Health inspection·June 27, 2023

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on interview and record review the facility failed to ensure the facility menu was followed. This failure had the potential to result in residents having unmet nutritional need due to substitution of nonequivalent foods. Findings: During an interview on 3/15/23 at 2:15 p.m. with the Dietary Supervisor (DS), DS was asked about food supplies and menu substitutions. DS stated the facility was having issues with the facility food delivery vendor. DS stated when the vendor did not have the ordered food item, the vendor would substitute another item such as cauliflower when broccoli was ordered, but not available. During an interview on 3/15/23 at 3:06 p.m. with the facility [NAME] 1, and [NAME] 2, (translation by Certified Nursing Assistant), [NAME] 1 stated sometimes the cooks did not have the food items they needed to cook the foods planned on the menu, and would have to substitute items and change the menu. [NAME] 2 stated the cooks would change the menu when they did not have the necessary ingredients. [NAME] 2 stated she checked the menu in advance and would tell DS what items were missing, and DS would change the menu using substitute items. During an interview and concurrent record review on 3/21/23 at 11:30 a.m., with DS, the Menu Substitution Log was reviewed. DS stated the Menu Substitution Log indicated the following dated entries: 2/4/23 (dinner): No tater tots, used mashed potatoes. No coleslaw, used Italian vegetables. 2/9/23 (breakfast): No cream of wheat to make hot farina, used oatmeal. 2/10/23 (lunch): Cranberry gelatin salad peach fluff wasn ' t prepared. No peaches. Used apricots, fresh strawberries. 2/11/23 (lunch): No pumpkin cheesecake, used pumpkin pie. 2/14/23 (lunch): No turkey meat to make meat balls for renal, gave ground beef. 2/16/23 (lunch): no berry cheesecake bar, used vanilla pudding. 2/16/23 (dinner): No diced ham, used diced chicken. 2/23/23 ( dinner): No bow tie pasta, used macaroni pasta. No mandarin oranges, used peaches. 2/28/23 (dinner): No soy sauce, used sweet and sour sauce. 3/1/23 (lunch): No cherry and cream squares, used banana pie. Didn ' t have all ingredients needed to make. 3/4/23 (lunch): No Dijon mustard for chicken and no chicken thighs, used chicken breasts with turkey gravy. No chicken gravy. No brussel sprouts, used carrots. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 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 056475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Post Acute 3269 D 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 0803 3/5/23 (breakfast): No muffin mix to make apple raisin muffins, used wheat toast and rest of English muffins. Level of Harm - Minimal harm or potential for actual harm 3/6/23 (dinner): No split peas to make soup, used vegetable soup. Residents Affected - Few 3/7/23 (lunch): No peanut butter cookie. Made chocolate chip cookies. 3/7/23 (dinner): No beef broth, used chicken broth. No cornbread, used biscuit mix. Not enough fresh fruit for fruit salad. During an interview on 3/21/23 at 1:00 p.m., with the Administrator (Admin), Admin stated she was aware that food substitutions were an issue. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 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 056475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Post Acute 3269 D 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 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, interview, and record review, the facility failed to maintain a safe environment when: Residents Affected - Few 1. The porch window was broken, and residents were exposed to sharp glass edges for over two weeks. 2. Twenty containers labeled, Caution Corrosive, were not stored in accordance with manufacturer's safety recommendations. These failures placed residents, staff, and visitors at risk for accident and injury. Findings: During an observation on 3/15/23, at 1:30 p.m., on the smoking porch, the porch window was broken with sharp edges exposed to residents. Resident 2 was observed on the porch, unsupervised. During a concurrent observation and interview on 3/21/23, at 10:40 a.m., with Licensed Vocational Nurse (LVN) 1, on the smoking porch, the porch window was broken with sharp edges, and Resident 2 and Resident 4 were on the smoking porch. LVN 1 confirmed the window was broken with sharp edges. A review of the facility's smoking list indicated six residents smoked, and designated times were 9:30 a.m., 2:30 p.m., and 7:30 p.m. The designated smoking location was the back patio smoking porch where the window was sheared and broken with sharp areas. In an interview on 3/21/23, at 12:00 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she took residents to the back porch to smoke. CNA 1 stated she saw the broken window over the past few weeks, and the area was not walled or roped off. During a concurrent interview and record review on 3/21/23, at 10:45 a.m., with the Maintenance Director (Main-D), the facility maintenance log was reviewed. The Main-D stated the window was broken for two weeks, but there was no documentation on the maintenance log that indicated there was a broken window on the smoking porch or a plan to repair the window. During an observation on 3/15/23, at 1:30 p.m., at the facility entrance, 20 containers labeled Caution Corrosive were stored. During an observation on 3/21/23, at 10:40 a.m., at the facility entrance, 20 containers labeled Caution Corrosive were stored. During a concurrent interview and record review, on 3/21/23, at 10:45 a.m., with Main-D, the Material Safety Data Sheet (MSDS) for the 20 corrosive containers was reviewed. The Main-D stated he was waiting for the company to pick up the containers. Review of the MSDS separated the chemicals into kitchen and laundry room categories and indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 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 056475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Post Acute 3269 D 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 Kitchen Chemicals: Level of Harm - Minimal harm or potential for actual harm 1. Residents Affected - Few [NAME]- Skin corrosion, causes severe skin burns and eye damage. May be harmful if swallowed. Do not inhale or ingest. Store locked up. 2. Pot-n-Pan Pink Suds- Eye and Skin irritation. Do not inhale or ingest. Handle in accordance with good industrial hygiene and safety practice. Use personal protection as recommended. Store containers in cool, dry and well-ventilated place. Keep out of reach of children. 3. Aqua Clean Diamond- Skin burns and eye damage. Do not breathe vapors or ingest. Store locked up. 4. Aqua Dry- Avoid contact with eyes, skin, inhalation, and ingestion. Causes severe eye damage and skin burns. Store locked up. 5. Aqua Pure- Severe skin burns and eye damage. Do not breathe vapors or ingest. Store locked up. Laundry Room: 6. Premium Power Surge- Harmful if swallowed, harmful in contact with skin, harmful if inhaled, causes skin irritation, may cause damage to organs through prolonged or repeated exposure. Dispose of contents/container to an approved waste disposal. Handle in accordance with good industrial hygiene and safety practice. Use personal protection as recommended. Store containers in cool, dry and well-ventilated place. Keep out of reach of children. 7. Aqua Bright Bleach- Causes severe skin burns. Do not breathe vapors or ingest. Store locked up. 8. Soil Buster Break- Causes severe skin burns and eye damage. Store locked up. May be harmful if swallowed and harmful when contacted with skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 5 of 5