Health inspection·February 6, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 2 ' s MDS, the MDS dated [DATE] indicated a BIMS score of 13 indicating no cognitive impairment. During a review of Resident 2 ' s progress note dated 12/23/23, the progress note indicated Resident 2 was hit on his left arm by a shoe that was thrown by another resident (Resident 1) while he was passing through the reception area. During a review of Resident 1 ' s progress note dated 1/13/24, the progress note indicated Resident 1 threw a plastic bottle at another resident (Resident 2), police was called and came to the building to take report. During a review of Resident 2 ' s progress note dated 1/13/24, the progress note indicated Resident 2 stated the bottle hit his left arm and that his thick jacket softened the impact. During an interview on 2/6/24 at 12:15 p.m. with CNA 1, CNA 1 stated Resident 2 usually goes around in his wheelchair and whenever Resident 1 sees Resident 2 passes by, Resident 1 tries to hit Resident 2. CNA 1 stated Resident 1 tries to hit other residents too, but most especially Resident 2. During an observation on 2/6/24 at 12:23 p.m. in A unit hallway, Resident 1 who was sitting in her WC outside her room, leaned forward and made a fist at Resident 2, while Resident 2 passed through the hallway to go into the reception area. During a concurrent interview and record review on 2/26/24, at 1:40 p.m. with Social Services Director (SSD), SSD looked for the care plan for psychosocial wellbeing for Resident 2, but unable to find it. She stated she would check with medical records. During a concurrent interview and record review on 2/6/24 at 2:20 p.m. with SSD, SSD looked for the IDT care conference notes done for Resident 2 (victim of the abuse) status post (S/P) the abuse incidents. SSD could not find any IDT notes for both incidents of 12/23/23 and 1/13/24 for Resident 2. SSD could only find the IDT notes for Resident 1, dated 1/15/24 for the abuse incident of 1/13/24. At 2:22 p.m. SSD confirmed no care plan and no IDT meetings for Resident 2 S/P the two cases of abuse, and no IDT meeting for Resident 1 after the abuse incident of 12/23/23. SSD stated IDT meeting is important so that staff members are aware in case of behavior or any triggers. It can help on what interventions to take place or to modify. SSD stated nursing and any of the IDT members are responsible to update the care plans. During a concurrent telephone interview and record review on 2/8/24 at 3:40 p.m. with the Director of Nursing (DON), the DON confirmed there was no IDT meeting done for the abuse incident of 12/23/23. DON stated IDT meeting is important for the team to discuss all the possible interventions to ensure Resident will be safe in the facility. DON stated care plan is the communication for all the members of the health care team. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Neglect & Exploitation Prohibition, undated, the P&P indicated, Each resident has the right to be free from .abuse . Definition: Abuse is willful infliction of injury .intimidation .with resulting harm, pain, or mental anguish .The company supervisors will immediately correct and intervene in reported or identified situations in abuse .is at risk of occurring .It is therefore the policy .to take all reasonable steps to prevent the occurrence of .abuse . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 If continuation sheet Page 2 of 5 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 02/06/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility ' s policy and procedure (P&P) titled, Comprehensive Plan of Care, undated, the P&P indicated, Each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychological needs identified . include interventions to attempt to manage risk factors . During a review of the facility ' s policy and procedure (P&P) titled, Care Plan Conference, undated, the P&P indicated, The care plan conference is held to identify resident needs and enable obtainable goals .Care plans are reviewed to meet the needs and requests of the resident/resident ' s family as identified during the conference . Event ID: Facility ID: 056447 If continuation sheet Page 3 of 5 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 02/06/2024 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** Based on interview and record review, the facility failed to develop an individualized comprehensive care plan with measured objectives and specific interventions for one of two sampled residents (Resident 2) when there was no care plan to address the physical, mental, and psychosocial wellbeing of Resident 2 after two cases of abuse. This deficient practice had the potential for Resident 2 ' s needs not to be identified and negatively impact his physical, mental, and psychosocial functioning. Findings: During a review of Resident 1 ' s Face Sheet, the Face sheet indicated Resident 1 was originally admitted [DATE] and re-admitted in February 2023 with diagnoses that included stroke with right sided weakness, high blood pressure, and depression. During a review of the Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 11/29/23, the MDS indicated a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve is an indication of moderate cognitive impairment.) score of 11 indicating moderate cognitive impairment. A review of the MDS for behavior for Resident 1, dated 11/29/23, indicated no potential indicators of psychosis, no physical, verbal behavioral symptoms or other behavioral symptoms directed at others. A review of the MDS for mood for Resident 1 indicated 00 indicating no symptoms present. During a review of Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was admitted in December 2022 with diagnoses that included abnormalities of gait and mobility, congestive heart failure (a chronic condition where the heart does not pump blood as well as it should), and high blood pressure. During a review of Resident 2 ' s MDS, dated 12/26/23, the MDS indicated a BIMS score of 13 indicating no cognitive impairment. During a review of Resident 2 ' s Progress Notes, dated 12/23/23, the Progress Notes indicated Resident 2 was hit on his left arm by a shoe that was thrown by Resident 1 while he was passing through the reception area. During a review of Resident 1 ' s Progress Notes, dated 1/13/24, the Progress Notes indicated Resident 1 threw a plastic bottle at Resident 2. During a review of Resident 2 ' s Progress Notes, dated 1/13/24, the Progress Notes indicated Resident 2 stated the bottle hit his left arm and that his thick jacket softened the impact. During an interview on 2/6/24 at 12:15 p.m. with CNA 1, CNA 1 stated Resident 2 usually goes around in his wheelchair and whenever Resident 1 sees Resident 2 passes by, Resident 1 tries to hit Resident 2. CNA 1 stated Resident 1 tries to hit other residents too, but most especially Resident 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 If continuation sheet Page 4 of 5 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 02/06/2024 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 During an observation on 2/6/24 at 12:23 p.m. in A unit hallway, Resident 1 was sitting in her wheelchair outside her room, leaned forward and made a fist at Resident 2, while Resident 2 passed through the hallway to go into the reception area. During a concurrent interview and record review on 2/26/24, at 1:40 p.m. with Social Services Director (SSD), SSD looked for the care plan for psychosocial wellbeing for Resident 2, but unable to find it. She stated she would check with medical records. During a concurrent interview and record review on 2/6/24 at 2:20 p.m. with SSD, SSD looked for the interdisciplinary Team (IDT) Care Conference notes done for Resident 2 status post the abuse incidents. SSD could not find any IDT notes for either incidents on 12/23/23 or 1/13/24. SSD could only find the IDT notes for Resident 1, dated 1/15/24 for the abuse incident of 1/13/24. At 2:22 p.m. SSD confirmed there were no care plans or IDT meetings for Resident 2 after the two cases of abuse. SSD states IDT meeting is important so that staff members are aware in case of behavior or any triggers. It can help on what interventions to take place or to modify. SSD states nursing and any of the IDT members is responsible to update the care plans. During a concurrent telephone interview and record review on 2/8/24 at 3:40 p.m. with the Director of Nursing (DON), DON confirmed there were no IDT meetings done for Resident 2 for either abuse incidents. DON stated IDT meeting is important for the team to discuss all the possible interventions to ensure Resident will be safe in the facility. DON stated care plan is the communication for all the members of the health care team. During a review of the facility ' s policy and procedure (P&P) titled, Comprehensive Plan of Care, undated, the P&P indicated, Each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychological needs identified .must address the resident ' s individual needs, strengths, and preferences .include interventions to attempt to manage risk factors . The interdisciplinary team, resident, and family will discuss and prioritize the resident ' s needs with input from the resident and/or family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056447 If continuation sheet Page 5 of 5