Health inspection·June 23, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility policy and procedure titled, Air temperature Readings, dated 4/16/2001 indicated, the acceptable range for air temperature is 71 degrees to 81 degrees F. 2. During an observation and concurrent interview with Resident 59 on 6/21/22 at 2:16 p.m., Resident 59's bed footboard was broken with one side almost touching the floor. Resident 59 stated the bed footboard had been broken for three weeks now, and the Certified Nursing Assistants (CNAs) knew about it but management has not done anything yet. Resident 59 further stated the broken bed footboard was a tripping hazard. 3. During a concurrent observation and interview on 6/21/22, at 9:15 a.m., with Resident 58, the closet doors in the room did not close, exposing personal items. Resident 58 indicated the doors have never closed. Further observations in multiple rooms revealed the closet doors in the rooms did not close for Residents 56, 36, 60, 41, 64, 13, 118, 119, 40, 62, 48, and 10. 4. During a concurrent observation and interview on 6/21/22, at 9:17 a.m., with Resident 58, the built in dresser drawers in the room were covered with a thick, textured paint and were difficult to open and close and were dirty inside. Resident 58 indicated the drawers stick and sometimes cannot be opened. Subsequent observations in multiple rooms revealed the same issue with the built in dresser drawers for Residents 53, 36, 60, 41, 12, 18, 118, 119, 40, 62, 48, and 10. 5. During an interview on 6/21/22, at 10:28 a.m., with Resident 52, Resident 52 indicated the lobby patio door does not operate when the handicap access buttons are pushed, and they were unable to use the door. During a concurrent observation and interview on 6/21/22 at 10:58 a.m., with the Regional Director of Maintenance (RDM), in the lobby, the automatic patio door did not open when the handicap access buttons were pushed. RDM indicated the door was locked at night and had not been unlocked in the morning. RDM unlocked the door, but the handicap access buttons continued to be nonfunctional. During a concurrent observation and interview on 6/23/22 at 9:45 a.m., with the Administrator (Adm), in the lobby by the automatic patio door, the door was closed. Adm indicated the door was new and the motion sensor that opens the door was not working. The handicap access buttons do not work with the new door because there are motion sensors both inside the lobby and in the patio that operate the door. Adm confirmed the door was not functional and indicated needed to be repaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 37's Resident Face Sheet indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included quadriplegia (paralysis from the neck down to all four limbs), contractures of the right and left arm, and right and left lower leg. Review of Resident 37's Minimum Data Set Assessment (MDS, an assessment tool used to direct resident care) dated 6/3/22 indicated Resident 37 required extensive staff assistance for turning/repositioning while in bed, and required total staff assistance with all other Activities of Daily Living (ADL) like personal hygiene, toileting, eating, and bathing. Resident 37 had functional limitations on both upper and lower extremities that interfered with daily function and placed Resident 37 at risk for injury. Review of Resident 37's Physician Order Report for 6/1/22-6/23/22 indicated the following orders dated 6/13/22: - Restorative Nursing Assistant (RNA) Program for Passive Range of Motion (PROM, when a therapist or provider causes movement to a joint) to bilateral (left and right) upper extremity twice weekly as tolerated for 90 days. - RNA Program for bilateral lower extremity twice weekly as tolerated for 90 days. - RNA to apply ankle splint to bilateral lower extremity twice weekly for 90 days, up to four hours a day, as tolerated. - RNA to apply hand splint to bilateral upper extremity twice weekly for 90 days, up to four hours a day as tolerated. - RNA to apply knee splint to bilateral lower extremity twice weekly for 90 days, up to four hours a day as tolerated. Review of Resident 37's Other care plan dated 6/13/22 indicated RNA program for PROM to bilateral lower extremity twice weekly as tolerated for 90 days, ROM of extremities as ordered and for RNA to apply ankle splint to both lower extremity twice weekly for 90 days up to four hours daily. During an observation and concurrent interview with Resident 37 on 6/20/22 at 12:15 p.m., Resident 37 was unable to move both upper and lower extremities. Resident 37 stated receiving range of motion exercises but not sure if it was from rehabilitation department or from RNA. Resident 37 did not have any splint on upper or lower extremity. During an interview with Certified Nursing Assistant (CNA) 3 on 6/23/22 at 10:38 a.m., CNA 3 stated Rehabilitation department staff had been assisting Resident 37 with exercises but has not seen RNA do any exercises for Resident 37. CNA 3 also stated Resident 37 has not had splints applied on any extremity. During an interview with RNA on 6/23/22 at 10:40 a.m., RNA stated she received the Rehab Department's referral for Resident 37 for the RNA program and splints on 6/13/22, but has not had the chance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0656 to start because RNA was re-assigned to work as a CNA. Level of Harm - Minimal harm or potential for actual harm The facility's policy and procedure titled, Comprehensive Plan of Care dated 11/17 indicated, Care Area Assessments triggered by the MDS must be considered for care plan development. Residents Affected - Few Care plans must be fully developed within 7 days after completing the comprehensive assessment (MDS). Based on observation, interview, and record review, the facility failed to implement or develop the Comprehensive Plan of Care policy and procedure for the following three (Resident 37, 56 and 57) of 22 sampled residents when; -Resident 56's care plan was not developed to ensure safe smoking interventions were implemented. For example, an apron to protect clothing and self against burns. -Resident 57 did not have a care plan to address an impairment of the lower extremities. - Resident 37 had no care plan developed for range of motion. These deficient practices had the potential for residents to not receive care and treatment services based on care assessment needs. Findings: 1. During an interview on 6/22/22 at 8:18 a.m., Resident 56 stated he was a smoker and smoked cigarettes as scheduled. Review of Resident 56's Significant change in status Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 11/7/21, indicated Resident 56's diagnoses included seizure disorder or epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and Traumatic Brain injury (a disruption in the normal function of the brain). During an interview on 6/22/22 at 8:29 a.m., the MDS coordinator (MDS) stated the care plan to address Resident 56's safe smoking was not developed. 2. Review of Resident 57's Significant change in status Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 2/9/22, indicated Resident 57 had impairment on both sides, lower extremity (hip, knee, ankle, foot). Resident 57's diagnoses included osteoarthritis of the knee (degeneration of joint cartilage and underlying bone, which causes pain and stiffness). During an interview on 6/23/22 at 9:18 a.m., MDS stated the care plan was not developed for Resident 57's contractures (condition of hardening or shortening of a muscle often leading to deformity and rigidity of joints) and limitation to lower extremities. 3. Review of Resident 37's Resident Face Sheet indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included quadriplegia (paralysis from the neck down to all four limbs), contractures of the right and left arm, and right and left lower leg. Review of Resident 37's Minimum Data Set Assessment (MDS, an assessment tool used to direct (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident care) dated 6/3/22 indicated Resident 37 required extensive staff assistance for turning/repositioning while in bed, and required total staff assistance with all other Activities of Daily Living (ADL) like personal hygiene, toileting, eating, and bathing. Resident 37 had functional limitations on both upper and lower extremities that interfered with daily function and placed Resident 37 at risk for injury. Review of Resident 37's Physician Order Report for 6/1/22-6/23/22 indicated the following orders dated 6/13/22: - Restorative Nursing Assistant (RNA) Program for Passive Range of Motion (PROM, when a therapist or provider causes movement to a joint) to bilateral (left and right) upper extremity twice weekly as tolerated for 90 days. - RNA Program for bilateral lower extremity twice weekly as tolerated for 90 days. - RNA to apply ankle splint to bilateral lower extremity twice weekly for 90 days, up to four hours a day, as tolerated. - RNA to apply hand splint to bilateral upper extremity twice weekly for 90 days, up to four hours a day as tolerated. - RNA to apply knee splint to bilateral lower extremity twice weekly for 90 days, up to four hours a day as tolerated. Review of Resident 37's Other care plan dated 6/13/22 indicated RNA program for PROM to bilateral lower extremity twice weekly as tolerated for 90 days, ROM of extremities as ordered and for RNA to apply ankle splint to both lower extremity twice weekly for 90 days up to four hours daily. During an observation and concurrent interview with Resident 37 on 6/20/22 at 12:15 p.m., Resident 37 was unable to move both upper and lower extremities. Resident 37 stated receiving range of motion exercises but not sure if it was from rehabilitation department or from RNA. Resident 37 did not have any splint on upper or lower extremity. During an interview with Certified Nursing Assistant (CNA) 3 on 6/23/22 at 10:38 a.m., CNA 3 stated Rehabilitation department staff had been assisting Resident 37 with exercises but has not seen RNA do any exercises for Resident 37. CNA 3 also stated Resident 37 has not had splints applied on any extremity. During an interview with RNA on 6/23/22 at 10:40 a.m., RNA stated she received the Rehab Department's referral for Resident 37 for the RNA program and splints on 6/13/22, but has not had the chance to start because RNA was re-assigned to work as a CNA. The facility's policy and procedure titled, Comprehensive Plan of Care dated 11/17 indicated, Care Area Assessments triggered by the MDS must be considered for care plan development. Care plans must be fully developed within 7 days after completing the comprehensive assessment (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident 29's Resident Face Sheet indicated Resident 29 was initially admitted to the facility on [DATE] with diagnoses that included left hand muscle contracture (condition of hardening or shortening of a muscle) and hemiplegia and hemiparesis of the left side (hemiplegia, weakness of one side of the body; hemiparesis, paralysis of one side of the body). Review of Resident 29's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/22 indicated Resident 29 required extensive assistance from staff for personal hygiene (like combing hair, brushing teeth, shaving, washing/drying face and hands) and dressing (like putting on and changing pajamas, or any items of clothing) and for turning and repositioning while in bed. Resident 29 also required total staff assistance (staff does 100% of the work) for transfers, toilet use, and bathing. resident 29's MDS also indicated Resident 29 had functional limitation that interfered with daily function, placing Resident 29 at risk for injury, on both sides of upper and lower extremities. Review of Resident 29's Physician Order Report for June 2022 indicated a physician order dated 5/30/22 for Resident 29 to receive Restorative Nursing Assistant (RNA) program for Active Assistive Range of Motion (AAROM, a helper or a provider helps the resident in completing the movement/exercises) to both lower extremity and both upper extremity twice weekly as tolerated. The report also indicated an order dated 5/30/22 that if RNA is not available, mobility and range of motion will be done by Certified Nursing Assistant (CNA) during care/Activities of Daily Living (ADL, like bathing, personal hygiene, turning/repositioning, eating, transferring from bed to wheelchair). During an interview with RNA on 6/22/22 at 11:10 a.m., RNA stated not being able to work with Resident 29 for awhile and could not remember the last time RNA program was done. RNA stated, if she had been re-assigned as CNA when facility was short of staff, which happened very often, the CNA who was assigned to Resident 29 would have to do the range of motion exercises during ADLs. During an interview with CNA 2 on 6/22/22 at 2:52 p.m., CNA 2 stated he did not know who, among his residents, were on RNA program. CNA 2 also stated not doing ROM exercises during ADLs and that no one had told them to. Review of Resident 29's Point of Care History for 5/1/22- 6/22/22 indicated Resident 29 had Assistive Active Range of Motion exercises with RNA on 6/8/22 and 6/9/22 (two times). Facility did not provide RNA care for the followings Resident 2 lower extremities contractures Resident 26 ambulation Resident 23 left hand splint applicated Resident 57 lower extremities contractures Resident 29 range of motion upper extremities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0688 Resident #29 Level of Harm - Minimal harm or potential for actual harm Position, Mobility Residents Affected - Some 06/20/22 11:35 AM right lower extremity bandaged up, resident stated the nurse changed the dressing just now. 06/22/22 10:56 AM RR MDS 4/19/22 indicated impairment on both upper extremities and both lower extremities. Physician orders: RNA program for AAROM to B LE/Left UE 2 times weekly as tolerated for 90 days, if RNA not available, ROM will be done by CNA during care/ADLs Hand roll to left hand contracture LN to check proper placement every shift 06/22/22 11:10 AM interview with [NAME] Arquisola, RNA, stated she started her shift today as a CNA, and had just been relieved because somebody showed up and took over her assignment, could not remember the last time she worked with resident cause it had been awhile. but was doing active ROM like extension of upper extremities for 15-20 minutes, but if not working as RNA for the day, CNA will have to do it during ADL care. 06/22/22 02:52 PM interview with [NAME], CNA, stated he did not know which of his residents were on RNA program, and nobody told them to do ROM exercises Based on observation, interview, and record review, the facility failed to provide four (Residents 2, 23, 26 and 29 ) sampled residents restorative nursing care (RNA). No RNA services were provided for Resident 2's lower extremities and contractures (hardening or shortening of a muscle) and no splint was applied for Resident 23's left hand. For Resident 26, no ambulation was provided or Resident 29's range of motion (ROM) to the upper extremities, all of which were ordered by the physician and according to the residents' plan of care. These deficient practices had the potential to cause a decrease in Residents 2, 23, 23, and 29 ROM. Findings: 1. Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 3/5/22, indicated Resident 2's Basic Interview of mental status (BIMS) score was 8 (meaning moderate cognitive impairment). Resident 2 had limited ROM and impairment to the upper (shoulder, elbow, wrist, and hand) and lower extremity hip knee, ankle and foot. The diagnoses included contracture of the muscle on the left upper arm and cerebrovascular accident (stroke). Review of the Physical Therapy (PT) Discharge summary dated [DATE] indicated Resident 2 had a PT evaluation and was to continue with ROM for the left lower extremity contracture. Review of the physician order report dated 6/13/22 indicated the physician prescribed Resident 2 to continue on the RNA program for passive range of motion (PROM) to the left lower and upper extremity (LL/LUE), two times per week, as tolerated for 90 days. 2. Review of the Annual MDS dated [DATE], indicated Resident 23 had limitation in ROM and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some impairment to the upper (shoulder, elbow, wrist, hand) and lower extremity hip knee, ankle and foot. Resident 22 had diagnoses that included hemiplegia/ hemiparesis (loss of strength or paralysis on one side of the body) and stroke. Review of Resident 23's ROM care plan dated 9/21/20 indicated Resident 23 was at risk for decline in ROM related to lower extremities and use of orthotics (external device). The care plan approach included the RNA to apply a hand splint to the left upper extremity, 3 x (times) for 90 days, up to four hours per day as tolerated. 3. Review of the general order dated 4/14/22, indicated the physician prescribed Resident 26 to receive RNA program for ambulation, 2-3 times a week, as tolerated for 90 days. During an interview on 6/21/22 at 1:10 p.m., the Restorative Nursing Assistant (RNA) stated she had not provided RNA services for Residents 2, 23, and 26. RNA further stated the facility has two RNA staff, one on vacation, and she had not worked as an RNA for some time because the facility was short of staff. During an interview on 6/22/22 at 9:15 a.m., the Director of Staff Development (DSD) stated she could not provide documentation that Residents 2, 23, and 26 received RNA care services. During an interview on 6/22/22 at 11:38 a.m., the Director of Nursing (DON) stated she was aware the RNA was reassigned to do Certified Nursing Assistant (CNA) duties because the facility was short of staff. 4. Review of Resident 29's Resident Face Sheet indicated Resident 29 was initially admitted to the facility on [DATE] with diagnoses that included left hand muscle contracture and hemiplegia and hemiparesis of the left side. Review of Resident 29's MDS dated [DATE] indicated Resident 29 required extensive assistance from staff for personal hygiene (combing hair, brushing teeth, shaving, washing face and hands), dressing and for turning and repositioning while in bed. Resident 29 also required total staff assistance for transfers, toilet use, and bathing. Further review showed Resident 29 had functional limitations that interfered with daily function, placing Resident 29 at risk for injury on both sides of the upper and lower extremities. Review of Resident 29's Physician Order Report reflected the order dated 5/30/22 for Resident 29 to receive the RNA program for Active Assistive ROM (AAROM, assists the resident in completing the movement/exercises), to both lower extremity and both upper extremity, twice weekly as tolerated. The order dated 5/30/22 indicated if the RNA is not available, mobility and ROM will be done by the CNA during Activities of Daily Living (ADL) care, such as bathing, personal hygiene, eating, turning/repositioning and transferring from bed to wheelchair). During an interview with RNA on 6/22/22 at 11:10 a.m., RNA stated she could not remember the last time the RNA program was done because she was re-assigned to work as a CNA when the facility was short of staff. RNA stated short staffing happened often, and the CNA assigned to Resident 29 would have to do the ROM exercises during ADL care. During an interview with CNA 2 on 6/22/22 at 2:52 p.m., CNA 2 stated he did not know which residents he had that were on the RNA program. CNA stated he was not doing ROM exercises during ADLs because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0688 no one said to do that. Level of Harm - Minimal harm or potential for actual harm Review of Resident 29's Point of Care History dated 5/1/22- 6/22/22 indicated Resident 29 had AAROM exercises with RNA on 6/8/22 and 6/9/22 (two times). Residents Affected - Some The facility's policy and procedure titled, Restorative Nursing Program dated 6/1/18 indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 licensed nursing staff routinely administered pain medication in the absence of pain for one of 22 sampled residents (Resident 7). Resident 7 was ordered Morphine (an opioid/narcotic), twice a day for moderate pain. Staff routinely administered the narcotic when the resident denied having pain. Staff also continued to administer the medication when Resident 7 had become lethargic. Residents Affected - Few This failure resulted in respiratory depression, and unnecessary admission to the hospital. Findings: Record review on 6/22/2022 of the document Resident Face Sheet showed the facility admitted Resident 7 on 3/22/2021. The diagnoses included arthritis. Record review on 6/23/2022 of the document, Minimum Data Set (MDS, a resident assessment tool for planning care) dated 3/14/2022, showed Resident 7 had clear speech, was able to express her ideas and wants and understood what was said to her. During the initial rounds on 6/20/2022 at 11:30 a.m., Resident 7 was observed awake, sitting up in bed but did not respond when greeted. In an interview on 6/20/2022 at 12:58 p.m., Family Member 1 stated the facility called her on 6/19/2022 to report Resident 7 had become sluggish and was not eating. Furthermore, on 6/22/2011 at 2:30 p.m., Family Member 1 stated she visited Resident 7 on 6/20/2022 (day after the change of condition and found the resident's voice to be sluggish which was a change for her. Record review on 6/21/2022 of the Physician Order Report: 5/1/2022-6/21/2022, showed an order for Morphine tablet extended release; 15 mg (milligram); amt: 15 mg;oral. Special Instructions: Give 1 tab (15 mg) by mouth twice a day for moderate pain. Twice a day; 10:00 a.m., 10:00 p.m. Review of the document, Medications Administration History: 6/1/2022 - 6/21/2022 showed Resident 7 received Morphine 15 mg twice a day for moderate pain throughout that time period. Review of the document, Pain Monitoring Administration History: 6/1/2022 - 6/20/2022 showed Resident 7 denied having pain. In an interview on 6/21/2022 at 2:45 p.m., Licensed Vocational Nurse 4 (LVN 4) stated the Morphine was for moderate pain, which, on a scale of 1-10 (10 being the most pain) moderate pain would have been 5. LVN stated she should have called the doctor since Resident 7 denied pain. LVN 4 stated it was important to assess the level of pain prior to administering the medication so staff can know whether to hold it or not. Too much can suppress respirations. In an interview on 6/21/2022 at 2:55 p.m., Registered Nurse 2 (RN 2) confirmed she was giving Resident 7 pain medication despite the fact that she had no pain. RN 2 stated, We still give it to her. RN stated the potential side effect of giving too much pain medication was respiratory depression. Review of the document, Observation Detail List Report (ODLR) dated 6/19/2022 at 8:40 a.m., showed Resident 7 had a change in mental status when she was Lethargic when awakened this morning for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0697 breakfast. Level of Harm - Minimal harm or potential for actual harm Further review of the document, Medications Administration History: 6/1/2022 - 6/21/2022 showed Resident 7 had received Morphine 15 mg at 10 a.m. (one hour and 20 minutes after the documented change in mental status). Residents Affected - Few In an interview on 6/22/2022 at 11:45 a.m., Licensed Vocational Nurse 2 (LVN 2) stated she was asked to check on Resident 7 on 6/19/2022 during morning rounds. LVN 2 stated Resident 7 was drowsy, lethargic, mumbling and refused her breakfast. Vital signs and oxygen saturations were stable. LVN 2 stated Resident 7 was typically more alert and would eat her breakfast. LVN 2 stated she gave the Morphine at 10 a.m. without regard to the change in condition at 8:40 a.m. because Resident 7 became more alert. LVN 2 stated administering too many narcotics may cause respiratory depression. Review of the document ODLR dated 6/19/2022 at 8:55 p.m., showed Resident 7 was observed to be More disoriented to her surroundings than normal. In an interview on 6/22/2022 at 1:31 p.m., LVN 3 stated on 6/20/2022, she administered Resident 7's Morphine at 11 a.m. when she had no pain. LVN 3 stated Resident 7 was lethargic at lunchtime and did not want to eat but staff encouraged her. In an interview on 6/22/2022 at 11:04 a.m., the Medical Doctor 1 (MD 1) MD 1 stated he would have expected staff to do a full assessment prior to administering the narcotic following the mental status change because Too many narcotics can cause respiratory depression. Review of the ODLR dated 6/20/2022 at 9:17 p.m., showed Resident 7 to be in Respiratory distress and was transferred to the hospital. Review of the document .Hospitalist ([physician) H & P (history and physical) dated 6/21/2022, showed Resident 7 was admitted to the hospital with diagnosis of acute respiratory failure and Consider opiates as patient is on morphine at facility More potent opiate medications, such as morphine, should be used only when the client's pain level is severe. Expect to institute appropriate tapering doses or substitute less-potent narcotic analgesics, as ordered, as the client's pain level decreases. The first sign of narcotic over-dose is often respiratory depression. [Textbook of Basic Nursing; [NAME] and [NAME] T. [NAME]. Wolters Kluwer/[NAME] & Wilkins; 2012] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, for one of one sampled resident (Resident 29) reviewed for dialysis (process when a machine filters the blood of wastes when the kidneys are not healthy enough to do it), the facility failed to ensure that a phosphate binder (binds/attaches to some of the phosphate in food reducing one's blood phosphorus levels) was administered as ordered by the physician. Residents Affected - Few This failure had the potential to result in increased blood phosphorus (mineral) levels. Findings: Review of Resident 29's Resident Face Sheet indicated Resident 29 was initially admitted with diagnoses that included end stage kidney failure, diabetes mellitus (abnormal levels of blood sugar), and dependence on hemodialysis. Review of Resident 29's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/22 indicated Resident 29 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 15, meaning cognitively intact. Furthermore, Resident 29 required staff supervision and set up help with meals. Review of Resident 29's Physician Order Report for the month of June 2022 indicated an order for Resident 29 to receive Renvela (a phosphate binder) 800 milligram (mg) tablet, one tablet by mouth three times daily with meals. Resident 29's order report indicated Resident 29 went to the dialysis center for hemodialysis every Tuesday, Thursday and Saturday from 10 a.m.- 2 p.m. During review of Resident 29's Medication Administration History (MAH) from 5/1/22-5/31/22, on 6/21/22 at 12:17 p.m., the May 2022 MAH indicated Resident 29 did not receive Renvela 13 out of 93 medication times. During review of Resident 29's MAH from 6/1/22-6/21/22, the MAH for June 2022 indicated Resident 29 missed 9 of 63 doses of Renvela. During an interview and concurrent review of Resident 29's MAH with Medical Records Director (MRD), on 6/22/22 at 10:07 a.m., MRD stated, if the MAH showed an asterisk and the licensed nurse initials in open close parenthesis, it means that the medication dose was not administered and there should be an explanation for why it was not administered. Resident 29's MAH for May 2022 and June 2022 indicated, Not administered: Resident unavailable Comment: [resident] out for dialysis. During an observation on 6/21/22 at 3:00 p.m., Resident 29 had just returned from dialysis and was being helped back to bed. During an interview with Licensed Vocational Nurse (LVN) 4 on 6/21/22 at 3:11 p.m., LVN 4 stated, when Resident 29 left for dialysis after breakfast, the night shift nurse would pack some food along with Renvela so Resident 29 could take Renvela with lunch while at dialysis center. LVN 4 stated sometimes Resident 29 would meet up with family at the dialysis center who would bring Resident 29 lunch. LVN 4 stated Resident 29 took Renvela independently and it was written in the dialysis book that Resident 29 brought to the dialysis clinic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and concurrent interview with Certified Dietary Manager (CDM) on 6/21/22 at 3:20 p.m., CDM went inside Resident 29's room to find out what Resident 29 wanted to eat after returning from dialysis center. During review of Resident 29's Dialysis Communication Record dated 6/11/22, 6/14/22, 6/16/22, 6/18/22 and 6/21/22, on 6/22/22 at 9:05 a.m., Resident 29's dialysis communication records indicated medications and meal provisions were not sent with Resident 29. During an interview with LVN 6 on 6/22/22 at 9:15 a.m., LVN 6 stated Resident 29 went to dialysis with a packed lunch. LVN 6 stated she was not sure if the phosphate binder was sent with the packed lunch, but if it was, there should be a physician's order indicating Renvela may be sent with Resident 29's packed lunch. LVN 6 stated the clinical record did not have a physician order for sending Renvela with the resident. During an interview with the Director of Nursing (DON) on 6/22/22 at 9:30 a.m., DON stated Resident 29 refused to take Renvela while at the dialysis clinic and mostly ate at the facility after returning from dialysis. During an interview with Resident 29 on 6/22/22 at 12:50 p.m., Resident 29 stated, when returning from the dialysis center after lunch hours, the assigned Certified Nursing Assistant would leave the lunch tray at the bedside for Resident 29 to eat. Review of Resident 29's dialysis care plan dated 9/21/20 indicated medications would be administered as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Review of Resident 29's Resident Face Sheet indicated Resident 29 was admitted with diagnoses that included major depressive disorder (persistently depressed mood). Review of Resident 29's Physician Order Report for 6/20/22-6/22/22 indicated a physician's order dated 3/10/22 for Resident 29 to receive mirtazapine (treats depression) 15 mg tablet, one tablet by mouth every bedtime, for depression manifested by yelling and screaming. Review of Resident 29's Behavioral Monitoring Administration History from 4/1/22-4/30/22 indicated zero episodes of yelling and screaming. Review of Resident 29's Behavioral Monitoring Administration History from 5/1/22-5/31/22 indicated zero episodes of yelling and screaming. Review of Resident 29's antidepressant care plan dated 7/22/21 indicated to monitor frequency of yelling and screaming and review medication regimen for possible Gradual Dose Reduction (GDR, an attempt to taper/reduce the dose of a medication). During an interview and concurrent review of Resident 29's clinical record with Director of Nursing (DON) on 6/23/22 at 8:12 a.m., DON stated the Interdisciplinary Team (IDT, a group composed of individuals from different departments) met on 4/20/22 and recommended for Resident 29 to be monitored for any changes in behavior. DON stated the dose had not been reduced since admission in 2017. DON also stated IDT had met on 6/8/22 and recommended to continue to monitor and follow up. DON further stated, Resident 29 received mirtazapine for yelling and screaming but had been generally calm and quiet, and had not been having any behavior problems. During an interview with the Director of Staff Development (DSD), on 6/23/22 at 8:27 a.m., DSD stated Resident 29 had episodes of yelling, once in a while, but not as bad as it would disrupt everyday activities and did not affect the staff ability to provide care. DSD stated Resident 29 was not disruptive. During a follow-up interview with DON on 6/23/22 at 11:21 a.m., DON stated. from 2019 until 2022, IDT/s meetings for GDR was for Resident 29 to continue current dose and IDT has not attempted to reduce the dose. During a telephone interview with the Pharmacy Consultant (PC) on 6/23/22 at 2:32 p.m., PC stated, GDR, by rule, should be attempted once a year. Review of the facility's undated policy and procedure titled, Medication Monitoring Medication Management, indicated that if medication was for a chronic or prolonged condition, the facility must ensure that the resident's expression of distress is not due to environmental stressors alone like alteration in customary routine, unfamiliar care provider, hunger or thirst or inappropriate staff response. The facility's policy and procedure titled, Psychotropic Medication Assessment and Monitoring, dated 3/16/22 indicated, the side effect and black box warning for psychotropic medications will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0758 Level of Harm - Minimal harm or potential for actual harm monitored. Record behavior, interventions and the effectiveness of interventions taken in the behavior monitoring record. Based on interviews and record review, the facility failed to ensure two sampled residents (Resident 2 and 29) were free from unnecessary drugs when; Residents Affected - Few -Resident 2 was administered Clonazepam (Klonopin- antianxiety) without adequate monitoring of behavior manifestations and medication side effects. -Resident 29 was administered Remeron (antidepressant) medication without appropriate indication and gradual dose reduction. These failures had the potential for residents to receive unnecessary medications and adverse medication side effects. Findings: Review of Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 3/5/22 indicated Resident 2's Basic Interview of mental status (BIMS) score was 8 (meaning moderate cognitive impairment). Resident 2 had no behavioral symptoms. Resident 2 diagnoses included, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). During an observation on 6/20/22 at 11:42 a.m., Resident 2 was in bed awake, verbal with incomprehensible sounds. Review of Resident 2's physician order report dated 5/24/22 indicated the physician prescribed Clonazepam 0.5 mg (milligram), one tablet by mouth twice daily for anxiety manifested by yelling and screaming to the point of exhaustion. Review of the Medication Administration Record (MAR), for June 2022 in the presence of the Director of Nursing (DON), indicated Resident 2 was administered Clonazepam 0.5 mg one tablet by mouth twice daily for anxiety. During an interview on 6/22/22 at 2:19 p.m., Registered Nurse (RN 1) stated Resident 2 was administered Clonazepam because she had anxiety and yelled during incontinent diaper changes, when turned side to side, and when the head of bed was raised. During an interview 6/22/22 at 2:32 p.m., Certified Nursing Assistant (CNA 2) stated when Resident 2 was informed of care prior to providing care she was cooperative. Further review of the MAR and concurrent interview on 6/22/22 at 12:06 p.m., DON stated Resident 2's behavior manifestation and medication side effects for use of Clonazepam monitoring was not documented. Review of Resident 29's Resident Face Sheet indicated Resident 29 was admitted with diagnoses that included major depressive disorder (persistently depressed mood). Review of Resident 29's Physician Order Report for 6/20/22-6/22/22 indicated a physician's order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0758 Level of Harm - Minimal harm or potential for actual harm dated 3/10/22 for Resident 29 to receive mirtazapine (treats depression) 15 mg tablet, one tablet by mouth every bedtime, for depression manifested by yelling and screaming. Review of Resident 29's Behavioral Monitoring Administration History from 4/1/22-4/30/22 indicated zero episodes of yelling and screaming. Residents Affected - Few Review of Resident 29's Behavioral Monitoring Administration History from 5/1/22-5/31/22 indicated zero episodes of yelling and screaming. Review of Resident 29's antidepressant care plan dated 7/22/21 indicated to monitor frequency of yelling and screaming and review medication regimen for possible Gradual Dose Reduction (GDR, an attempt to taper/reduce the dose of a medication). During an interview and concurrent review of Resident 29's clinical record with Director of Nursing (DON) on 6/23/22 at 8:12 a.m., DON stated the Interdisciplinary Team (IDT, a group composed of individuals from different departments) met on 4/20/22 and recommended for Resident 29 to be monitored for any changes in behavior. DON stated the dose had not been reduced since admission in 2017. DON also stated IDT had met on 6/8/22 and recommended to continue to monitor and follow up. DON further stated, Resident 29 received mirtazapine for yelling and screaming but had been generally calm and quiet, and had not been having any behavior problems. During an interview with the Director of Staff Development (DSD), on 6/23/22 at 8:27 a.m., DSD stated Resident 29 had episodes of yelling, once in a while, but not as bad as it would disrupt everyday activities and did not affect the staff ability to provide care. DSD stated Resident 29 was not disruptive. During a follow-up interview with DON on 6/23/22 at 11:21 a.m., DON stated. from 2019 until 2022, IDT/s meetings for GDR was for Resident 29 to continue current dose and IDT has not attempted to reduce the dose. During a telephone interview with the Pharmacy Consultant (PC) on 6/23/22 at 2:32 p.m., PC stated, GDR, by rule, should be attempted once a year. Review of the facility's undated policy and procedure titled, Medication Monitoring Medication Management, indicated that if medication was for a chronic or prolonged condition, the facility must ensure that the resident's expression of distress is not due to environmental stressors alone like alteration in customary routine, unfamiliar care provider, hunger or thirst or inappropriate staff response. The facility's policy and procedure titled, Psychotropic Medication Assessment and Monitoring, dated 3/16/22 indicated, the side effect and black box warning for psychotropic medications will be monitored. Record behavior, interventions and the effectiveness of interventions taken in the behavior monitoring record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 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, and record review, for one of three sampled residents (Resident 29) reviewed for food concerns, the facility failed to provide food at a safe and appetizing temperature when Resident 29 was served a lunch tray that had been sitting at the bedside for two hours or more. Residents Affected - Few This failure had the potential to result in food borne illness and resulted in Resident 29 being served cold food. Findings: Review of Resident 29's Resident Face Sheet indicated Resident 29 had been known to the facility since 7/21/17 with diagnoses that included diabetes (abnormal levels of blood sugar), major depressive disorder (persistently depressed mood), and dependence on hemodialysis (treatment to filter water and waste from a patient's blood when the kidneys are not working normally). Review of Resident 29's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/22 indicated Resident 29 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 15, meaning cognitively intact. Furthermore, Resident 29 required staff supervision and set up help with meals, and required total assist for locomotion around the facility. During an interview with Resident 29 on 6/20/22 at 11:35 a.m., Resident 29 stated during meal times, the Certified Nursing Assistants (CNAs) would just pass the trays and move on to the next room. Resident 29 stated, CNAs have said they did not have time to warm up food if the food was cold. Resident 29 stated he went to dialysis every Tuesday, Thursday and Saturday. During an interview with Licensed Vocational Nurse (LVN) 4 on 6/21/22 at 12:20 p.m., LVN 4 stated Resident 29 left for dialysis after 8 am on dialysis days, and returned to the facility after lunch hours. During an observation on 6/21/22 at 3:00 p.m., Resident 29 had just returned from dialysis and was being helped back to bed. During an observation and concurrent interview with the Certified Dietary Manager (CDM) on 6/21/22 at 3:20 p.m., CDM went inside Resident 29's room and came out of the room carrying a lunch tray. CDM stated it was Resident 29's lunch tray that was left at the bedside. CDM stated she would take it to the kitchen to be thrown out because it was not supposed to be kept inside the room. During an interview with Resident 29 on 6/22/22 at 11:35 a.m., Resident 29 stated, upon returning from dialysis (on dialysis days), the lunch tray would be at the bedside and would eat whatever is on the lunch tray, even when the food was cold. Resident 29 stated, sometimes, Resident 29 would ask the CNA to warm up the food but would see a sad face, so Resident 29 would just eat the cold lunch. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 store and prepare food in accordance with professional standards of food service safety when: Residents Affected - Some 1. Dietary Aide (DA) 1 did not wear a hair net while inside the kitchen. 2. An opened container of syrup was stored inside the refrigerator beyond its use-by date. 3. Storage bins for rice, lentils and food thickener had dusty covers. 4. Soft and sprouted potatoes were stored. 5. A dented seven-pound can of chocolate pudding was stored together with non-dented canned food items in the dry storage area. These failures had the potential to result in food-borne illnesses. Findings: During initial kitchen tour observation and concurrent interview with the Certified Dietary Manager (CDM) on 6/20/22 at 10:25 a.m., the following were observed; 1. DA 1 did not wear a hair net while inside the kitchen. 2. There was an opened container of syrup with a use-by date of 5/6/22. CDM stated she was responsible in checking the refrigerators making sure all food items beyond their use-by dates were thrown out. CDM further stated she checked the refrigerators on 6/19/22 (day prior) and missed the container syrup. CDM stated she should have thrown it out. 3. Storage bins for rice, lentils and food thickener had dusty covers on them, some had chunks of white crumb-like substances on them. The storage bins were on the bottom of a metal shelf (see IMG_0261.jpg). 4. Potatoes that were stored inside a carton by the refrigerators/freezers were soft and sprouted (see IMG_0260.jpg). 5. Inside the dry food storage area, a seven-pound dented can was stored on a rack together with ready-to-use non-dented cans. CDM took the dented can from the rack and placed it in a container of dented cans outside the dry storage area. During a follow-up visit to the kitchen on 6/22/22 at 11:27 a.m., [NAME] 1 and [NAME] 2 were both wearing hair nets that did not completely cover their hair. Review of the facility's policy and procedure titled, SANITATION AND INFECTION CONTROL, Personal Hygiene indicated a hair net and/or head covering that completely cover all hair should be worn during meal preparation and service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the licensed staff did not provide the necessary rehabilitative services for one of 22 sampled residents. (Resident 25). Resident 25 had bilateral foot drop (inability to lift the front part of the foot causing the toes to drag on the ground which may be due to muscular problems or other underlying issues). Staff had not supported Resident 25's feet with a splint and there were no RNA (Restorative Nursing Assistant) visits documented in the clinical record. Residents Affected - Few This failure resulted in the potential decrease in muscle strength in her feet and general range of motion. Findings: Record review on 6/22/2022 of the document, Resident Face Sheet showed diagnoses that included Joint Derangement (disturbance in the normal resting position of the joint that results in obstruction of movement). Review of the document, MDS 3.0 Nursing Home Quarterly . (resident assessment) dated 4/12/2022, showed Resident 25 was unable to walk, was bed-bound, and required extensive care from staff for dressing, toilet use and personal hygiene. The Functional Limitation in Range of Motion (ROM) showed Resident 25 had impairment on both sides of her lower extremities. On 6/23/2022 at 9:45 a.m. Resident 25 was observed to have bilateral foot drop. In a concurrent interview, Licensed Vocational Nurse 2 (LVN 2) confirmed the foot drop and stated Resident 25 had a splint for her hand (which was noted on her right wrist) but not on her feet. LVN 2 stated her feet have Always been like that. In a concurrent observation and interview on 6/23/22 at 10:11 a.m., the facility's Rehabilitation Director (RD) confirmed Resident 25's foot drop. RD stated Resident 25 was not currently receiving physical therapy services but was seen by the RNA. RD stated the RNA had been working with Resident 25 on ROM and Resident 25 would benefit from the use of a splint for her foot drop. In an interview on 6/23/22 at 10:26 a.m., RNA stated she supervised Resident 25's ROM in her upper and lower extremities. RNA was aware of the foot drop and stated Resident 25 had no splint for her feet and was Not sure if it had ever been tried. In an interview on 6/23/22 at 10:39 a.m., the facility's administrator stated there were no documented RNA visit notes in the clinical record for Resident 25. Record review on 6/23/2022 of the document, Care Plan dated 3/29/2021, showed Resident 25 . was at risk for a decline in ROM and/or functional mobility. The goals included, Decrease risk for further decline in ROM. Review of theInterdisciplinary Resident Referral dated 8/01, showed staff were to document any changes in contracture (foot drop) status and, Forward this form to the specific department for intervention. There was no documented referral made for Resident 25's foot drop. The most common treatment (for foot drop) is to support the foot with light-weight leg braces (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0825 Level of Harm - Minimal harm or potential for actual harm .Exercise therapy to strengthen the muscles and maintain joint motion also helps to improve gait. National Institute of Neurological Disorders and Stroke. [ninds.nih.gov/health-information/disorders/foot-drop] Last reviewed April 2, 2022 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of four (Resident 49) sampled residents reviewed for advanced directives, the facility failed to ensure medical records were complete and accurate when Resident 49's Physician Order for Life -Sustaining Treatment (POLST, a form that gives seriously-ill patients control over end-of-life care decisions including medical care, prevents unwanted treatments and ensure patient's wishes are honored) was incomplete and not signed by Resident 49 or the Resident Representative. This failure had the potential to result in unwanted treatment and medical interventions and not honoring Resident 49's wishes for end-of-life care. Findings: Review of Resident 49's Resident Face Sheet indicated Resident 49 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental illness), visual loss, history of breast cancer, congestive heart failure (progressive disorder affecting pumping power of the heart muscle), and dyspnea (difficult or labored breathing). Resident 49's face sheet indicated Do Not Resuscitate (to NOT revive from unconsciousness or apparent death). During an interview and concurrent review of Resident 49's clinical record with Director of Nursing (DON), on [DATE] at 8:49 a.m., DON stated Resident 49's POLST indicated Do Not Resuscitate/DNR order signed by Resident 49's Attending Physician (AP) 1. DON also stated there was no advanced directive in the clinical record and because the POLST was not signed by Resident 49 or Resident 49's Resident Representative, if and when Resident 49 goes into cardiac arrest, licensed nurses would be expected to do chest compressions to revive Resident 49. Resident 49's POLST form indicated an order to DNR but did not indicate other medical interventions or any order for artificially administered nutrition. During an interview and concurrent review of Resident 49's POLST with Registered Nurse (RN) 2 and Licensed Vocational Nurse (LVN) 5, on [DATE] at 9:07 a.m., both stated, since the POLST was not signed by Resident 49 or Resident 49's representative, Resident 49 will be treated as Full Code (resuscitation efforts will be performed such as chest compressions). During an interview with Social Services (SS) on [DATE] at 9:21 a.m., SS stated Resident 49's POLST should have been sent to Resident 49's conservator for signature as soon as it was signed by AP 1 but that was not done. SS stated Resident 49's POLST was prepared and signed by SAP 1 in [DATE] (more than a year ago). During a follow-up interview with SS on [DATE] at 12:47 p.m., SS stated she had contacted Resident 49's conservator and was told that POLST should be signed by Resident 49 or resident representative. Review of the facility's policy and procedure titled, Physician Orders for Life-Sustaining Treatment (POLST), last updated [DATE] indicated the following: The admitting licensed nurse will note existence of a POLST form in the clinical record and review its completeness. Social Worker will conduct an initial review of the POLST with the resident or legally recognized decision-maker within the first required 14-day assessment period as part of the care planning process. The POLST will be reviewed by the facility's Interdisciplinary Team (IDT, a group of individuals representing different (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0842 Level of Harm - Minimal harm or potential for actual harm departments of the facility) during quarterly care planning conference. The physician should discuss the benefits and efficacy and appropriateness of treatment and medical interventions with the resident /resident representative and is responsible for discussing treatment options. A fully executed, dated copy of the POLST should be retained in the medical records in the resident's chart. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 B 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure the Air-conditioning (AC) system on A side was cooling when residents' rooms [ROOM NUMBERS] air temperature was 83 degrees. {Acceptable air temperature ranges between 71 degrees to 81 degrees Fahrenheit(F)} This deficient practice had the potential to cause residents discomfort and susceptible to heat exhaustion. Findings: During an interview on 6/21/22 at 10:25 a.m., Resident 52 stated that the temperature in rooms on A side was too hot. Resident 52 stated the AC system was not working properly, reported this to the nurse and was transferred to another room. Resident 52 further stated he was concerned for other residents. During rounds on A side on 6/21/22 at 11:55 a.m., and accompanied by the Regional Maintenance Director (RMD), rooms [ROOM NUMBERS]'s air temperature was 83 degrees F. RMD stated the facility had no maintenance supervisor and will check the AC for proper functioning. During an interview on 6/21/22 at 12:47 p.m., the Certified Nursing Assistant/Restorative Nursing Assistant (RNA) stated she was assigned to care for residents in Rooms 14, 15 and 16 . RNA stated the facility was aware of the hot temperatures in Rooms 14, 15 and 16. During an interview on 6/21/22 at 12:29 p.m., the Administrator (Admin) stated the AC was not cooling. Admin stated rooms [ROOM NUMBERS] were getting warmer and a call was placed for urgent repair of the AC system. During an interview on 6/22/22 at 9:57 a.m., Admin stated the repair contractor indicated the AC compressor for A side was faulty and not working. During an interview on 6/23/22 at 9:06 a.m., Admin stated the contractor found out that the AC vent to the A side was closed. The facility policy and procedure titled, Preventative Maintenance Program dated 4/15/2001, indicated, a basic preventative maintenance program results in a cleaner, safer, and more efficient operation with fewer deficiencies and emergency repairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 If continuation sheet Page 23 of 23