM's certificate on 10/20/22 at 10:05 a.m., the DM stated she let her Certified Dietary Manager certificate expire and she did not renew it. A copy of a certificate titled The Certifying Board for Dietary Managers included the DM's name and was dated 10/31/2009. In an interview on 10/20/22 at 12:41 p.m., the RD stated she was contracted to work at the facility four hours a week. In an interview on 10/20/22 at 2:29 p.m., the Administrator stated was aware that DM's certification for CDM was not up to date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 9 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and facility document review, the facility failed to ensure kitchen staff competency when staff were not competent regarding their job duties. Residents Affected - Many This failure had the potential for tasks not being carried out in a safe and sanitary manner resulting in contamination of utensils and equipment used by residents and food borne illness for 38 residents who ate food from the kitchen out of a facility census of 38. Findings: During the Federal Re-certification Re-visit survey conducted from 10/18/22 to 10/21/22, multiple issues were identified with storing and preparing food in a safe and sanitary environment and staff competency as far as carrying out tasks in a safe and sanitary manner (cross-reference F812). In an interview with the Dietary Manager (DM) on 10/20/22 at 10:05 a.m., DM stated to evaluate if staff understood the training/in-services she provided, she asked questions. DM said in a group session, maybe only one person would answer so she was not sure if everyone understood the training. DM also stated there was a communication gap. DM said some do not speak English and she did not use an interpreter when giving a training. In an interview with DM on 10/21/22 at 10:34 a.m., DM stated there were no competency evaluations completed for the kitchen staff. Review of the job description titled, FNS [Food and Nutrition Services] Director dated 2018, indicated one of the qualifications for the position was to train staff how to properly prepare and serve food and how to keep the kitchen clean and sanitary. In addition, a responsibility included to assure all food and nutrition service staff were oriented per policy form. During an interview with Dishwasher (DW) on 10/19/22, at 9:50 a.m., DW demonstrated how to wash dishes in the event manual dishwashing was needed. DW showed how he would use two six gallons (a unit of volume measurement) bus tub bins, approximately six inches in height, filled with rinse and sanitizer solution. These two bus tub bins would be placed next to the dishwashing sink. The bin for sanitizer would be filled with approximately six gallons of water and five oz (ounces, a unit of volume measurement) of a quaternary ammonia-based sanitizer. DW stated he would not measure the final concentration of the sanitizer solution. DW stated dishware and cookware would be placed into the respective buckets. DW did not state how long dishware and cookware needed to be immersed in sanitizer solution. For oversized items that could not be fully immersed, DW stated he would use a scoop to pour rinse or sanitizer solution over the oversized items. During an interview with Dietary Manager (DM) on 10/19/22, at 11:15 a.m., DM stated the procedure for manual dishwashing. DM stated a six gallon bucket would be placed next to the two-compartment dishwashing sink located next to the stove. DM stated a three-compartment sink is ideal for manual dishwashing, but the kitchen did not have a three-compartment sink. DM stated the six gallon bucket would be filled with sanitizer solution. DM stated oversized items would be partially immersed for one minute and then rotated to immerse the unsanitized portion of the item. A review of the manufacturer's instructions on the container of the quaternary ammonia-based (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 10 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete sanitizer indicated for food contact sanitizing product was diluted at one to two oz. per four gallons of water and indicated a one minute immersion time on food contact surfaces. For six gallons of water this would be 1.5 ounces to 3 ounces of sanitizer added to sanitize food contact surfaces. A review of facility's policy and procedure titled, Manual Dishwashing, dated 2018, indicated the procedure for manual dishwashing utilized a bin that allows pots and pans to be fully submerged. The procedure indicated manufacturer recommended concentration was measured and used for sanitizer step. Event ID: Facility ID: 056370 If continuation sheet Page 11 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure 38 of 38 sampled residents had food prepared and stored in a safe and sanitary manner when: Residents Affected - Many 1. Internal temperature of foods was above 41°F in the walk-in refrigerator and inaccurate thermometers were used to monitor temperatures of the refrigerator; 2. frozen meat was not thawed with proper procedures; 3. thawed meats and produce were not stored appropriately in the refrigerator; 4. staff did not perform hand hygiene moving from dirty to clean tasks; 5. staff did not follow manufacturer instructions for cleaning and sanitizing equipment; 6. food and supplements were stored outside of building without temperature control and exposed to pests; 7. moldy and unusable foods were not discarded; 8. staff did not follow sanitization steps for cleaning countertops; 9. dishwashing machine temperature logs indicated wash and rinse temperatures were below manufacturer specification for more than four months; 10. walk-in freezer floor had food debris and red liquid on floor; 11. opened and thawing foods were found unlabeled in walk-in refrigerator; 12. air vent above food preparation area was dirty; 13. resident diet information was taped to tray; 14. a cracked food container lid was in use and unusable cookware was found in kitchen; 15. air gaps were not present for two sinks in the food preparation area; and 16. staff did not use appropriate sink for handwashing. These failures placed the facility's 38 residents who received food from the kitchen at risk of foodborne illness. Findings: 1. During an interview with the Dietary Manager (DM) and a concurrent observation of the inside of the walk-in refrigerator on 10/18/22, at 10:20 a.m., three thermometers were observed on a shelf in the back of the refrigerator. The temperatures on the thermometers read 21 degrees Fahrenheit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 12 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 (°F ), 38 degrees °F, and 48 degrees °F. DM confirmed the different temperatures indicated on the thermometers. The surveyor's calibrated thermometer was left in the refrigerator next to the facility's thermometer. Items stored in the refrigerator included temperature control for safety foods (TCS food, food that require time/temperature control for safety to limit microorganism growth or toxin formation) such as milk, thawing raw chicken, thawing raw porkchops, cooked chopped ham, sliced tomatoes, cooked eggs, and facility prepared corn salad. An observation on 10/18/22, at 10:35 a.m., showed the surveyor's thermometer read 45 degrees F when measuring refrigerator temperature. During a concurrent observation and interview on 10/18/22, at 1:10 p.m., with DM, the DM used a food thermometer to check the internal temperature of various foods in walk-in refrigerator: -Corn salad: 45.2°F -Boiled and peeled eggs: 44.6°F -Milk: 42.2°F -Margarine: 46.5°F DM stated the internal temperatures of the foods taken were at an unsafe temperature. There were no longer three thermometers in the refrigerator. The one thermometer found in the back of the walk-in refrigerator indicated the temperature was 32°F. The surveyor's calibrated thermometer was placed next to the facility's thermometer for 10 minutes and the temperature read 44.2 degrees °F . During an interview on 10/18/22, at 1:15 p.m., with Dishwasher (DW), DW stated the milk was delivered on 10/18/22 and put away in the walk-in refrigerator at approximately 9:30 a.m. During an observation on 10/19/22, at 10:11 a.m., a thermometer in the walk-in refrigerator indicated the temperature was 30°F. Surveyor thermometer indicated walk-in refrigerator temperature was 41.4°F. Foods observed in the refrigerator from the previous day still remained in the refrigerator such as the diced ham. During an interview on 10/20/22, at 12:45 p.m., with Registered Dietitian (RD), RD stated she had previously completed a kitchen inspection in August 2022 but did monthly kitchen sanitation checks. RD stated she did not find walk-in refrigerator temperatures to be out of range, but she did not check the internal temperatures of foods stored in the walk-in to ensure the thermometers in the refrigerator were correct. RD stated she could not recall location of thermometers in walk in refrigerator and said internal thermometers should be located on shelves at the front of the refrigerator close to the door, not the back. A review of FDA (Food and Drug Administration) Food Code, dated 2017, indicated that except during preparation, cooking or cooling, temperature for foods held in the refrigerator be 41°F or less. According to the 2017 FDA Food Code Annex, the placement of the temperature measuring device is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 13 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 important. If the device is placed in the coldest location in the storage unit, it may not be representative of the temperature of the unit. Food could be stored in areas of the unit that exceed Code requirements. Therefore, the temperature measuring device must be placed in a location that is representative of the actual storage temperature of the unit to ensure all TCS foods are stored at least at the minimum temperature required. Residents Affected - Many 2. During an observation and interview on 10/18/22, at 11:45 a.m., with DM and [NAME] 1, two packaged pot roasts on a shallow tray were in a kitchen sink at room temperature. [NAME] 1 stated the two roasts had been thawing for more than six hours in the sink. DM stated the pot roasts should be submerged with running water. DM placed the meats into a large container and submerged them under running water. When the containers were full of water, the meats were not fully submerged in water. DM measured the internal temperatures of the pot roasts which were 48.4°F and 46.4°F. Both pot roasts were soft to the touch with liquid juices inside plastic packaging. [NAME] 1 was unable to describe proper procedure for thawing meat. DM stated proper thawing procedure was to place frozen product submerged under running water. DM stated food was above safe temperature and food would be discarded. A review of facility policy and procedure (P&P) titled, Thawing of Meats, dated 2018, indicated frozen meat is thawed under running, potable water and the meat can't remain in the temperature danger zone for more than four hours including the time to thaw. FDA Food Code, dated 2017, indicated thawing foods be submerged under running water and not allowed to rise above 41°F for more than four hours including the time food is exposed to running water. 3. During a concurrent observation and interview on 10/18/22, at 10:35 a.m. with DM, three containers were inspected on a bottom shelf of the walk-in refrigerator. The containers were stored side by side and came into contact with one another. The first container was a cardboard container with opened packages of lettuce. The second container was plastic and held thawing hot dogs and thawing pork chops in their original packaging. The third container was plastic and had thawing chicken thighs, thawing diced chicken, thawing bacon all in original packaging, as well as cooked diced ham in a previously opened plastic bag. Juices were found in the bottom of the third container. DM stated the meats should not be thawing with different meats, and produce should not be stored on the same level as thawing meat. DM stated there is risk of cross-contamination. DM said raw chicken is especially dangerous and needed to be stored separately. DM stated the cooks and herself were responsible for ensuring proper storage and thawing of food products in the walk-in refrigerator. A review of facility policy and procedure (P&P) titled Thawing of Meats, dated 2018, indicated drip pans be used under thawing food to avoid drippings from contaminating food. The P&P further indicated food meats from difference animals be kept separate to avoid cross contamination. A review of FDA Food Code, dated 2017, indicated food be protected from cross contamination by separating raw animal foods from fruits and vegetables before they are washed. 4. During an observation on 10/19/22, at 9:15 a.m., DW was processing dishware in the dirty sink of the dish washing area. Dirty dishes were placed into a dishrack and the rack was inserted into a dishwashing machine. After the dishwashing machine processed the dishes, DW, without performing hand hygiene, moved to clean side of the dish washing area and removed the rack of clean dishes from dish washing machine. DW removed clean items from the rack and rearranged them on a different rack. DW (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 14 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 was observed to perform same actions in subsequent observations of dishwashing for the next 15 minutes. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/19/22, at 9:30 a.m., with DW, DW stated he only washed his hands in the dishwashing sink when he entered and exited the kitchen. DW stated he did not need to wash his hands when moving between the dirty and clean side of the dishwashing area. Residents Affected - Many During an interview on 10/19/22, at 9:40 a.m., with DM, DM stated the expectation of the DW was to wash his hands when moving between the dirty and clean side of the dish washing area. During an observation and interview on 10/20/22, at 9:45 a.m., with Dietary Aide (DA), DA was observed cleaning the juice dispensing machine in the kitchen. DA was observed wearing disposable gloves performing food preparation prior to starting the juice machine cleaning procedure. DA did not remove those gloves prior to starting the cleaning procedure. DA removed the drip tray from the juice machine and entered the dirty side of the dishwashing area and processed the drip tray in the dishwashing machine. DA rinsed his gloved hands with water and dried it with paper towels. DA disposed of the paper towels in a trash can and touched the surface of the trash can lid. Without changing gloves or performing hand hygiene, DA removed the drip tray and dried the drip tray using paper towels. DA disposed of the paper towels in a trash receptacle and again touched the surface of the trash can lid. Without changing glove or performing hand hygiene, DA reinstalled drip tray to juice machine. During an interview on 10/20/22, at 12:45 p.m., with RD, RD stated during a previous kitchen inspection, she assessed the handwashing technique of kitchen staff, but she did not observe if staff were following policy about when to perform hand hygiene. A review of facility P&P, titled Hand Washing Procedure, dated 2018, indicated staff wash hands with soap and water after handling soiled dishes and utensils, and after touching trash can or lid. A review of the FDA Food Code, dated 2017, indicated staff wash their hands after handling soiled equipment or utensils, during food preparation to prevent cross contamination, after engaging in activities that contaminate the hands, and before donning gloves. In addition, single-use gloves shall be used for only one task such as working with ready-to-eat food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 5. During a concurrent observation and interview on 10/20/22, at 9:45 a.m., with DA, DA demonstrated how to clean the juice dispensing machine. DA was observed wearing disposable gloves performing a different task prior to starting the juice machine cleaning procedure. DA did not remove those gloves prior to starting the cleaning procedure. DA used a cloth rag which was sitting in the food preparation sink. The rag was wet with water. DA wiped down the exterior and interior surfaces of the juice machine with the wet rag. DA removed the nozzles of the juice machine and rinsed the nozzles in the sink with running water. DA then dried the nozzles using paper towels before reinstalling the nozzles back onto the machine. DA removed the drip tray from the juice machine and entered the dirty side of the dishwashing area. DA processed the drip tray in the automatic dishwashing machine. Without changing gloves, DA removed the drip tray and dried the drip tray using paper towels before reinstalling into the juice machine. DA stated he cleaned the juice machine three times a week. DA stated he rinsed the nozzles with water but did not use sanitizer to clean the nozzles. During an interview on 10/20/22, at 10:05 a.m., with DM, DM stated DA did not follow instructions for cleaning the juice dispensing machine that were located on the inside of the juice machine front (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 15 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 door. DM stated DA flushed the nozzles and did not follow sanitizer step when cleaning the nozzles of the juice machine. DM stated machine was clean but not sanitized. DM also confirmed the rag DM used to wipe the machine was a rag soaked in water. During an interview on 10/20/22, at 12:45 p.m., with RD, RD stated the juice machine appeared clean in a previous inspection but did not observe staff cleaning the juice machine. A review of the juice dispensing machine's manufacturer daily cleaning instructions indicated an initial flush with water from the machine. The instruction then indicated nozzles are cleaned with hot water, sanitizer and rinsed. The instructions indicated the exterior and interior surfaces are wiped with clean disposable towels. According to the 2017 FDA Food Code, cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution. 6. During a concurrent observation and interview on 10/18/22, at 9:45 a.m., with DM, two metal wire food storage racks were found outside of the facility near the back kitchen exit. The shelves were covered with a plastic zip cover which was open on the bottom. What resembled decomposing food debris was found on the ground beneath the shelves. The top of the rack cover had a layer of gray debris and what resembled dried leaves. DM stated the food stored outside was not temperature controlled. On one shelf, liquid supplements in original cardboard packaging were found. The packaging indicated the supplements be kept from extreme temperatures. On the other shelf, two plastic containers with lids were found. One container had russet potatoes, and another had red potatoes. Additional empty containers were also stored on this shelf. The empty containers contained old food debris. DM stated the containers were dirty and it was staff responsibility to maintain cleanliness of containers. DM confirmed the storage rack surroundings had to be cleaned, such as under the rack. DM stated the local weather could produce temperatures and moisture levels that would affect food stored outside. In addition, an opened cardboard box filled with bananas was on a cart outside the walk-in refrigerator. DM stated the bananas were stored outside for a couple of days before storing in the walk-in refrigerator because when bananas were delivered moist. DM stated storing them outside allowed them to dry before placing into the refrigerator. DM stated storing the food outside was the facility's usual practice but she did not think it was okay for the food to be stored outside. During an interview on 10/20/22, at 12:45 p.m., with RD, RD stated she had noticed the food was being stored outside and could not be temperature controlled. RD further clarified she did not make a recommendation to relocate food inside the facility. A review of FDA Food Code, dated 2017, indicated food be protected from contamination by storing food in a clean, dry location where it is not exposed to dust or other contamination. In addition, one function of a food establishment is storing food. The perimeter walls and roofs of a food establishment shall effectively protect the establishment from weather and the entry of insects, rodents, and other animals. 7. During a concurrent observation and interview on 10/18/22, at 9:40 a.m., with DM, two containers of potatoes on the outside shelves were inspected with DM. Both containers held over 20 potatoes each. At least four potatoes had a white fuzzy matter on the surface, and most of the russet potatoes were sprouting. DM confirmed some of the potatoes were moldy and they were sprouting. DM stated the [NAME] and herself were responsible for inspecting and discarding moldy or unusable food as soon as they find it. A plastic container of more than 20 green bell peppers in the walk-in refrigerator was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 16 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 inspected. All of the green bell peppers had numerous spots of black rot. Some of the peppers had a gray fuzzy matter on the surface. The DM confirmed the peppers were covered in black spots and some had mold. DM stated those should not be used. An observation and concurrent interview with [NAME] 1 on 10/18/22, at 10:52 a.m., showed a bowl of green peppers covered with black spots on the countertop inside the kitchen. [NAME] 1 stated had to use a bell pepper for the rice pilaf on the menu that day and tried to find the best one to use. During an interview on 10/20/22, at 12:45 p.m., with RD, RD stated staff were expected to discard unusable food immediately. A review of facility P&P titled Storing Produce, dated 2018, indicated boxes of produce be checked for rotten, spoiled items. The P&P further indicated if food items were rotten or spoiled, the items would be discarded. 8. During a concurrent observation and interview on 10/19/22, at 9:50 a.m., with [NAME] 2, [NAME] 2 demonstrated how she filled red buckets to clean countertops. A red bucket filled with white rags but no liquid was in the food preparation sink. The rags were wet. [NAME] 2 removed the wet rags from the red bucket then filled it with soap and water. [NAME] 2 then placed the wet cloth rags back into the red bucket. [NAME] 2 stated she then uses those rags with soap and water to wipe down counters and other surfaces throughout the work shift. [NAME] 2 stated she used a towel to dry the surfaces after she wiped them with the wet, soapy rags. [NAME] 2 stated she did not have a sanitizer step when cleaning kitchen surfaces. [NAME] 2 stated she did not add bleach or sanitizer to the bucket, and rarely used bleach for cleaning. [NAME] 2 further clarified she used bleach to remove grease stains from surfaces, but not for general cleaning. During an interview on 10/19/22, at 10:00 a.m., with DM, DM stated [NAME] 2 had not followed proper procedure for cleaning counter tops. DM stated proper procedure was to fill red bucket with water and sanitizer and to use a green bucket with water as a rinse. A review of facility's P&P titled, Shelves, Counters, and Other Surfaces including Handwashing Sinks Cleaning Procedure, dated 2018, indicated surfaces are washed with a warm detergent solution, rinsed with water, wiped dry with a clean cloth, and sprayed with sanitizer. According to the 2017 FDA Food Code, cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution. 9. During an observation and interview on 10/18/22, at 9:10 a.m., with DW, the dishwashing machine was observed through multiple cycles. A thermometer located on the dishwashing machine indicated water temperatures of 115°F for the wash cycle and 120°F for the rinse cycle. DW stated the dishwashing machine was a low temperature unit, and the temperatures of the wash and rinse cycle should be between 115°F and 120°F. DW stated he records the temperature of the wash and rinse cycle and concentration of chemical sanitizer on a Dish Machine Temperature Log. DW also demonstrated how he checked the sanitizer strength of the dish machine. DW ran the dish machine through a wash and rinse cycle then placed a chemical sanitizer test strip inside the water draining from the machine. DW compared the color of the strip to the color chart located inside the test strip container. DW stated the chemical was okay according to the color. In an interview on 10/19/22, at 2:30 p.m., DM stated the sanitizer strength of the dish machine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 17 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 should be checked by placing the chemical test strip on a plate after a completed rinse cycle, not in the draining water from the dish machine. During a concurrent record review and interview on 10/19/22, at 2:30 p.m., with DM, the Dish Machine Temperature Logs, dated June 2022 to October 2022, for the dishwashing machine were reviewed. The logs indicated the dishwashing machine operated below 120°F every day from June 2022 to October 2022. DM stated the water temperature of the wash and rinse cycle should be above 120°F. DM stated she was responsible for reviewing the temperature logs and correcting issues with the dishwashing machine function but had not realized the temperatures were below manufacturer specification. During a concurrent observation and interview on 10/20/22, at 8:45 a.m., with DM, DM identified a manufacturer label on the dishwashing machine which indicated the minimum temperature for the wash and rinse cycle should be no lower than 120°F. A review of facility P&P titled, Dish Washing, dated 2018, indicated low-temperature machines operate at manufacturer's recommendation posted on the machine. The P&P further clarified low temperature machines should operate at a temperature range of 120°F - 140°F. In addition, a temperature log will be kept and maintained by the dishwashers to assure the dish machine is working correctly. Also, for a low temperature dish machine, the chlorine sanitizer strength is to be 50-100 ppm on dish surface of the final rinse. A review of FDA Food Code, dated 2017, indicated temperature of wash solution in low temperature dishwashers that use chemicals to sanitize may not be less than 120°F. 10. During a concurrent observation and interview on 10/18/22, at 10:00 a.m., with DM and DW, the walk-in freezer was inspected with DM. What resembled food debris and red, dried liquid film was found on the freezer floor. DM stated the walk-in freezer floor should be cleaned by DW but did not know when it was last cleaned. DW stated the walk-in freezer floor was last cleaned on 10/12/22 but did not document when it was done. DW stated the floor was cleaned one time per week when the delivery came in. In an interview and concurrent observation on 10/20/22, at 10:05 a.m., DM stated a cleaning schedule was recently developed. DM pointed out the section for freezer cleaning on the schedule which indicated the freezer floor to be cleaned one time per week. DM stated she guessed the cleaning schedule should also say clean as needed in the case the floor became dirty between the weekly cleaning. A review of facility P&P titled, Refrigerator and Freezer, dated 2018, indicated spills should be cleaned up immediately. 11. During a concurrent observation and interview on 10/18/22, at 10:00 a.m., with DM, DM confirmed following food items were found in the walk-in refrigerator without an appropriate label to indicate when they were opened or expired: one opened package of shredded cheddar cheese, one opened package of shredded mozzarella cheese, and one opened package of diced ham. In addition, thawing meats were not dated to indicate when they were placed in the refrigerator to thaw or when they were to be used including: two boxed packages of frozen chicken, one boxed package of frozen bacon, two boxed packages of frozen hot dogs, and two boxed packages of frozen pork chops. DM stated it was the responsibility of the cooks and herself to ensure food products were labeled with an opened or expiration date when opened or placed in the refrigerator to thaw. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 18 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 During an interview on 10/18/22, at 10:20 a.m., with [NAME] 1, [NAME] 1 stated he placed the meats in the walk-in refrigerator, but did not label with a date when he put them in. [NAME] 1 stated it was his responsibility to label the frozen foods with when he placed the frozen meats into the walk-in refrigerator. During an interview on 10/18/22, at 10:25 a.m., with [NAME] 2, [NAME] 2 stated she opened the two packages of shredded cheese and the package of diced ham on 10/17/22, but did not label them. During an interview on 10/20/22, at 12:45 p.m., with RD, RD stated food labeling was a high priority for her. A review of facility P&P titled, Procedure for Refrigerated Storage, dated 2018, indicated leftovers and open packages of refrigerated foods needed to be labeled and dated with open date. A review of facility P&P titled, Thawing of Meats, dated 2018, indicated meats thawing in refrigerator should be labeled with pull and use by date. 12. During an observation on 10/18/22, at 9:20 a.m., a ceiling vent fan was observed with speckled, dark brown substances over a significant amount of the vent surfaces. The ceiling vent fan was directly over a counter where a juice dispensing machine and food preparation takes place. During an interview on 10/19/22, at 8:55 a.m. with Maintenance Supervisor (MS), MS stated housekeeping supervisor was responsible for cleaning the ceiling vent fan. During an observation and interview on 10/19/22, at 11:30 a.m., with Housekeeping Supervisor (HS) and maintenance staff (M1), the ceiling vent fan in the kitchen was observed with dark brown substances on the surfaces. HS stated the fan was dirty and maintenance was responsible for cleaning the ceiling vent fan. HS stated he was not responsible for cleaning indoor vents. M1 stated maintenance was responsible for cleaning the ceiling vent fan and it was last cleaned on February 2022. M1 stated he did not document the time and there was no cleaning schedule for the vents. M1 stated there was no policy or schedule for cleaning ceiling vents. A review of FDA Food Code, dated 2017, indicated intake and exhaust air ducts shall be cleaned so they are not a source of contamination by dust, dirt and other materials. 13. During an observation on 10/18/22, at 12:45 p.m., the trays which resident meals are served on were observed to have a tray card with resident diet information taped to the upper surface of the tray. The tape was peeling and rough. Trays with tray cards still affixed were processed by dishwasher. During an interview on 10/20/22, at 11:30 a.m., with DM, DM stated she was aware of resident tray cards taped to tray. DM stated it was an infection risk because tape could not be adequately sanitized. DM stated she thought taping the tray cards to the trays started during the pandemic. During an interview on 10/20/22, at 12:45 p.m., with RD, RD stated she had been aware of the tray cards but did not make recommendations to change the practice. RD stated she thought bacteria and germs could get under the tape. RD stated she thought it was a new practice DM started. Review of the facility's P&P titled, Sanitation dated 2018, indicated all utensils and equipment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 19 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. According to the 2017 FDA Food Code, Food-contact surfaces are to be smooth and free from open seems, inclusions, pits, and similar imperfections. In addition, nonfood-contact surfaces of equipment are to be free of unnecessary projections and crevices and designed and constructed to allow easy cleaning. Also, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of corrosion-resistant, and smooth material. 14. During an observation and interview on 10/18/22, at 10:15 a.m., with DM, a lid with multiple cracks 2-3 inches in length was used to cover a container of cake in the walk-in refrigerator. DM stated the lid was not suitable to prevent contamination and removed the lid from use. During an observation and interview on 10/18/22, at 11:05 a.m., with [NAME] 1, four pans for cooking were found on a storage shelf near the kitchen stove. One non-stick pan had the black non-stick food contact surface worn off revealing a brown layer underneath. Wear marks extending to the bare metal were on the food contact surface, and another non-stick pan had the black non-stick food contact surface worn off to the bare metal underneath. One steel pan had a build-up of hard residue and pitting on the cooking surface. Another steel pan had pits in the metal, deep wear marks and blackened discoloration around the rim of the cooking surface. Rubber material on the hand of the same pan was coming apart. [NAME] 1 stated the four pans were not usable for cooking and should have been removed from service. During an interview on 10/20/22, at 10:05 a.m., with DM, DM stated she was responsible for identifying and removing unusable equipment from use. During an interview on 10/20/22, at 12:45 a.m., with RD, RD stated unusable cookware needed to be discarded. Review of the facility's P&P titled Sanitation, dated 2018, indicated all utensils and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. A review of FDA Food Code, dated 2017, indicated multi-use food-contact surfaces be smooth, free of breaks, open seams, cracks, chips, pits and similar imperfections. Also, food-contact surfaces are to be clean to sight and touch, and food contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. In addition, nonfood-contact surfaces are to be free of unnecessary crevices. 15. During an observation on 10/18/22, at 10:45 a.m., two food preparation sinks in the kitchen were found to have the drainpipe directed into the wall of the kitchen. Further inspection indicated there was no air gap for those two sinks. During an interview with MS on 10/19/22, at 9:00 a.m., the MS stated the drainage plumbing of the two sinks went into the wall and did not terminate in an air gap. According to the 2017 FDA Food Code, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 20 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 16. In an interview and concurrent observation with DW on 10/19/22, at 9:15 a.m., DW stated the only time he washed his hands was when he entered the kitchen. DW stated he used the sink which was part of the dish machine counter. DW demonstrated washing his hands in this sink. DW used soap from a soap dispenser attached to the wall above this sink. There was a handwashing sink 4-5 steps away from the dish machine sink. Residents Affected - Many In an interview on 10/20/22, at 12:40 p.m., the RD stated staff should only wash hands in the handwashing sink and not in the sink in the dish machine counter. RD stated she did not know there was a soap dispenser by the dish machine sink. According to the 2017 FDA Food Code, food employees are to clean their hands using a handwashing sink and a handwashing sink, and a handwashing sink may not be used for other purposes other than handwashing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 21 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 observation, interview, and record review, the facility failed to implement infection prevention and control practices for one resident for a census of 38 when the following was observed: Residents Affected - Some 1. Registered Nurse (RN) 1 did not perform proper hand hygiene during wound care; 2. RN 1 did not use sterile gloves during wound care; 3. RN 1 did not sanitize overbed table before wound care; 4. RN 1 did not sanitize reusable supplies with alcohol; and 5. RN 1 did not dispose of contaminated supplies. These failures created a risk for cross-contamination (transfer of bacteria or other microorganisms from one substance to another) that could result in serious illness. Findings: During a concurrent observation and interview on 10/19/22, at 10:05 a.m., RN 1 was observed performing a resident's wound care. RN 1 was observed donning (put on) gloves, removed old dirty dressing from resident's wound, doffed gloves (remove), donned on clean gloves then cleansed mid-upper back wound with Bermal (cleansing spray) without performing hand hygiene. RN 1 doffed gloves again, then donned new gloves without performing hand hygiene. RN 1 then proceeded to apply non-sterile dressing to the resident. RN 1 brought the tray containing unused dressing, gloves, two packets of Bacitracin (ointment), cleansing spray, three rolls of medical tape and contaminated scissor back inside treatment cart. RN 1 stated, she will use the same supply for treatment of another resident. RN 1 acknowledged this was not acceptable practice. During an interview on 10/19/22, at 10:48 a.m., with the Director of Staff Development/Infection Preventionist (DSD/IP), the DSD/IP acknowledged RN 1 did not follow infection control practices by not performing hand hygiene in between glove changes and when RN 1 did not dispose of contaminated supplies. A review of facility's Wound Care policy and procedure (P&P) dated, 10/2010, the P&P indicated, 5 .Wash and dry your hands thoroughly. 6. Put on gloves.10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound.14. Be certain all clean items are on clean field.19. Use clean field saturated with alcohol to wipe overbed table.21. Wipe reusable supplies with alcohol as indicated (i.e., outsides of containers that were touched by unclean hands, scissor blades, etc.). 22. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 22 of 23 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 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement policies and procedures to ensure all staff were fully vaccinated for COVID-19 (a highly infectious respiratory disease) when staff vaccination rate was less than 100% and Certified Nurse Assistant (CNA) 2 did not have a non-medical exemption for the COVID-19 vaccine. Residents Affected - Few This failure resulted in staff not receiving COVID-19 vaccine series and boosters without valid exemption. Findings: During a concurrent interview and record review, on 10/19/22, at 1:48 a.m., with Director of Staff Development/Infection Preventionist (DSD/IP), COVID-19 Staff Vaccination Status for Providers, dated 10/8/22, indicated as follows: i. Completely vaccinated - 53 ii. Granted non-medical exemption - 1 iii. Not vaccinated without exemption without exemption/delay - 1 iv. Total staff - 55 DSD/IP confirmed, CNA 2 did not have non-medical exemption for the COVID-19 vaccine. A review of facility's policy and procedure (P&P) titled, CORONAVIRUS DISEASE (COVID-19), Vaccination of Staff, dated 11/2021, indicated under religious exemptions 6. Requests for religious exemption must be completed on the Request for Religious Exemption Form. The information on the form is used to assess whether the request is based on a sincerely held religious believe and is used to determine eligibility for religious exemption. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 23 of 23