Health inspection·January 12, 2024

F 0550 not standing. Level of Harm - Minimal harm or potential for actual harm During an interview with the infection preventionist (IP) on 1/12/24 at 10:50 a.m., she stated CNA should have sit down to feed Resident 24 and not standing. Residents Affected - Few Review of the facility's policy, Assistance with Meals, dated 3/2022, indicated . 3. Residents who cannot feed themselves would have been fed with attention to safety, comfort, and dignity, for example: a. not standing over the residents while assisting them with meals; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 2 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure documentation of whether the advance directive was discussed with one of 12 residents (Resident 13) was discussed with the resident or family upon admission/re-admission, when the Physicians Order for Life-Sustaining Treatment (POLST) section D was not filled in completely. This failure had the potential of the incorrect treatment being administered in a life-threatening emergency. Findings: During a chart review for Resident 13, a POLST, dated 2/14/17, was located. Section D had three check boxes: 1. Advance directive dated___ available and reviewed. 2. Advance directive unavailable. 3. No advance directive. None of these boxes were checked. So, no indication if advance directive was discussed with Resident 13 or her family. During an interview with the infection preventionist (IP), on 1/10/24 at 11:46 a.m., she confirmed the latest POLST in chart, dated 2/14/17, did not indicate about advance directive (Section D is blank). During an interview on 1/10/24 at 12:01 p.m., with the IP, she stated that medical records confirmed that Resident 13 was readmitted on [DATE], and the family did not indicate about advance directive, so section D on POLST was not filled out. During an interview on 1/12/24 at 9:45 a.m., with the director of nursing (DON), he stated the doctor should have review the advance directive, and a representative (staff member, usually DON or admission coordinator) would review with the Resident and/or responsible party (RP). Someone should have verified the previous POLST on Resident's readmission, or at least discussed with Resident 13 or her RP if there are any updates. A review of the facility's policy and procedure (P&P), titled Advance Directive, revised 09/2022, indicated .Information about whether or not the resident has executed an advance directive was displayed prominently in the medical record in a section of the record that was retrievable by any staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 3 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0584 Level of Harm - Minimal harm or potential for actual harm 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 maintain safe and comfortable temperature of 71 to 81 degrees Fahrenheit (F) when: Residents Affected - Some 1. One of 12 sampled residents (Resident 9) complained that the room was cold; and 2. 12 resident rooms, dining/activity room, living room, and one of the two hallways were found to be below the comfortable temperature range. This failure had the potential to result in residents' decreased sense of well-being and exposed to an uncomfortable environment. Findings: During a concurrent observation and interview on 1/10/24 at 10:05 a.m., Resident 9 was in the dining/activity room with blankets over her. Resident 9 stated she informed the staff that the room was cold, and the staff provided blankets. During a concurrent environmental tour and interview on 1/10/24 at 10:40 a.m., and at 3:12 p.m. with the maintenance staff (MS), the MS measured the temperature of the following rooms using the infrared thermometer (a handheld device used to measure the temperature from a distance): Dining/Activity Room = 63.3 F Hallway MM = 70.2 F Living Room = 63.7 F Room AA = 68.2 F Room BB = 63.1 F Room CC = 70.9 F Room DD = 67.8 F Room EE = 68.5 F Room FF = 67.8 F Room GG = 68.4 F Room HH = 66.7 F Room II = 68.2 F Room JJ = 65.5 F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 4 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0584 Room KK = 65.7 F Level of Harm - Minimal harm or potential for actual harm Room LL = 70.9 F Residents Affected - Some The MS stated the nurse should have inform him if a resident complained of cold room temperature. The MS stated he was not informed about the cold rooms. During an interview on 1/11/24 at 9:01 a.m. with certified nursing assistant C (CNA C), CNA C stated they offered blankets to the residents and reported it to the licensed nurse. During an interview on 1/11/24 at 9:41 a.m. with the director of nursing (DON), he stated the facility staff would monitor the temperature and notify the licensed nurse. During an interview on 1/11/24 at 3:34 p.m. with the MS, he stated he did not check the temperature of the rooms. Review of facility's Homelike Environment policy, dated February 2021, indicated The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect personalized, homelike setting. These characteristics include comfortable and safe temperatures (71-81 degrees Fahrenheit). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 5 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their abuse policy for one of 12 residents (7) when activities assistant J (AA J) reported that she heard certified nursing assistant K (CNA K) slapped Resident 7 twice, but the incident was not reported to the state agency department. Residents Affected - Few Findings: Review of Resident 7's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 7's Daily Nurses Notes by the infection preventionist (IP), dated 11/30/23 at 6 p.m., indicated one staff reported that while passing by Resident 7's room, she heard another staff slapped Resident 7 twice. During an interview with the IP on 1/11/24 at 3:15 p.m., she stated AA J reported to her about Resident 7's room when she heard CNA K slapped Resident 7 twice. The IP stated the facility did the investigation and did not substantiate the allegation, so the facility did not report the incident to the state agency department. During an interview with the director of nursing (DON) on 1/11/24 at 4:55 p.m., he stated he reviewed the facility's abuse policy and confirmed Resident 7's allegation should have been reported to the state agency department. Review of the facility's policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 9/2022, indicated Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; . 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 6 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 6's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including depression (feeling empty, sad, or worthless), bipolar disorder (extreme mood swings that include emotional highs and lows), psychosis (conditions in which people have trouble distinguishing between what is real and what is not), and chizoaffective disorder (a mental health disorder that is marked by having false, fixed beliefs, hearing voices or seeing things that aren't there, periods of increase in energy and decrease need for sleep, and depression). Residents Affected - Few Review of Resident 6's PASRR Level 1 Screening Document, dated 1/16/19, indicated Resident 6 was not marked for having diagnosed mental disorder such as schizoaffective disorder, psychosis, depression, or bipolar disorder. During an interview with the director of nursing (DON) on 1/12/24 at 12:40 p.m., he reviewed Resident 6's PASRR Level 1 Screening Document and stated Resident 6 should be marked for having diagnosed mental disorder because Resident 6 had schizoaffective disorder, psychosis, depression, and bipolar disorder diagnoses. Review of the facility's policy titled admission Criteria revised date 3/2019, indicated all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre- admission Screening and Resident Review (PASRR) process. The facility conducts a level 1 PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. If the level 1 screen indicates that the individual may meet the Criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. The social worker is responsible for making referrals to the appropriate state- designated authority. Upon completion of the Level II evaluation, the state PASRR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs and weather placement in the facility is appropriate. Based on interview and record review, the facility failed to develop and accurately assess the preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) requires specialized services such as referral to a mental health authority), received mental illness diagnoses and did not receive a level two screening to ensure they received the services needed for two of twelve sampled residents (5 and 6). This failure had the potential to put the residents at risk for not receiving appropriate care and services. Findings: Review of Resident 5's clinical record indicated she was admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses including bipolar disorder (mental illness which a person can experience mood swings (period of overly happy or periods of feeling sad), anxiety disorder (feelings of worry and fears), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a concurrent interview and record review on 1/10/24, at 10:12 a.m., with the director of nursing (DON), he reviewed Resident 5's PASSR dated 5/5/21, indicated the resident did not have a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 7 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete mental illness and no referral for a level two screening (an evaluation to determine the need for services and the appropriate setting for those with Disabilities). No other PASRR with the updated diagnoses to include the mental illnesses was located in Resident 5's medical record and he confirmed the PASRR was not coded correctly and stated that diagnosis of bipolar and anxiety disorder was not indicated. During a concurrent interview and record review on 1/10/24, at 10:30 a.m., with the minimum data set nurse (MDSN), She reviewed Resident 5's clinical record and stated Resident 5 was originally admitted on [DATE] with diagnoses including bipolar disorder. Event ID: Facility ID: 555841 If continuation sheet Page 8 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for two of 12 sampled residents (Residents 5 and 10) when: 1. Resident 5's antipsychotic medication (medications work by altering brain chemistry to help reduce psychotic symptoms like having false, fixed beliefs, hearing voices or seeing things that aren't there, and disordered thinking) care plan was incomplete and not person-centered; and 2. For Resident 10, there was no care plan developed specifically for communication deficit related to language barrier. These failures had the potential for inaccurate development and implementation of personalized and resident-centered care plans that would address the residents' identified concerns and needs. Findings: 1. Review of Resident 5's clinical records indicated she was re admitted to the facility on [DATE] with diagnoses of bipolar disorder (mental disorder characterized by periods of elevated mood) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning, often with poor decision-making). During a concurrent interview and record review on 1/10/24 at 9:51 a.m., with the minimum data set nurse (MDSN), she reviewed Resident 5's care plans and stated a care plan for Zyprexa (an antipsychotic medication that can treat several mental health conditions) was initiated on 2/16/22 and revised on 12/22/23, the care plan was focused on psychotropic medications for bipolar disorder and did not indicate Resident 5's history of behavior manifestations to monitor for bipolar disorder. The MDSN further stated the care plan was incomplete and not person-centered care planning because Abnormal Involuntary Movement Scale (AIMS, a rating scale that was designed in the 1970s to measure involuntary movements known as tardive dyskinesia). 2. During observations on 1/8/24, at 10:05 a.m.,1/9/24, at 9:02 a.m., Resident 10 was lying in bed in her room and was using gestures talking in her own native language other than English and on 1/9/24, at 9:05 a.m., Resident 10 was communicating with certified nursing assistant D (CNA D) through gestures, pointing and using her native language other than English. Review of Resident 10's clinical record indicated she was admitted on [DATE], and had diagnoses of cognitive communication deficit, history of falling, hypertension (high blood pressure), and type 2 diabetes mellitus (high blood sugar). During an interview and concurrent record review on 1/10/24 at 11:24 a.m., with the MDSN, she reviewed Resident 10's minimum data set (MDS, an assessment tool), dated 10/25/23, indicated the resident had communication problem sometimes could makes self-understood and sometimes could understand others. The MDSN confirmed there was no care plan developed specifically intended for communication deficit related to language barrier and person-centered care planning should have been developed. Review of the facility policy and procedure Care plans Comprehensive Person- Centered, revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 9 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0656 Level of Harm - Minimal harm or potential for actual harm 3/2022, indicated The comprehensive, person- centered resident care plan was developed within 7 days upon resident's admission, reviewed quarterly, annually or as often as needed as there is a change of condition. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is develop and implemented for each resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 10 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 interview and record review, the facility failed to ensure the residents received the necessary care and services for one of 12 residents (6) when Resident 6's electrocardiogram (EKG, records the electrical signal from the heart to check for different heart conditions) was not done every year as ordered by the physician. This failure had the potential to affect the resident's care and could jeopardize her health and well-being. Residents Affected - Few Findings: Review of Resident 6's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 6's physician order indicated she had an order for her EKG to be checked every year to rule out QT (the space between the start of the Q wave and the end of the T wave on EKG which indicates the time it takes for the heart to contract and refill with blood before it beats again) prolongation (occurs when the heart muscle takes longer to contract and relax than usual; it can affect heart rhythms and lead to sudden cardiac arrest), started on 2/25/20. Review of Resident 6's clinical record indicated the EKG was done for her was on 2/15/21. During an interview with the director of nursing (DON) on 1/12/24 at 11:03 a.m., he reviewed Resident 6's clinical record and confirmed the EKG was done for Resident 6 was on 2/15/21. There was no documented evidence EKG for year 2020, and 2022. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated registered nurses should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 11 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow their oxygen administration policy for one of two sampled residents (Resident 8) when staff did not place an Oxygen in Use sign outside the entrance to the resident's room. This failure had the potential to compromise the resident's safety. Residents Affected - Few Findings: Review of Resident 8's clinical record indicated she was admitted on hospice care (to assist in the care and comfort of individuals with terminal illness) with a diagnosis of hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time). Resident 8 had a physician order, dated 12/15/23, for oxygen at 2 liters per minute (LPM, oxygen flow rate) via nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen source) as needed for shortness of breath. During an observation on 1/8/24 at 9:43 a.m., Resident 8 was lying in bed receiving oxygen via NC. There was no Oxygen in Use sign posted outside the entrance to Resident 8's room. During a concurrent observation and interview on 1/8/24 at 10:33 a.m. with licensed vocational nurse B (LVN B), LVN B acknowledged there was no Oxygen in Use sign posted outside the room entrance. She stated there should have a sign posted outside the room. During an interview on 1/9/24 at 9:41 a.m. with the director of nursing (DON), the DON stated there should have been an Oxygen in Use sign posted outside the room. Review of facility's Oxygen Administration policy, dated October 2010, indicated place an Oxygen in Use sign on the outside of the room entrance door. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 12 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview, and record review, the facility failed to follow the manufacturer's recommendations for maintaining the bed side rails for 15 residents (3, 4, 5, 6, 7, 8, 10, 12, 13, 14, 17, 18, 22, 23, and 24). This failure had the potential to place the residents at risk of entrapment and injury. Findings: During an observation on 1/12/24 at 2:02 PM, Resident 13 was in bed sleeping, and had both upper 1/4 side rails in the up position. During an observation on 1/12/24 at 2:02 PM, Resident 23 was observed having 1/4 upper side rails up whenever she was in bed. During an observation on 1/9/24 at 10:35 a.m., the beds of Residents 4, 6, 7, 17, and 22 had partial side rails on both sides. During an interview with the maintenance staff (MS) on 1/10/24 at 2:14 p.m., he stated for the first three months the residents had bed side rails, he inspected the bed side rails every week. After that three months, he inspected the bed side rails every month. However, the MS was only able to provide the logs for the bed side rail assessments from 1/2023 to 4/2023. The MS stated he did not assess the bed side rails from 5/2023 to 11/2023, but he inspected the bed side rails last month in 12/2023. However, the MS was still not able to provide the log for his assessment in 12/2023. The MS stated the residents' bed side rails should have been inspected every month. MS acknowledged there were no assessment log documented, and there were no proof the bed side rail assessments were done. Review of the facility's 2023 user manual, User-Service Manual Joerns Bed Frames Easy Care Bed, indicated Maintenance: Maintenance/Inspection Information: Visually inspect the bed and accessories for broken welds or cracks and check for loose hardware on a monthly basis. If any broken welds or cracks are found, remove bed from service immediately and replace affected parts. Tighten any loose hardware . Preventative Maintenance: . A thorough inspection should be conducted monthly . 3. Check monthly for loose bolts, nuts, pins, and other retaining hardware. Tighten any loose hardware . 5. Visually inspect the bed frame and accessories for any cracking, bending, or hole enlargement. If found, remove the bed from service immediately, and replace the affected parts. During an observation on 1/12/24 at 2:44 p.m., the bed of Resident 5 had partial side rail on one side. During an observation on 1/12/24 at 2:47 p.m., the bed of Resident 24 had partial side rails on both sides. During an observation on 1/12/24 at 2:50 p.m., the bed of Resident 10 had partial side rail on one side During an observation on 1/8/24 at 8:58 a.m., Resident 12 was in bed sleeping with half side rails in the up position. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 13 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0700 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/9/24 at 9:02 a.m., Resident 12 stated he used the side rails to help him get up in bed. During a concurrent observation and interview on 1/8/24 at 9:02 a.m., Resident 3 had the half side rails in the up position. Resident 3 stated he used the side rails for positioning and to help him to get out of bed. Residents Affected - Some During an observation on 1/8/24 at 9:43 a.m., Resident 8 was in bed sleeping with the half side rails in the up position. During an observation on 1/8/24 at 9:47 a.m., Resident 14 was in bed with half side rails in the up position. During an observation on 1/8/24 at 9:49 a.m., Resident 18 was in bed sleeping with half side rails in the up position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 14 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 ensure the emergency kits (E-kits, containers with specialty medications which may be needed in an emergency) did not contain expired medications, when two of four E-kits had expired medications. This failure had the potential of a resident being administered an emergency medication which was expired, and not effective. Findings: During an observation of the facility's medication room, on 1/09/24 at 1:43 PM, with licensed vocational nurse E (LVN E), the injectable E-kit (E-kit with liquid medications which are administered by needle, either directly or through an IV (catheter inserted into a blood vessel for direct access)) had a. 3 ampules of Chlorpromazine (used to treat mental illness) that had expiration dates of 12/2023, b. 3 ampules of Gentamycin (used to treat infections) 80 milligrams (mg, a metric unit of mass) per 2 milliliters (ml, a metric unit of volume) that had expiration dates of 12/2023, c. 2 ampules of Epinephrine (a hormone involved in the body's fight-or-flight response) 1 mg/1 ml that had expiration dates of 12/2023, d. 2 ampules of Atropine (used to treat heart rhythm problems, stomach or bowel problems) 1 mg/1 ml that had expiration dates of 11/2023, and e. an IV supply E-kit bin that had an expiration date of 4/2023. During an interview on 1/9/24 at 1:54 PM, with licensed vocational nurse E (LVN E), he stated there was no excuse for the IV E-kit to be expired, and he also acknowledged the medications in the injectable E-kit which were expired. During an interview on 1/12/24 at 9:50 AM, with the director of nursing (DON), he stated the nurses should be monitoring expiration dates on the E-kits. DON also stated pharmacy should have monitored the expiration dates on the E-kits. A review of the facility's policy and procedure (P&P), titled Medication Storage: Storage of Medication, indicated .outdated, contaminated, discontinued, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 15 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 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 Residents Affected - Some 1. The medication cart was locked when unattended; and 2. The opened multi-dose containers of house medications/supplements had no open date. These failures had the potential of medication (or other items) being taken without the nurse's knowledge and medications being held past the usage period after being opened. Findings: 1. During an observation, on 1/8/24 at 8:29 a.m., the medication cart was in the nurses station, unattended and unlocked. After approximately one minute, a nurse came into the nurses station. During an interview, on 1/8/24, at 08:30 a.m., with licensed vocational nurse A (LVN A), she stated when she got report, at about 8:00 a.m., the medication cart was unlocked. She stated she did not notice until she was asked, by surveyor, about cart being unlocked, which was at 8:30 a.m. During an interview, on 1/12/24 at 9:54 AM, with the director of nursing, (DON), he stated the unlocked cart was unacceptable. It should have been locked at any time. A review of the facility's policy and procedure (P&P), titled Administering Medications, revised April 2019, indicated .the medication cart was kept closed and locked when out of site of the medication nurse or aide. 2. During an observation of medications being administered to residents, on 1/8/24 at 9:31 AM, with LVN A, Aspirin (used to treat pain, fever, headache, and inflammation) 81 milligrams (mg, a metric unit of mass), Vitamin B12 (plays an essential role in red blood cell formation), Docusate capsules (used to treat constipation), and Florastor (a supplement to help promote the body's own natural intestinal flora) were all opened but did not have a date written on them as to when they were first opened. During an interview on 1/8/24 at 9:31 AM, with LVN A, she confirmed that there were no open dates on the four containers. A review of the facility's policy and procedure (P&P), titled Administering Medications, revised April 2019, indicated .When opening a multi-dose container, the date opened is recorded on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 16 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. Food preparation equipment were not maintained clean and/or in good condition including: a. Commercial can opener b. Cutting boards; 2. Five dented can goods were stored on the rack with ready to use cans; 3. Nine bananas with multiple blackish dots on top of the tray cart inside the dry storage area has no date; 4. One orange fruit soft and rotten with grayish particles, three pieces of green peppers has multiple blackish spots with grayish particles without date and one white onion inside the plastic has no date; and 5. One [NAME] bottled with approximately 300 milliliters (ml, a metric unit of volume) yellow liquid has no label and two bottles of opened Ajax powder cleanser was stored between the sink and the stove with food on top of the stove or cooking equipment. These failures had the potential to cause food contamination and food-borne illness for 23 residents who received food from the kitchen out of a census of 24. Findings: 1.a. An observation in the kitchen and concurrent interview with the cook on 1/8/24 11:32 a.m., showed a commercial can opener stored in a holder attached to a preparation table. The can opener blade surface was covered with a thick, wet, brownish residue. Also on the blade, in the seam where the blade attached to the can opener, and on the cogwheel (the part of the can opener that helps turn the can), there was a thick, brown residue. The shaft (handle) of the can opener was sticky to touch. The cook confirmed the above observations and he stated the can opener was rusty and dirty. 1.b. An observation on 1/8/24 at 12:10 p.m., showed plastic cutting boards stored in a rack on the bottom shelf of the preparation table located across from the stove. Two green cutting boards had deep cut marks and one yellow plastic cutting board had significant cut marks on the surface. During a concurrent observation and interview on 1/8/24 at 12:11 p.m., with the cook she confirmed the above observation and stated that the cutting boards were in poor condition and need to be thrown. The cook further stated that everything in the kitchen should be clean and when equipment was worn, like cutting boards, and should have been replaced. Review of the policy and procedure titled Sanitization dated 11/2022, indicated all utensils, equipment was kept clean, maintained in good repair and are free from corrosions, breaks, cracks and etc (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 17 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 . Cutting boards are washed and sanitized between uses. The food service area was maintained in a clean and sanitary manner. 2. During an observation tour and concurrent interview on 1/8/24 at 8:23 a.m., one dented can of 6.63 Lbs. unsweetened applesauce, two Mandarins oranges cans, and two cans of Las [NAME] chili beans vegetables were stored in the rack along with the ready to use cans inside the dry food storage room. The cook stated the dented cans should have been seperated. Review of the facility's policy titled, Food Storage-Dented Cans, dated 2018, indicated All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return . 3. During the initial tour of the kitchen on 1/8/24 at 8:17 a.m., nine bananas with multiple blackish dots on top of the tray cart inside the dry storage area has no delivery date. During a concurrent observation and interview on 1/8/24 at 8:21 a.m., with the cook, she confirmed the above observation and the food delivered to the facility needs to be marked with a received date or without dated delivery sticker. Review of the facility's policy titled, Storing Produce, dated 2018, indicated, check boxes of fruit and vegetables for rotten, spoiled items Throw away all spoiled items . Bananas should be stored at room temperature. When fully ripe, bananas may be stored in the refrigerator for five days, as long as they have no open skins 4. During a concurrent observation and interview on 1/8/24 at 8:45 a.m., with the cook and she confirmed that there was one orange fruit soft and rotten with grayish particles, three pieces of green peppers has multiple blackish spots with grayish particles without date and one white onion inside the plastic without received date or without dated delivery sticker. She further stated there should have delivery received date or dated delivery sticker on it. Review of the undated facility's policy titled, Labeling and Dating of foods, indicated All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Food delivered to facility needs to be marked with a received date Delivery sticker is dated, and it can serve as the delivery date for the product Produce is to be dated with received date. Review of the facility's policy titled, Storing Produce, dated 2018, indicated, check boxes of fruit and vegetables for rotten, spoiled items Throw away all spoiled items, when storing vegetables that should remain crisp, such as green peppers celery and etc .they will stay fresh longer if you place them in a sealed bag or container. 5. During a concurrent observation and interview on 1/8/24 at 11:04 a.m., with the cook she confirmed there were one spray bottled with approximately 300 mls yellow liquid has no label and two bottles of opened Ajax powder cleanser was stored between the sink and the stove. The stove or cooking area had food on top. The cook stated that chemicals should have been stored in the storage area away from the food service area and all containers of poisonous and toxic materials should have been labeled for easy identification. The cook open the unlabeled [NAME] bottled, smelled and stated this liquid is pine sol used to clean the floor. Review of the facility's policy titled, Poisonous and Toxic Materials, dated April 2007, indicated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 18 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 Poisonous and toxic materials shall be stored in areas away from the food service area . All containers of poisonous and toxic materials will be prominently and distinctively marked or labeled for easy identification. When not in use, poisonous and toxic materials will be stored on selves that are used for no other purpose, or stored in a place outside the food storage, food preparation, and cleaned equipment and utensil storage area. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 19 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control practices for 5 of 12 residents (6, 8, 10, 18, and 24) when: Residents Affected - Some 1. For Resident 6, oxygen tubing was not changed for 3 weeks; storage bag for oxygen tubing was not changed for about one and a half year; the humidifier bottle was undated; and the filter of oxygen concentrator was so dusty; 2. Certified nursing assistant F (CNA F) did not sanitize her hands before serving lunch tray to Resident 10; and 3. CNA G, CNA H, and CNA I did not sanitize their hands after carrying the chair and before feeding Resident 24, Resident 8, and Resident 18. These failures had the potential to spread infection in the facility. Findings: 1. Review of Resident 6's admission Record indicated she was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) diagnosis. Review of Resident 6's physician order, dated 8/30/22, indicated she had a physician order for oxygen 2 liters (L, a metric unit of volume) per minute per resident's request every shift for comfort. During an observation with the infection preventionist (IP) on 1/8/24 at 8:52 a.m., Resident 6 was on oxygen, and her oxygen tubing was dated 12/18/23; the humidifier bottle was undated, and the filter of the oxygen concentrator was so dusty. The filter had a layer of dust on it. During a concurrent interview with the IP, she stated the oxygen tubing should be changed every week; the humidifier bottle should have been dated and changed every week; and the filter of oxygen concentrator should be cleansed every week. During an observation and interview with the IP on 1/8/24 at 12:06 p.m., Resident 6's storage bag for oxygen tubing was dated 6/26/22. Resident 6 stated she put her oxygen tubing in the storage bag when she went out of the room, but her storage bag had not been changed for months. The IP stated the storage bag for oxygen tubing should have been changed every week. Review of the facility's undated policy, Oxygen Equipment, indicated Procedure for Oxygen Equipment: . 3. Pre-filled humidifiers are to be dated and replaced every week. 4. Tubing should be replaced every week . 7. Oxygen concentrator filters will be cleansed every week. 2. During an observation on 1/8/24 at 12:10 p.m., CNA F threw trash into the trash can, CNA F fixed Resident 4's scarf then went to the meal cart and carry the lunch tray to Resident 10. CNA F opened the tea bag and put it in the cup of hot water for Resident 10 without sanitizing her hands. During an interview with CNA F on 1/8/24 at 12:15 p.m., CNA F stated she should have sanitize her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 20 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 hands before serving the residents their meals. Level of Harm - Minimal harm or potential for actual harm During an interview with the IP on 1/12/24 at 10:50 a.m., she stated CNA should have sanitize their hands before serving the residents their meals. Residents Affected - Some 3. During an observation and interview with CNA G on 1/8/24 at 12:25 p.m., CNA G carried a chair over, sit down, and fed Resident 24 without sanitizing his hands. CNA G stated he should have sanitize his hands before feeding the residents. During an observation and interview with CNA H on 1/8/24 at 12:35 p.m., CNA H carried a chair over, sit down, and fed Resident 8 without sanitizing her hands. CNA H stated she should have sanitize her hands before feeding the residents. During an observation and interview with CNA I on 1/8/24 at 12:40 p.m., CNA I carried a chair over, sit down, and fed Resident 18 without sanitizing his hands. CNA I stated he should have sanitize his hands before feeding the residents. During an interview with the IP on 1/11/24 at 11:14 a.m., she stated CNA should have sanitize their hands before feeding the residents. Review of the facility's policy, Handwashing/Hand Hygiene, dated 8/2019, indicated The facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: . l. After contact with objects . o. Before or after eating or handling food; p. Before and after assisting a resident with meals; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 21 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain the reach-in freezer in good and safe operating condition when the reach-in freezer had ice-build up and freezer temperature was negative forty degrees Fahrenheit. This failure had the potential to cause the freezer to be ineffective for keeping food frozen and may lead to food spoilage and food-borne illness (illness resulting from contaminated food) for 23 residents who received food from the kitchen out of 24 residents. Residents Affected - Many Findings: During the kitchen initial tour with the cook on 1/8/24, at 8:30 a.m., she confirmed the temperature logs for refrigerator 1, 2 and freezer were blank. She stated that checking of the temperature for refrigerator 1, 2 and freezer was done at 6:00 a.m., and p.m. every day but she forgot to log this morning. During the kitchen initial tour with the cook on 1/8/24, at 8:33 a.m., the reach-in freezer had significant ice build-up inside, outside the freezer doors and both sides of the freezer gaskets. The outside thermostat and the two thermometers inside the freezer indicated negative forty degrees Fahrenheit. The cook confirmed the above observation and stated the maintenance needs to come and check the freezer problem. During an interview on 1/8/24 at 3:00 p.m., with the maintenance staff (MS), he stated he was aware about the problem in the reach-in freezer this morning 1/8/24 at 9:30 a.m., and he fixed the thermostat late this morning. The MS further stated the company that the facility was contracted with will be in the facility later this afternoon or tomorrow morning 1/9/24. During a concurrent observation and interview with the MS on 1/8/24 at 3:13 p.m., the reach-in freezer still had significant ice build-up inside, outside the freezer doors and both sides of the freezer gaskets. The MS checked the two thermometers inside the freezer and thermostat oust side the freezer and it was negative twenty-nine degrees Fahrenheit. During a concurrent interview and record review on 1/11/24 at 10:10 a.m., with the director of nursing (DON), he reviewed the work order from the service company of the freezer dated 1/9/24 indicate thermostat kit was replaced and cleaning coil. During a concurrent observation and interview on 1/11/24 at 10:19 a.m., with the DON, he checked the thermostat outside the refrigerator, two thermometers inside the freezer and it was 19 degrees Fahrenheit, the freezer gasket on the left side was ripped and on the right-side bottom part was loose. He stated the maintenance would replace the gasket today. 2017 Food Code Section 4-501.11 states that equipment must be maintained in a state of repair and condition that meets the requirements specified by the food code. Review of the facility's policy titled, Refrigerators and Freezers, dated November 2022, indicated This facility would ensure safe refrigerator and freezer maintenance, temperatures, and sanitation Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and closing in the evening. The supervisor takes immediate action if temperatures are out range. Actions necessary to correct the temperatures are recorded on the tracking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 22 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0908 Level of Harm - Minimal harm or potential for actual harm sheet, including the repair personnel and/or department contracted. Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Maintenance schedules per manufacturer guidelines are scheduled and followed. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 23 of 24 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 555841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Post Acute 238 Virginia Avenue Campbell, CA 95008 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of resident rooms have at least 80 square feet per resident. Findings: 1. room [ROOM NUMBER], a four-person room, measured 73.4 square feet per resident. 2. room [ROOM NUMBER], a four-person room, measured 73.4 square feet per resident. 3. room [ROOM NUMBER], a four-person room, measured 73.4 square feet per resident. During the survey, none of the rooms were observed to inhibit the staff from providing care or services, or the residents from receiving adequate care and services. The staff and residents moved freely in the rooms unhampered by the lack of space. Wheelchairs were easily accommodated. The residents had no concerns regarding the space or privacy in their room. Recommend waiver remain in effect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555841 If continuation sheet Page 24 of 24