Health inspection·March 22, 2024

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/19/24 at 11:17 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated not knowing if Resident 38 had any negative behavior. During an interview on 3/19/24 at 12:19 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 38 was calm when up in the wheelchair but got restless when back to bed. CNA 1 stated Resident 38 would want to be back to bed when up in the wheelchair only to ask to be back up in the wheelchair after going to bed. CNA 1 also stated Resident 38 moved a lot in bed needing frequent checks by staff for safety. During a follow-up interview and concurrent review of clinical records on 3/19/24 at 12:27 p.m. with LVN 1, Resident 38's MAR from January 2024 to March 2024 was reviewed. LVN 1 stated the MAR for March 2024 indicated Resident 38 had no behaviors during the morning, afternoon, and night shifts. LVN 1 also stated the MAR indicated there was no monitoring for adverse effects from seroquel use. LVN 1 stated, adverse effects that staff should watch out for include drowsiness, increased behavior episodes and nausea (feeling an urge to vomit). During an interview and concurrent review of clinical records on 3/19/24 at 1:52 p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated, in January 2024, pain management was revised to address agitation and behaviors which did not help. MDSC stated, on 2/29/24, Resident 38 was re-evaluated by rehabilitation team with the goal to continue therapy to help with pain management, but Resident 38's participation with therapy did not improve, so quetiapine was started to address agitation. During a review of Resident 38's Psychological Assessment, dated 3/6/24, the Psychological Assessment indicated Resident 38's presenting problem: Agitation/Combative, mental status: confused but pleasant and cooperative. The Psychological Assessment indicated Resident 38 was Restarted 3/1 on quetiapine. During an interview on 3/19/24 at 3:11 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 38's only behavior in the evening shift was calling out and talking a lot but never physically restless even after being helped back to bed. During a review of Resident 38's care plans, the care plans indicated there was no care plan to address use of quetiapine. During a review of quetiapine's Product Monograph, last revised 11/29/21, the Product Monograph indicated an Increased mortality in elderly patients with dementia. It further indicated elderly patients with dementia treated with quetiapine are at an increased risk of death, of which cause of death varied to be either cardiovascular (a general term for conditions affecting the heart or blood vessels) or infectious in nature. The Product Monograph indicated most commonly adverse drug reactions included somnolence (a state of drowsiness or strong desire to fall asleep), dizziness, dry mouth, elevations in serum triglyceride (a type of fat, called lipids, that circulate in your blood), elevation in low density lipoprotein cholesterol (LDL, sometimes called bad cholesterol, makes up most of your body's cholesterol. High levels of LDL cholesterol raise your risk for heart disease and stroke) and decrease in high density lipoprotein cholesterol (sometimes called good cholesterol, absorbs cholesterol in the blood and carries it back to the liver. The liver then flushes it from the body. High levels of HDL cholesterol can lower your risk for heart disease and stroke), weight gain, decreased hemoglobin (a protein in your red blood cells that carries oxygen to your body's organs and tissues and transports carbon dioxide from your organs and tissues back to your lungs) and extrapyramidal symptoms (movement dysfunction such as continuous spasms and muscle contractions, motor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 2 of 4 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 03/22/2024 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 0758 restlessness, rigidity, slowness of movement, tremor, and irregular, jerky movements). Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled Antipsychotic Medication Use, last revised July 2022, the P&P indicated the following: Residents Affected - Few 1. Residents will only receive antipsychotic medications when necessary to treat a specific condition for which it is indicated for. 2. Antipsychotic medications shall generally be used only for the following conditions as documented in the record .: a. schizophrenia (serious mental disorder in which people interpret reality abnormally, may result in hallucinations, delusions and extremely disordered thinking and behavior), b. schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), c. schizophreniform disorder (mental health disorder that causes symptoms of psychosis like hallucinations, delusions and disorganized speech), d. delusional disorder (one or more firmly held false beliefs), e. mood disorders ., f. psychosis in the absence of dementia, g. medical illness with psychotic symptoms and/or treatment-related psychosis or mania .h. Tourette's Disorder ( involves repetitive movements or unwanted sounds (tics) that can't be easily controlled), i. Huntington Disease (causes progressive breakdown of the brain's nerve cells), j. hiccups (not induced by medications) or k. nausea and vomiting associated with cancer or chemotherapy (cancer treatment that uses powerful chemicals to kill fast-growing cells in your body). 3. Antipsychotic medications will not be used if the only symptoms are one or more of the following: a. wandering; b. poor self-care; c. restlessness; d. impaired memory; e. mild anxiety; f. insomnia; g. inattention or indifference to surroundings; h. sadness or crying alone that is not related to depression or other psychiatric disorders; i. fidgeting; j. nervousness; or k. uncooperativeness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 3 of 4 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 03/22/2024 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on interview and record review, the facility failed to operate and provide services in compliance with State regulations when an unusual occurrence of a fall with major injury was not reported to the State Agency. This failure had the potential to result in the lack of oversight for resident safety. Findings: During a review of Resident 7's Progress Notes, dated 3/8/24, the Progress Notes indicated Resident 7 was found sitting on the floor at the bedside while getting ready for the day. The Progress Notes indicated Resident 7 went to a day program but was sent back to the facility after vomiting and verbalizing Not feeling well. During a review of Resident 7's Radiology Results Report, dated 3/9/24, the Radiology Results Report indicated a vertebral compression fracture at L1. During a review of Resident 7's SNF/NF to Hospital Transfer Form, dated 3/9/24, and Patient Visit Information, dated 3/10/24, the Transfer Form indicated Resident 7 was transferred to the hospital for further management on 3/9/24. The Patient Visit Information indicated Resident 7 returned to the facility the next day, 3/10/24, with diagnoses that included closed fracture lumbar vertebra. During an interview on 3/20/24 at 12:07 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, since the fall incident, Resident 7 could not have the head of bed elevated long enough to drink or eat enough. CNA 2 stated Resident 7's pain has caused Resident 7 so much confusion that Resident 7 did not know what she wanted. During an interview on 3/20/24 at 1:06 p.m. with Administrator (Adm), Adm stated Resident 7's fall was not reported to the State Agency because Adm stated not being aware of a requirement to report falls with major injuries. Adm stated the facility did not have a policy and procedure to address reporting of falls with major injury such as fractures. During a review of Barclays California Code of Regulations Title 22, Title 22 indicated, under Article 5. Administration, Section 72541, Unusual Occurrences, occurrences such as major accidents which threaten the welfare, safety or health of patients shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) to the local health officer and the Department. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 4 of 4