Health inspection·July 24, 2025

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on observation, interview, and record review, licensed nursing staff did not fully assess and treat the declining mental status for one of 15 sampled residents (Resident 36). Resident 36 had been declining the use of medication to treat a mental condition. The medication also became unavailable through the pharmacy. Staff did not follow up with the physician to initiate a new plan of treatment.This resulted in the high probability Resident 36 experienced unnecessary behaviors and falls.Record review of the document admission Record showed the facility admitted Resident 36 on 1/14/2021 and diagnoses included Paranoid Schizophrenia (a mental illness characterized by disturbances in thinking, perception, and behavior. It's marked by intense delusions and hallucinations, particularly auditory, and often involves paranoia)Record review of the document Care Plan Report dated 6/9/2025 showed Resident 36 had behaviors which included being Resistive to medications, lab work, assistance with ADLs (activities of daily living) and mobility. The goal was for her to Participate in care and behave in a safe and respectful manner 5/7 days a week.During an interview on 7/21/2025 at 10:05 a.m., Resident 36 was asked about her care at the facility. She became tearful and stated she Did not want to talk about it.During an interview on 7/23/2025 at 10 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 36 was alert but confused and could get tearful when asked to do something she did not want to do. LVN 1 stated staff Try to talk calm to her.Record review of the document Order Summary Report dated 7/23/2025, showed Resident 36 was to be administered a Secuado Transdermal Patch once per day for schizophrenia.Record review of the document Progress Notes *NEW* (MD note) dated 5/28/2025 showed Resident 36 was paranoid schizophrenic and was on Secuado with good response.Further review of the Progress Notes *NEW* showed the following:On 6/8/2025: Resident 36 was found on the floor next to her bed.On 6/9/2025: Resident 36 refused neuro status checksOn 6/12/2025: Resident 36 refused her medicationsOn 6/27/2025: Resident 36 was refusing medications which led to elevated blood pressures.On 7/8/2025 Secuado patch was unavailable at attempted pharmacies.Record review of the document Progress Notes *NEW* dated 7/15/2025 showed Resident 36 had an unwitnessed fall and was found on the floor. She was having Increased delusions: trying to go to Hawaii. The Secuado patch remained unavailable.Record review of the document Psychotropic MAR (Behavior and SE Monitors Only dated July 2025, showed staff had monitored Resident 36 daily for behaviors. Review of the document showed Resident 36 had 3-6 episodes of behaviors (paranoia) each day. During an interview on 7/23/2025 at 11:45 a.m. the facility's Director of Nursing (DON) confirmed the behaviors and stated Resident 36 had not been wearing the Secuado patch and, as a result, she was Getting more behaviors.Record review of the document Progress Notes *NEW* dated 7/15/2025 showed Social Services had Notified and emailed MD for recommendation of more effective than Secuado Transdermal Patch.resident still has confusion. Waiting for reply.During an interview on 7/23/2025 at 11:45 a.m. the DON was asked if there had been a response from the doctor. She stated the Director of Social Services had reported to her the doctor wanted to have Resident 36 re-evaluated before developing a new plan. The DON confirmed the evaluation had not been scheduled and she would have expected staff to follow-up sooner due to Resident 36's increase in falls and delusions. The DON stated Resident 36 was Up and down and it was getting Challenging. She stated Resident 36 typically would tell staff I am going home. However recently she was telling staff she was Going to Hawaii.Record review of the document Progress Notes*NEW* dated 7/23/2025 showed the physician ordered a referral to psychiatry for the evaluation. Record review of the document Prescriber showed the order was placed on 7/23/2025.Record review of the document Behavioral Assessment Intervention, and Monitoring dated 2001, showed The IDT (interdisciplinary team) thoroughly evaluates new or changing behavioral symptoms to identify underlying causes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 2 of 6 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 07/24/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm and address any modifiable factors that may have contributed to the resident's change in condition, including: physical or medical changes (for example): .change related to medication; and/or worsening of or complications related to other condition. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 3 of 6 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 07/24/2025 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 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.

F761 Labeling and Storage of Drugs and Biologicals Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the medication storage room (a locked room used to store medications and medical supplies) when following was noted: A. In the medication and medical supplies cart (a mobile cart that stored medication and supplies for immediate use), there were: 1. Two vials of four milligrams/four milliliters (4mg/4 ml) Lasix (furosemide, diuretic medication to eliminate excess fluid from the body) for Resident 67 were kept inside a brown plastic bag. The bag had sticky liquid sticking to it and it was kept in the first drawer of the cart.2. An opened, used, multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) (a substance used in a skin test to help diagnose tuberculosis (TB) infection) was not dated.3. An opened, used Latanoprost 0.005% eye drops (medication used to treat elevated pressure in the eye) bottle was not dated for Resident 12.4. An opened, used Brimonidine eye drops (medication used to lower the pressure in the eyes and to relieve redness of the eye) bottle was dated 5/20 for Resident 13. B. There were molded foods inside a lunch box under the sink in the medication storage room. These failed practices could contribute to unsafe medication and medical supplies storage in the facility.During a concurrent observation and interview on 07/23/25 at 08:59 a.m. with the Licensed Vocational Nurse (LVN) 1 in the facility's medication storage room, there were 2 vials of Lasix inside a brown plastic bag in the first drawer of a medication cart. There was sticky liquid underneath the bag. LVN 1 stated she did not know why the medication was not returned or destroyed since Resident 67 was discharged . LVN 1 stated facility needed to follow the policy to return or destroy these medications after the resident was discharged . During a record review of the admission Record (admission Record is a document used to communicate basic information about a resident) printed on 7/24/2025, the record indicated Resident 67 was discharged from the facility on 04/07/25. During a concurrent observation and interview on 07/23/2025 at 09:16 a.m. with LVN 1 in the facility's medication storage room, there were opened, used medication vial and eye drops bottle without dates, including a Tuberculin Purified Protein Derivative (Mantoux) vial, and Resident 12's Latanoprost 0.005% eye drops. LVN 1 stated all the opened, used medication vial and eye drops bottles should be dated so the nurses would discard the unused vial and eye drops after 28 days. There was an opened, used Brimonidine eye drops dated 5/20. LVN 1 stated the Brimonidine eye drops belonged to Resident 13, but she did not know it was the date, 20 or the year, 2020 written on the eye drops label. LVN 1 stated it was important to write down the date with month, date and the year to provide clarity. During a concurrent observation and interview on 07/23/25 at 09:33 a.m. with LVN 1 in the facility's medication storage room, there were white fuzzy growth on the foods inside a lunch box, kept under the sink. LVN 1 stated it was the staff's lunch box, and it was not supposed to be under the sink. LVN 1 looked at the lunch box and stated the food was molded. During an interview on 07/23/25 at 09:42 a.m. with Director of Nursing (DON), the DON stated the staff should not keep their food in the lunch box under the sink inside the medication storage room. The DON stated the molded foods would cause unsafe and unhygienic environment in the medication storage room posing a potential contamination to the medications and medical supplies in the room. During a review of facility's Policy and Procedure (P&P) titled Medication Labeling and Storage dated February 2023, the P&P indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 4 of 6 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 07/24/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm destroying these items . Multi-dose vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555418 If continuation sheet Page 5 of 6 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 07/24/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: [NAME] (CK) 1 did not wear a beard restraint while preparing resident food.The kitchen dry storage, refrigerator, and resident refrigerator had multiple beyond use by date food items.Food items in the dry storage were stored less than six inches from the floor.The ice scoop was open to air.These failures had the potential for contamination of food resulting in food borne illness for the 54 residents who received food from the kitchen. During a concurrent interview and observation on 7/21/25, at 10:00 a.m. with CK 1, CK 1 stated they were preparing French bread for the resident's lunch. CK 1 was not wearing a beard restraint, and their mustache and sideburns were uncovered. CK1 stated they would put on a hair net to cover their facial hair.During a concurrent observation and interview on 7/21/25 at 10:05 a.m., with Kitchen Manager (KM), the kitchen refrigerator and dry storage were observed. The refrigerator had one container of tomatoes with a use by date of 6/15/25, one sour cream with a use by date of 6/25/25, one whipped butter with a use by date of 6/15/25 and one container of cooked rice with a use by date of 7/10/25. The dry kitchen had one chopped onion spice with a use by date of 6/17/25, one dill weed spice with a use by date 5/25/25, and one cream of tartar spice with a use by date 5/10/25. The dry storage had one crate of onions, two crates of potatoes and one unsealed bag of rice that were stored approximately three inches above the floor. KM stated food that was past their use by date should have been thrown out and was a risk for foodborne illness. KM stated food should have been stored 6 inches above the floor to prevent contamination. During an observation on 7/21/25, at 10:55 a.m., the resident refrigerator had one nutritional shake with a use by date of 6/30/25.During an observation on 7/21/25, at 10:36 a.m., the ice scoop was observed in the resident hallway uncovered and open to air.During a concurrent observation and interview on7/21/25, at 12:35 p.m., with KM, The ice scoop was observed in the resident hallway uncovered and opened to air. KM stated the ice scoop should have been covered and it was a risk for contamination.During an interview 7/24/25, at 12:47 p.m., director of nursing (DON), DON stated food that was stored less than 6 inches from the floor, and food beyond their use by date, were a potential risks for food borne illness to the residents. DON stated an uncovered ice scoop was a risk for contamination. During a review of the facility's policy and procedure (P&P) titled, Policy and Procedure, reviewed 1/10/23, the P&P indicated, Dietary (Food and Nutrition Services) staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent their hair from contacting exposed food. The P&P indicated Beards, sideburns and mustaches shall be covered.During a review of the facility's policy and procedure (P&P) titled, Food receiving and Storage, reviewed July 2025, the P&P indicated, Food shall be received and stored in a manner that complies with safe food handling practices. The P&P indicated Food in designated dry storage areas shall be kept off the floor (at least 6 inches) . The P&P indicated All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).During a review of the facility's policy and procedure (P&P) titled, Cleaning Procedure #24 Ice Machine, dated 2023, the P&P indicated, Ice Scoop . Keep it protected from contamination (in a sanitary enclosed holder). Event ID: Facility ID: 555418 If continuation sheet Page 6 of 6