Health inspection·January 27, 2022

F 0636 Level of Harm - Minimal harm or potential for actual harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed to ensure two (Resident 3 and Resident 16) of 24 residents' annual assessments were completed within 14 days of the Assessment Reference Date (ARD, ). Residents Affected - Some This failure to complete the annual assessments for 55 and 62 days had the potential to place Resident 3 and Resident 16, respectively, at risk for delayed or unidentified care needs. Findings: During a review of Resident 3's medical record, it indicated the Minimum Data Set (MDS, a resident assessment tool used to guide care) was 55 days overdue. An incomplete annual assessment was dated 11/19/21 and was still in progress on 1/27/22. During a review of Resident 16's medical record, it indicated the MDS was 62 days overdue. An incomplete annual assessment was dated 11/12/21 and was still in progress on 1/27/22. During an interview with MDS assessment nurse (MDS 1), MDS 1 stated, is behind on discharge assessments, has a plan to get it completed, and overlooked Resident 3 and 16's annual assessments. MDS further stated, needs a better system to track resident assessments. During a review of the facility's policy and procedure titled (P&P), Resident Assessments, revised November 2019, the P&P indicated, Annual Assessment (Comprehensive) - Conducted not less than once every twelve months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 2 of 7 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 555418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Healthcare Center 718 Bartlett Ave 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 one sampled resident (Resident 106), received treatment and care for non-pressure ulcers (open areas that is not caused by shear or pressure but may be caused by poor circulation) when Resident 106's left foot and blackened toes on both feet were not identified and treated. This failure had the potential to result in delayed healing and infection for Resident 106. Residents Affected - Few Findings: During a review of Resident 106's admission Record, dated 1/26/22, the admission Record indicated, Resident 106 was initially admitted on [DATE] and has multiple medical diagnoses'; it indicated peripheral vascular disease (slow and progressive circulation disorder that reduces blood supply to the feet) and dementia (loss of memory and impaired decision-making ability). During a concurrent observation and interview on 1/24/22, at 1:55 p.m., with Treatment Nurse (TN), at Resident 106's bedside, Resident 106 feet were observed. Resident 106's feet were elevated on a pillow, left foot's second toe had thick grayish-black dry skin and an ulcer covering the entire top portion of the toe. The left foot's second toe also had an eschar (collection of dry, dead tissue within a wound) on the left middle side of the toe (please see IMG_0228.jpg). Resident 106's second and third toes on the right foot were blackened. TN stated, Resident 106's legs were monitored for worsening of edema but not for the ulcer and darkened skin color. TN further stated, some of Resident 106's toes darkened for some time but could not state when it started. TN could not say if this was a new change in Resident 106's health status. TN stated a podiatrist (a foot doctor) came to the facility but did not know for sure if the podiatrist saw Resident 106's feet. During a concurrent interview and record review, on 1/24/22, at 2:17 p.m., with Director of Nursing (DON), Resident 106's Podiatric Evaluation and Treatment, dated 11/1/21 was reviewed. DON stated, the podiatrist came in November 2021 and saw Resident 106. The Podiatric Evaluation Treatment indicated a recommendation for a follow-up with the vascular team (doctors that are highly trained to treat diseases of the vascular system, the arteries and veins that carry blood to different parts of the body). It also indicated, eschar on left 2nd and 3rd toes and dusky (discoloration sometimes from lack of blood supply) appearance to toes. DON stated the vascular surgeon was not contacted yet and the facility was still working on the referral. During an additional interview with DON, on 1/25/22, at 9:25 a.m., DON stated, the Interdisciplinary Team (a group of individuals representing different departments of the facility) had a conference with Resident 106's representative two weeks ago but the podiatrist's recommendation was not discussed. DON further stated, Resident 106 had a chronic problem with open areas in skin but could not state if this was the same skin problem as in the past. DON stated, did not see Resident 106's feet since this concern was identified on 1/24/22. During a follow-up observation and concurrent interview, on 1/25/22, at 10:13 a.m., with TN, DON, and Social Services Director (SSD), at Resident 106's bedside, TN stated it was a new skin issue. TN stated she saw it on 1/24/22, after it was identified by this writer but did not document the finding because TN thought it was already in Resident 106's record. DON confirmed there was no documentation of Resident 106's foot problems in the clinical record as the facility did not know about it. DON could not answer if Resident 106's foot problem appeared like it had developed over the last 48 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 3 of 7 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 555418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Healthcare Center 718 Bartlett Ave 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hours. TN also stated, because a change in condition report was not completed, Resident 106's attending physician and representative were not notified of the skin issue. During a review of Resident 106's Progress Notes, dated 1/25/22, the Progress Notes indicated, raised circular skin on Resident 106's left second toe measured 1.2 centimeters (cm) by 1.3 cm and on the third toe, measured 0.5 cm by 0.8 cm. During an interview on 1/26/22, at 11:50 a.m., with Wound Doctor (WD), WD stated, the wound on Resident 106's left foot's 2nd toe looked like an arterial ulcer. WD also stated an ultrasound would be needed to check for blood supply. During a follow-up interview with TN, on 1/26/22, at 12:37 p.m., TN stated, there was no training provided in identifying and recognizing skin changes. During a concurrent interview and review of the facility's in-service education, with DON, on 1/27/22, at 11:42 a.m., DON stated, a training titled, Peripheral Vascular Disease, dated 2021, was provided to licensed staff. Review of the training material indicated symptoms and treatments of peripheral arterial disease were covered. TN's name was not listed on this staff training log. During an interview with Licensed Vocational Nurse (LVN) 1, on 1/26/22, at 12:40 p.m., LVN 1 stated she saw the changes in Resident 106's feet but thought they were not something new. LVN 1 further stated she monitored Resident 106's feet but could not explain why it was monitored. During a review of Resident 106's Treatment Administration Record (TAR), dated December 2021 and January 2022, the TAR did not indicate Resident 106's feet/toes skin treatment before 1/25/22. During a review of Resident 106's clinical record, various dates, it indicated the following: - Skin/Wound Note, dated 12/8/21 and 12/15/21, indicated No noted impairments in skin nor new skin issues. - Skin Wound Note, dated 1/8/22, indicated Weekly skin check completed for resident [without] noted impairments in skin. - Skin/Wound Note, dated 1/14/22, indicated No noted new issues. - Nursing Weekly Summary, dated 1/23/22, indicated No new skin issues this week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 4 of 7 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 555418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Healthcare Center 718 Bartlett Ave 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 - Some 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 store and dispose of controlled medications (medications with potential or risk for abuse) when Ativan (medication for anxiety) vials were not disposed and stored in an unlocked refrigerator for one discharged resident. These deficient practices had the potential for loss or diversion of the controlled medications. Findings: During a concurrent observation and interview on 1/24/22, at 11:13 a.m., with Director of Staff Development (DSD), in the medication storage room, seven vials of Ativan 2mg/ml. were observed in an open plastic container in an unlocked refrigerator. DSD stated, the medications belonged to a resident who was discharged on 8/11/21. During an interview on 1/27/22, at 9:08 a.m., with Director of Nursing (DON), DON stated, discontinued schedule II-V medications (medications with potential or risk for abuse) should be submitted to the DON on the same day the resident is discharged , or on the same day the attending physician gave an order for the medication to be discontinued. DON further stated, schedule II-V medications should be in a locked container while awaiting destruction by the pharmacy consultant and a licensed nurse. During a review of facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, revised April 2019, the P&P indicated, All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of. The P&P further stated, Disposal of controlled substances [medications with potential or risk for abuse] must take place immediately (no longer than three days) after discontinuation of use by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 5 of 7 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 555418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Healthcare Center 718 Bartlett Ave Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. During a concurrent observation and interview on 1/24/22, at 11:10 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 was observed entering Resident 105's room without donning PPE and giving cloth protectors to both Residents 105 and Resident 85. Resident 105's room was a yellow room (are where residents who were exposed to other residents that tested positive for COVID-19 were cohorted). CNA 1 stated, I'm sorry and she should have donned a gown and worn gloves before entering the room. Residents Affected - Many During a review of Long Term Care Facility COVID-19 Outbreak Control Recommendations from the Alameda County Health Care Services Public Health Department, dated 10/19/21, under Transmission-Based Precautions and Other Infection Control Measures, it indicated, in the yellow rooms of COVID-exposed residents, N-95 respirator, eye protection, gowns, and gloves with hand hygiene before donning and after doffing gloves are done upon room entry and between residents. Based on observation, interview, and record review, the facility failed to follow their policies and procedures to mitigate the spread of COVID-19 (a respiratory virus that can cause mild to serious respiratory illness) when resident room doors were left open in the COVID-19 positive wing with no physical barrier between COVID-19 positive and COVID-19 negative residents and when an employee did not wear personal protective equipment (PPE, equipment worn to minimize exposure to hazards) before entering a room requiring transmission-based precautions (infection-control precautions in health care). These deficient practices had the potential to spread infection among residents and for Residents 3, 16, 48, 50, 51, 71, 72, 77, 80, 85, 96, 98. 99. 100, 103, 104, 105, 106, 107, 108, and 111 to contract COVID-19. Findings: 1. During an observation on 1/24/22, at 11:30 a.m., the red zone (area for COVID-19 positive residents) and yellow zone (area for COVID-19 exposed residents) were observed separated by red tape on the floor with no physical barrier between the zones, and the doors to COVID-19 positive resident rooms 3, 4, 5, 6, 7, 9, 10, and 11 were open. It was also observed the doors to rooms 2, 12, 14, 15, 16, 17, 18, 19, 21, and 22 were opened exposing those residents to COVID-19. During an interview on 1/24/22, at 12:30 p.m., with Infection Preventionist (IP) and Administrator (ADM), IP stated, they were told by Alameda County Public Health (ACPH) they could have the doors open if a resident is a fall risk. ADM stated the nurse from Healthcare Associated Infections Program (HAI) said they did not need the barrier between the different zones. IP further stated they follow the county recommendations. During an interview on 1/24/22, at 4:21 p.m., with Alameda County Public Health Nurse (PHN), PHN stated, there should be a barrier between the red and yellow zone to separate the red and yellow zones, if doors need to be left open for resident safety. PHN stated if there is not a barrier, the doors need to be closed for all the rooms. During a review of Long Term Care Facility COVID-19 Outbreak Control Recommendations from the Alameda County Health Care Services Public Health Department, dated 10/19/21, under Resident Placement, Movement Restrictions & Transferring Residents, it indicated, doors should remain closed, if possible, in the red and yellow zones. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 6 of 7 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 555418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Healthcare Center 718 Bartlett Ave Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVD-19) Prevention Control, dated March 2020, the P&P indicated, The response to the current outbreak of coronavirus disease is based on the most current recommendations from health policy officials, state agencies and the federal government. The P&P further indicated, Residents with suspected or confirmed COVID-19 infection are placed in a separate room or cohorted with other residents with the same infection status. Event ID: Facility ID: 555418 If continuation sheet Page 7 of 7