Health inspection·September 14, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. .Based on observation, interview, and record review, the facility failed to provide an orderly and homelike environment for two of 23 sampled residents (Resident 52 and resident 119), when an old, uncovered sign that showed the name of the previous resident (Resident 42) was not removed from the shared room currently occupied by Resident 52 and Resident 119. This failure had the potential to affect Resident 52 and Resident 119's well-being and cause mental confusion in a setting meant to be their home. Findings: During a concurrent observation and interview on 9/11/23, at 8:06 a.m., with Certified Nursing Assistant 2 (CNA 2), an uncovered typewritten sign (stating, Family will do laundry. followed by a handwritten name of Resident 42) was posted on the closet door visible from both Resident 52 and Resident 119's beds. CNA 2 stated Resident 42's family posted the uncovered sign which was not removed when Resident 42 was sent out to the hospital then later discharged from the facility. CNA 2 stated the old sign should have been removed because it didn't belong to the current residents occupying the shared room. CNA 2 stated housekeeping should have removed the old sign. During an interview on 9/11/23, at 8:50 a.m., with the Housekeeping Aide 1 (Hskg. Aide 1), Hskg. Aide 1 stated housekeeping should remove the personal signs on the wall when a resident is discharged from the facility. Hskg. Aide 1 further stated CNAs or any staff who noticed the old sign was still posted, should have removed it. During an interview on 9/12/23, at 11:45 a.m., with the Director of Nursing (DON), the DON stated old signs posted on the wall showing name of previous resident or anything that pertained or belonged to the old occupant should have been removed by either the housekeeping, CNAs, or Licensed Nurses (LNs) at the time the old resident was discharged or when the bed hold was up for the old occupant. Review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised date February 2021, the P&P indicated, Residents are provided with a safe, clean, comfortable, and homelike environment .Staff provides person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences .The facility staff and management minimizes, to the extent possible, the characteristics of the facility and reflect a depersonalized, institutional setting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 2 of 19 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 09/14/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to verify the physician's wound care treatment order for one of 23 sampled residents (Resident 29) prior to rendering wound treatment. Residents Affected - Few This failure had the potential to not promote the healing of Resident 29's wounds. Findings: A review of the face sheet for Resident 29, indicated Resident 29 was admitted to the facility on [DATE]. During a review of Resident 29's Surgical Consult, dated 9/6/23, the Surgical Consult indicated, Resident 29 had left foot wounds caused by venous stasis disease (veins cannot send the blood from the legs back to the heart). During a concurrent observation and interview on 9/12/23, at 1:29 p.m., with Infection Preventionist (IP), in Resident 29's room, IP administered Resident 29's left foot wound care without checking the physician's wound care order. IP stated the risk of doing the wound treatment without checking the physician's order was giving the wrong wound care to Resident 29. During an interview on 9/14/23, at 11:07 a.m., with Director of Nursing (DON), DON stated, IP should have checked the wound treatment order before administering the wound care for Resident 29 to prevent mistakes in giving wound care. During a review of the facility's policy and procedure (P&P) titled, Wound Care, dated 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Wound treatment administered per order of attending physician and/or wound physician .License nurse to verify that there is physician's order for wound care prior to rendering treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 3 of 19 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 09/14/2023 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 23 sampled residents (14) was referred and was provided podiatry services. Residents Affected - Few This deficient practice resulted in Resident 14 to have pain and at risk of injury because of her long toenails. Findings: A review of Resident 14's face sheet, dated 8/14/23, indicated Resident 14 was admitted to the facility on [DATE] with a diagnosis of peripheral vascular disease (narrowing of the tubes that carry blood to the different parts of the body which can cause poor blood flow to the legs). A review of Resident 14's Minimum Data Set (MDS, a comprehensive assessment tool to guide care), dated 7/5/23, indicated Brief Interview for Mental Status (BIMS, a screening tool to identify resident's cognitive status) score of 13, indicating Resident 14 had intact cognitive function. During a concurrent observation and interview on 9/11/23, at 9:50 a.m., with Resident 14, in Resident 14's room, Resident 14 had long toenails. Resident 14 stated all her toenails were long, painful and were rubbing against each other. During a concurrent observation and interview on 9/11/23, at 9:52 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 14's room, Resident 14 had long toenails. LVN 1 described each of Resident 14's toenails as approximately ½ inch long. LVN 1 stated long toenails could cause Resident 14 pain. During a concurrent interview and record review on 9/12/23, at 10:51 a.m., with the Social Service Director (SSD), the Podiatry Worksheet, dated 6/21/23, was reviewed. The Podiatry Worksheet indicated, the last time Resident 14 had her toenails trimmed was on 6/21/23. SSD stated she was responsible for making the podiatrist referrals in the facility. SSD stated, Resident 14 requested podiatry services, and SSD made the podiatrist referral, on 8/14/23. SSD further stated Resident 14 had not been seen by the podiatrist yet, and SSD did not follow up with the resident's podiatrist referral since 8/14/23 because the podiatrist only went to the facility every 3 months. During an interview on 8/14/23, at 11:05 a.m., with Director of Nursing (DON), DON stated that facility could refer the residents to podiatrist as needed. DON stated the risks for Resident 14 who had long toenails were pain, discomfort and a wound could be created by the long toenails which could get infected. During a review of the facility's policy and procedure (P&P) titled, Foot Care, dated 2018, the P&P indicated, Residents will receive appropriate care and treatment in order to maintain mobility and foot health .Residents will be provided with foot care and treatment in accordance with professional standards of practice. Overall footcare will include the care and treatment of medical conditions associated with foot complications (e.g., . peripheral vascular disease, etc.). Residents will be assisted in making transportation appointments to and from specialists (podiatrist .) as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 4 of 19 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 09/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to provide a safe environment for one of 23 sampled residents (Resident 27) when Certified Nursing Assistant 1 (CNA 1) transferred Resident 27 from bed to shower chair using a mechanical lift (a mechanical device used to assist with transfer and movement of residents who required support for mobility beyond the manual support provided by caregivers alone) by himself and without assistance. This failure had the potential to result in serious avoidable resident injury. Findings: A review of Resident 27's admission Record, dated 9/12/23, indicated Resident 27 was admitted to the facility in 2021 with diagnoses of Parkinson's disease (a chronic disorder that affects movement causing tremors, stiffness, and loss of balance) and other abnormalities of gait and mobility. A review of Resident 27's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 6/13/23, indicated resident required extensive assist with 2 or more person-transfer from bed to chair. A review of Resident 27's Care Plan, dated 8/28/23, indicated, Resident requires [mechanical] lift for safe transfer .Interventions/Tasks - 2 person assist at all times when operating mechanical lift . During a concurrent observation and interview on 9/11/23, at 9 a.m., with Registered Nurse 1 (RN 1), outside by Resident 27's room, Certified Nursing Assistant 1 (CNA 1) transferred Resident 27 from bed to shower chair using the mechanical lift by himself and without assistance from another staff. RN 1 stated mechanical lift transfers were usually 2-person assist. RN 1 also stated sometimes CNAs called licensed nurses to assist with transfers when other CNAs were unavailable. During an interview on 9/12/23, at 8:30 a.m., with CNA 1, CNA 1 stated Resident 27 required a mechanical lift during transfer from bed to chair or chair to bed. CNA 1 stated he transferred Resident 27 using the mechanical lift by himself even though he knew the resident was a 2-person assist. CNA 1 stated transfers with mechanical lift required 2-persons for safe resident transfer. During an interview on 9/14/23, at 10:03 a.m., with the Director of Nursing (DON), the DON stated when a resident required extensive assist, it could be because a resident is not able to follow directions and/or he/she needed more assistance during care. DON also stated some residents can be on extensive assist or total assist (when a resident is totally dependent and not able to help at all). DON stated that either way, use of a mechanical lift always required a 2 or more person-assist for safe transfer. A review of the facility's Patient Lift Owner's Manual titled Battery Operated Patient Lift, revised date 8/10/16, indicated, .TRANSFER FROM BED .Roll the patient onto one side with the assistance of another caregiver .The second caregiver can now pull the remainder of the sling (a cloth harness placed under and around patients with mobility issues to assist during safe transfers from a bed to chair and to help in reducing possible injury for both the patient and the caregiver) from the other side of the patient so that the sling lays flat .Lift the patient above the bed using the hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 5 of 19 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 09/14/2023 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 0689 control . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 6 of 19 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 09/14/2023 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 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 observation, interview, and record review, the facility failed to provide pain-relieving medication to one of 23 sampled residents (Resident 120) before a Stage 4 pressure ulcer (severe tissue damage that extends to muscles, bones and/or tendons) wound dressing change was rendered. Residents Affected - Few This failure resulted in Resident 120's avoidable, unnecessary pain and discomfort during Resident 120's wound treatment which affected Resident 120's ability to maintain his highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 120's admission Record, dated 9/14/23, indicated resident was admitted to the facility on [DATE] with diagnosis of Stage 4 pressure ulcer of sacral region. A review of Resident 120's clinical record titled, Admit/Readmit Assessment, dated 9/12/23, indicated Resident 120 had moderately impaired cognition. Resident 120's Pain Assessment indicated resident verbalized and/or exhibited non-verbal symptoms of pain and had a numeric pain scale (pain rate where 0 is no pain, and 10 is worst pain possible) of 3-4 (mild pain). A review of Resident 120's Physician Order, dated 9/8/23, indicated, Acetaminophen tablet 325 milligrams (mgs) give two (2) tablets via PEG tube (Percutaneous Endoscopic Gastrostomy, a feeding tube) every 4 hours as needed for general discomfort . A review of Resident 120's Care Plan, dated 9/11/23, indicated, Resident 120 had a Stage 4 pressure ulcer on sacrum (present on admission). The Care Plan also indicated, Administer medications as ordered . Further review of the Care Plan, dated 9/11/23, indicated, The resident is at risk for pain related to medical diagnoses .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .Monitor/record/report to Nurse any signs/symptoms (s/sx) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing) . During a concurrent observation and interview on 9/13/23, at 11:10 a.m., with the Infection Preventionist (IP) and Licensed Vocational Nurse 2 (LVN 2), Resident 120's wound dressing change was observed. Resident 120 was noted to be stiff and grimacing during the entire time of wound treatment. Resident 120 was also heard saying, Stop, once before the treatment ended. After Resident 120's wound treatment was completed, IP stated she did not assess resident's pain level nor offered the resident pain medication 30 minutes prior to start of the wound dressing change. IP also stated she did not know if the resident took any pain medication from RN 1 in the morning. During an interview on 9/13/23, at 11:50 a.m., with Registered Nurse 1 (RN 1), RN 1 stated she assessed Resident 120 for his pain level during the start of the morning shift but since the resident denied any pain, RN 1 did not offer resident any pain-relieving medication. RN 1 stated IP did not request any pain-relieving medication for Resident 120 prior to rendering wound treatment. A review of the facility's policy and procedure (P&P) titled Wound Treatment, undated, indicated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 7 of 19 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 09/14/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm .Assess resident for pain prior to treatment, if pain indicated, offer pain medication as ordered, administer pain medication as ordered, and wait 30 minutes - 1 hour for medication to be effective prior to rendering treatment. If pain medication is denied, ask resident if agreeable to render treatment. If not agreeable, cease treatment and contact physician . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 8 of 19 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 09/14/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) and safe use of emergency medications when: 1. Random controlled medication use audit for three of three sampled residents (Residents 53, 59, and 62) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications; and 2. Three of nine emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were not replaced timely after being opened or expired. The failure had the potential for not having emergency medications/supply on hand when needed or expired medications given to the residents. Findings: 1. During the survey, CDRs for three random residents (Residents 53, 59, and 62) receiving PRN (as needed for) controlled medications were requested for review. During an interview with the Director of Nursing (DON) on 9/12/23 at 1:57 p.m., she stated any time a resident requested a PRN controlled medication, the nurse removes the medication from the locked compartment in the medication cart, signs it out of the CDR, administers it to the resident, and then documents the administration on the resident's MAR. a. A review of Resident 62's clinical record indicated he had a physician's order, dated 2/27/23, for Norco (hydrocodone-acetaminophen, a controlled medication for pain) 5/325 milligrams (mg, unit of measurement) 1 tablet by mouth every 8 hours as needed for severe chronic pain. A review of her CDR for Norco indicated she infrequently requested for the PRN Norco. During a concurrent interview and record review with the DON on 9/12/23 at 2 p.m., a review of Resident 62's CDR for Norco 5/325 mg and the April and September 2023 MARs indicated the nursing staff removed and signed out 1 tablet on 4/20/23 at 1700 (5 p.m.) and on 9/1/23 at 9 a.m. but did not document the respective administration on the MARs. The DON confirmed two Norco tablets were not documented as given to the residents and unaccounted for. b. A review of Resident 53's clinical record indicated a physician's order for Norco 5/325 mg, give 1 tablet every 4 hours as needed for moderate pain, dated 6/7/23. During a concurrent interview and record review with the DON on 9/12/23 at 2:09 p.m., a review of Resident 53's CDR for Norco 5/325 mg and the July and August 2023 MARs indicated the nursing staff removed and signed out 1 tablet on 7/17/23 at 1800 (6 p.m.) and on 8/10/23 at 7:15 a.m. without documenting the respective administration on the MARs. The DON confirmed this finding. c. A review of Resident 59's clinical record indicated a physician's order for oxycodone (a potent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 9 of 19 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 09/14/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few narcotic for pain) 10 mg, 1 tablet every 4 hours PRN moderate pain, and 2 tablets every 4 hours PRN severe pain, dated 8/10/23. During a concurrent interview and record review with the DON on 9/12/23 at 2:13 p.m., a review of Resident 59's CDR for oxycodone 10 mg and the September 2023 MAR indicated the nursing removed and signed out 2 tablets on 9/9/23 at 6:15 p.m. but did not document the administration on the MAR. The DON verified two oxycodone tablets for Resident 59 were unaccounted for. A review of the facility's policy and procedures (P&P) titled Controlled Substances, dated 4/2019, indicated: The facility complies with all laws, regulations, and other requirements related to handling . and documentation of controlled medications . The nurse administering the medication is responsible documenting record of administration of dose. A review of the facility's P&P titled Medication Administration, dated 4/2019, indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication . the individual administering the medication records in the resident's medical record . the date and time the medication was administered . 2. On 9/11/23 at 9:44 a.m., a visit to Station 2 Medication Room was conducted with Registered Nurse 1 (RN 1). Three expired e-kits were identified. The CIII-CV E-kit (kit containing Scheduled 3 to Schedule 5 controlled medications) had the expiration date of 4/2023. Two medications, the lorazepam and temazepam (medications to treat agitation and anxiety) tablets, inside the kit had the expiration date of 4/2023. Two large IV Supply e-kits (kit containing solutions and supplies for intravenous injection) were identified with the expiration date of 7/2023. A review of the Emergency Drug Kit Usage Report (log) inside each e-kit indicated one was opened with a content removed on 6/9/23 (3 months ago), and the other was opened on 6/19/23. RN 1 confirmed the findings and acknowledged they should have been replaced. During an interview with the DON on 9/11/23 at 10:04 a.m., she stated, Usually when we use it, we fax to the pharmacy [for replacement] right away. She stated the facility staff requested the replacement shortly after they were opened, but she was not sure what happened and why they were not replaced since June 2023. During a telephone interview with the Consultant Pharmacist (CP) on 9/12/23 at 11:29 a.m., he stated the e-kits should be replaced right away after opening. A review of the facility's P&P titled Emergency Medications, dated 4/2007, indicated: Any time medications and supplies used from the emergency medication kit are used, pharmacy should be contacted immediately for replacement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 10 of 19 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 09/14/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) inspect the emergency medication kits (e-kits) on a monthly basis in accordance with the facility policy and procedures (P&P). Also, the CP failed to identify and report to the facility medication irregularities during the monthly medication regimen review (MRR) for two of 23 sampled residents (14 and 27). The failures resulted in opened and expired e-kits not being replaced timely for resident use; and undetected medication irregularities had the potential for residents not achieving highest therapeutic outcomes. Findings: 1. During a visit to Station 2 Medication Room with Registered Nurse 1 (RN 1) on [DATE] at 9:44 a.m., three expired e-kits were identified in a locked cabinet. The CIII-CV E-kit (kit containing Scheduled 3 to Schedule 5 controlled medications) had the expiration date of 4/2023. Two medications, the lorazepam and temazepam (medications to treat agitation and anxiety) tablets, inside the kit had the expiration date of 4/2023. Two large IV Supply e-kits (kit containing solutions and supplies for intravenous injection) were identified with the expiration date of 7/2023. RN 1 confirmed the findings and acknowledged they should have been replaced. During a telephone interview with the CP on [DATE] at 11:30 a.m., he stated he saw those expired e-kits during one of the previous visits and asked a nurse to request for replacement, but did not document that on the report to the facility. During another interview with the CP on [DATE] at 10:30 a.m., when asked whether he inspected the e-kits during the monthly visits to the facility, the CP stated, When I can. He explained that he did so whenever the nurse was available to open the locked cabinet for him to inspect. He added, I try to. The CP was asked to show written reports indicating he inspected the e-kits on a monthly basis, he showed an example of a report indicating random medication room/med cart audit completed. He stated he did not make any written reports specific to the inspection of the e-kits. A review of the facility's P&P titled Emergency Medications, dated 4/2007, indicated: The Consultant Pharmacist shall inspect the emergency medication kits monthly and record the findings on the record maintained with each kit. 2a. A review of Resident 27's clinical record indicated he had physician's orders for and had been receiving Oyster Shell (calcium carbonate) 500 milligrams twice daily at 9 a.m. and 5 p.m.; and ferrous sulfate (to prevent or treat low blood iron level) 325 mg twice daily at 9 a.m. and 5 p.m., both dated [DATE]. A review of Lexicomp (www.[NAME].com), a nationally recognized drug information resource, indicated the concurrent use of calcium carbonate and ferrous sulfate would lead to Risk Rating D (meaning significant) drug-drug interaction. Specifically, Lexicomp indicated calcium carbonate may decrease the absorption of Iron Preparations . The absorption of ferrous sulfate has been shown to be reduced by 15% to 24% with calcium carbonate. It further indicated to consider separating the doses of the two medications as much time as possible in patients who require chronic use of both agents and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 11 of 19 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 09/14/2023 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 0756 monitor for decreased therapeutic effects of oral iron preparations. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the DON on [DATE] at 9:58 a.m., she confirmed Resident 27 had been receiving both medications at the same time each day since [DATE]. She reviewed the drug information online and stated the calcium would decrease the iron absorption if given together at the same time. She also reviewed Resident 27's clinical record and stated the resident has had low hemoglobin (amount of protein in the red cells able to transport oxygen to all cells in the body ) and hematocrit (represents the percent of red cells in the blood) in February 2023, indicating he was anemic (problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). She also stated the resident had a chronic wound which bled often. When asked whether the CP identified as an irregularity and made a recommendation to separate the two medications, the DON reviewed the resident's clinical record and the MRR binder (which contained the CP's recommendations), and stated she could not find any. Residents Affected - Few During an interview with the CP on [DATE] at 10:40 a.m., he stated he typically would make a suggestion to the nurse based on the resident's reference, but did not make a written recommendation for separating the iron and calcium administration for Resident 27. He confirmed that co-administration of the two medications would lead to decreased absorption of iron. He agreed that he should have made the recommendation in order to minimize the effect of the drug interaction so the resident could receive the full therapeutic effect of the iron. 2b. A review of Resident 14's clinical record indicated she had been receiving Risperdal (an antipsychotic medication) 2 mg once daily since [DATE]. However, there was no documented evidence the facility staff monitored for its adverse effects (or side effects). During a concurrent interview and record review with the CP on [DATE] at 10:45 a.m., he stated, for residents receiving psychotropic medications (drugs that affects brain activities associated with mental processes and behavior), he would make sure the the facility staff monitor for their effectiveness and side effects. He reviewed Resident 14's clinical record and confirmed there had been no monitoring of Risperdal's side effects since [DATE] (10 months ago). He stated it was discontinued when the medication was reduced on that day. When asked whether he identified this as an irregularity and made a recommendation to the facility during the monthly MRR for Resident 14, he stated, It's something that I missed. A review of the facility's P&P titled Psychotropic Medication Use, dated 7/2022, indicated, Residents receiving psychotropic medications are monitored for adverse consequences. A review of the facility's P&P titled, Medication Regimen Reviews, dated 5/2019, indicated, The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility . The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems .other irregularities, for example . inadequate monitoring for adverse consequences; potentially significant drug-drug .interactions. A review of the facility's P&P titled, Pharmacy Services- Role of the Consultant Pharmacist, dated 4/2019, indicated, The Consultant Pharmacist will provide specific activities related to medication regimen review including . Providing the facility with written and electronic reports and recommendations related to all aspects of medication and pharmaceutical services review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 12 of 19 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 09/14/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during the medication administration observation for three of five residents (Residents 11, 20, and 36). Resident 20 received a corticosteroid (aka steroid) oral inhaler without rinsing her mouth with water afterwards; Resident 11 did not receive two medications as scheduled; and Resident 36 did not receive two medications as prescribed. Residents Affected - Some The failures had the potential for the residents not receiving the full therapeutic effect of medications, or adverse affects, compromising their health. Findings: 1. During a medication administration observation on 9/11/23 at 8:05 a.m., Registered Nurse (RN ) 2 was observed preparing 8 medications for Resident 20 including an oral inhaler containing a combination of budesonide and formoterol (budesonide belongs to a class of drugs known as corticosteroids. It works by reducing the irritation and swelling of the airways. Formoterol belongs to the class of drugs known as long-acting beta agonists. It works by relaxing the muscles around the airways so that they open up and you can breathe more easily) 160 micrograms (mcg)/4.5 mcg. On 9/11/23 at 8:16 a.m., at the resident's bedside, RN 2 was observed administering two puffs of the oral inhaler and asking the resident to drink some water after she finished all her medications. RN 2 did not ask the resident to rinse her mouth with water after the inhaler administration. During an interview on 9/11/23 at 8:33 a.m., RN 2 stated she did not ask the resident to rinse her mouth after the oral inhalation because she did not think it was a steroid medication. A review of the pharmacy label on the budesonide-formoterol inhaler with RN 2 indicated, Rinse mouth after use. A review of Resident 20's physician's order indicated to give budesonide-formoterol 160/4.5 mcg/actuation, inhale 2 puffs orally two times a day related to asthma with acute exacerbation, dated 8/8/23. A review of Lexicomp, a nationally recognized drug information resource, indicated the following for the administration of budesonide-formoterol oral inhalation: Rinse mouth with water (spit out without swallowing) after each use to reduce risk of oral candidiasis (oral thrush infection). A review of the facility's policy and procedures (P&P) titled Medication Administration, dated 4/2019, indicated: Oral inhalers are administered per physician orders and manufactures guidelines. 2. On 9/11/23 at 9:06 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed going into Resident 11's room and informing Resident 11 she did not have his eye drops this morning and was waiting for the pharmacy to deliver. In an interview on 9/11/23 at 9:08 a.m., LVN 1 stated the resident had an eye drop medication, brimonidine (medication to treat glaucoma), which was due this morning but they ran out of it since yesterday evening. During a medication administration observation on 9/11/23 at 9:19 a.m., LVN 1 was observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 13 of 19 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 09/14/2023 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 0759 administering 10 medications to Resident 11. The medications did not include brimonidine eye drops. Level of Harm - Minimal harm or potential for actual harm A review of Resident 11's clinical record indicated a physician's order, dated 2/7/23, for brimonidine ophthalmic solution 0.2%, instill 1 drop into left eye two times a day for glaucoma. The facility scheduled it to be administered at 9 a.m. and 6 p.m. daily. Residents Affected - Some A review of Resident 11's clinical record also indicated a physician's order for Miralax powder (a medication to prevent constipation) 17 grams by mouth one time a day for bowel regularity, dated 10/29/22. A review of Resident 11's September 2023 Medication Administration Record (MAR) indicated the facility scheduled Miralax to be administered daily at 9 a.m.; and that LVN 1 documented she administered the Miralax at 9 a.m. on 9/11/23. This was not observed earlier during the administration of 10 medications at 9:19 a.m. During another interview with LVN 1 on 9/11/23 at 1:48 p.m., she stated she did not have the brimonidine eye drop for Resident 11 yet, and confirmed it was not given last night and this morning. Regarding the Miralax, LVN 1 stated she charted the Miralax administration this morning by mistake, and she had not given it yet. She stated, I missed that one. She went to the medication room and momentarily came back with a Miralax bottle, and stated she will give it now. A review of the facility's 4/2019 P&P titled Pharmacy Services Overview indicated, Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 3. On 9/11/23 at 9:28 a.m., RN 1 was observed using the blood pressure (BP) monitor to obtain Resident 36's BP and pulse (heart rate) at his bedside. After finished, she stated the resident's pulse was 54 beats per minute (regular pulse for adults ranges from 60 to 100 beats per minute). During a medication administration observation on 9/11/23 at 9:35 a.m., RN 1 was observed administering 7 medications to Resident 36 including one tablet of Vitamin B Complex (a medication containing a combination of various B vitamins such as B1, B2, B3, B5, B6, B9, and B12) and a tablet carvedilol (medication for high blood pressure) 6.25 mg. A review of Resident 36's clinical records indicated the following physician's orders: - Vitamin B and C Complex (B complex with C), give one tablet by mouth one time a day for supplements, dated 7/22/23; and - Carvedilol 6.25 mg, give 1 tablet by mouth two times a day for hypertension (high BP). Hold for . HR<60, dated 7/20/23. During an interview with RN 1 on 9/11/23 at 1:53 p.m., she showed the Vitamin B Complex bottle and stated that was what she had been administering to the resident. She stated, It's just B-Complex, not B-Complex with C [as ordered]. She acknowledged they were not the same. Regarding the carvedilol administration, RN 1 confirmed twice that she should have held it, as ordered, because the resident's HR was 54. A review of the facility's P&P titled Medication Administration, dated 4/2019, indicated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 14 of 19 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 09/14/2023 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 0759 Medications are administered in accordance with prescriber orders, including any required time frame . Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 15 of 19 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 09/14/2023 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure two of 23 sampled residents (Residents 10 and 27) and a non-sampled resident (Resident 39) were free from a significant medication error when they received insulin (medication to lower blood sugar) past the discard (expiration) date. This deficient practice had the potential for ineffective use of the insulin, which would result in uncontrolled high blood sugar for the residents. Residents Affected - Few Findings: 1. On 9/11/23 at 10:18 a.m., an inspection of Medication Cart #2 with Registered Nurse 1 (RN 1) revealed the following: - A Basaglar Kwikpen (a pre-filled insulin pen containing a long-acting insulin called insulin glargine) for Resident 27, which had a written open date of 8/3/23. - A Lantus SoloStar (a pre-filled insulin pen containing insulin glargine) for Resident 39, which had a written open date of 8/10/23. On 9/11/23 at 10:45 a.m., a review of the pharmacy label on both insulin pens with RN 1 indicated to discard 28 days after opening. RN 1 confirmed the insulin pen for Resident 27 would have expired on 9/1/23 (28 days after opening); and Resident 39's Lantus SoloStar would have expired on 9/8/23. She reviewed Resident 27's current medication administration record (MAR) and stated he had a physician's order to receive 6 units of insulin glargine at each bedtime; and had received 9 doses since 9/1/23. A review of Resident 27's physician's order, dated 7/25/23, indicated to give insulin glargine 100 units/milliliter, inject 6 units subcutaneously (under the skin) at each bedtime for type 2 diabetes (disease that impairs the body's ability to regulate blood sugar). During a concurrent interview and record review with the Director of Nursing (DON) on 9/12/23 at 1:52 p.m., she stated Resident 39's Lantus SoloStar, which was opened on 8/10/23, would have expired on 9/8/23 (28 days after opening). A review of the physician's order with the DON indicated to give Lantus SoloStar, 6 units in the morning and 3 units at bedtime, dated 9/6/23. The DON reviewed the current MAR and stated the resident received a total of 7 doses since the medication expired on 9/8/23. She stated it is important to discard the insulin after 28 days because it may not be as effective anymore. A review of Lexicomp, a nationally recognized drug information resource, indicated to store opened (or in-use) insulin glargine prefilled pens at room temperature and use within 28 days. 2. On 9/12/23 at 11:19 a.m., an inspection of Medication Cart #3 with Licensed Vocational Nurse 1 (LVN 1) identified a Lantus SoloStar pen for Resident 10 with a written open date of 8/12/23. LVN 1 verified the pen would have expired on 9/10/23 (28 days after opening). She reviewed Resident 10's current MAR and stated the resident received a dose of 12 units each day on 9/10 and on 9/11/23. Review of Resident 10's physician order, dated 1/6/23, indicated to give Lantus 12 units subcutaneously at bedtime related to type 2 diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 16 of 19 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 09/14/2023 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 0760 Level of Harm - Minimal harm or potential for actual harm A review of Resident 10's September 2023 MAR indicated he received 12 units at 9 p.m. on 9/10 and 9/11/23. During an interview with the Consultant Pharmacist (CP) on 9/13/23 at 10:45 a.m., he stated giving insulin past its 28-day discard date would not be as effective. Residents Affected - Few A review of an online publication by the Consumermedsafety.org (a nationally recognized medication safety organization), titled Storage of Insulin, it indicated, Never use insulin if expired. The expiration date will be stamped on the vial or pen. Remember if not in the fridge, the date on the vial or pen does not apply. You must throw away after 28 days since outside the fridge. (https://consumermedsafety.org; accessed 9/18/23) During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 1/1/2020, the P&P indicated, The expiration/beyond use date on the medication label is checked prior to administering. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 17 of 19 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 09/14/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure three of nine emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) did not expire; expired insulin (medication to lower blood sugar) prefilled pens were removed from the medication carts for two of two medication carts inspected; and an opened multi-dose vial had an open date in one of two medication refrigerators inspected. The failure resulted in insulin pens given past the expiration date; and the potential for residents to receive expired medications which would result in unsafe and ineffective use. Findings: 1. During a visit to Station 2 Medication Room with Registered Nurse 1 (RN 1) on 9/11/23 at 9:44 a.m., three expired e-kits were identified. The CIII-CV E-kit (kit containing Scheduled 3 to Schedule 5 controlled medications) had the expiration date of 4/2023. Two medications, the lorazepam and temazepam (medications to treat agitation and anxiety) tablets, inside the kit had the expiration date of 4/2023. Two IV Supply e-kits (kit containing solutions and supplies for intravenous injection) had the expiration date of 7/2023. RN 1 confirmed the findings. 2. On 9/11/23 at 10:18 a.m., an inspection of Medication Cart #2 with RN 1 revealed the following: - A Basaglar Kwikpen (a pre-filled insulin pen containing a long-acting insulin glargine) for Resident 27, which had a open date of 8/3/23. - A Lantus SoloStar (a pre-filled insulin pen containing insulin glargine) for Resident 39, which had a written open date of 8/10/23. On 9/11/23 at 10:45 a.m., a review of the pharmacy label on both insulin pens with RN 1 indicated to discard 28 days after opening. RN 1 confirmed the insulin pen for Resident 27 would have expired on 9/1/23 (28 days after opening); and Resident 39's Lantus SoloStar would have expired on 9/8/23. She reviewed Resident 27's current medication administration record (MAR) and stated he had a physician's order to receive 6 units of insulin glargine at each bedtime; and had received 9 doses since 9/1/23. A review of Lexicomp, a nationally recognized drug information, indicated to store opened (or in-use) insulin glargine prefilled pens at room temperature and use within 28 days. 3. On 9/11/23 at 11:15 a.m., during a visit to the Station 1 Medication Room with the Director of Nursing (DON) identified an open aplisol (an agent to aid diagnosis of tuberculosis infection) solution vial without a written open date. A review of the manufacturer's label with the DON indicated to discard 30 days after opening. The DON confirmed it should have been written with an open date. 4. On 9/12/23 at 11:19 a.m., an inspection of Medication Cart #3 with Licensed Vocational Nurse 1 (LVN 1) identified a Lantus SoloStar pen for Resident 10 with a written open date of 8/12/23. LVN 1 verified the pen would have expired on 9/10/23 (28 days after opening). She reviewed Resident 10's current MAR and stated the resident received a dose of 12 units each day on 9/10 and on 9/11/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 18 of 19 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 09/14/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Consultant Pharmacist (CP) on 9/13/23 at 10:45 a.m., he stated giving insulin past its 28-day discard date would not be as effective. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 1/1/2020, the P&P indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. A review of the facility's P&P titled, Medication Storage, dated 11/2020, indicated: The nursing staff is responsible for maintaining medication storage . in a .safe . manner . outdated, or deteriorated drugs . are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056475 If continuation sheet Page 19 of 19