Health inspection·March 16, 2023

F 0755 he moved his body against the wheelchair to help with the itch and that his itchiness was 6-7 out of 10. Level of Harm - Minimal harm or potential for actual harm During a review of facility's policy and procedure titled ORDERING AND RECEIVING NON-CONTROLLED MEDICATIONS dated 2007 it indicated, Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. Residents Affected - Some 2. During a medication administration concurrent observation on 3/13/23 at 11:00 a.m., with LVN 2, LVN 2 was observed administering 6 medications via the resident's GJ tube (gastrostomy-jejunostomy tube -insert in the abdomen that delivers nutrition and medications directly to the stomach). Then she administered Morphine Sulfate 20 mg/milliliter (ML) by placing 0.25 mL under the resident's tongue. A review of Resident 2's clinical record indicated a physician's order, dated 11/08/22, for morphine concentrate solution: 100 mg/5 mL (20 mg/mL): amount 0.25 mL twice a day at 09:00 and 21:00 for pain. Monitor respirations. Administer by GJ tube. During a subsequent interview on 3/13/23 at 2:34 p.m., LVN 2 stated that the Physician's order indicated to give morphine via GJ tube. LVN 2 stated I made a mistake and gave it via wrong route. During a review of facility's policy and procedure titled Administering Medication, dated April 2019 it indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication, and .the individual administering the medication records in the resident's medical record .the route of administration . 3. The Controlled Drug Records (CDRs) for five (5) random residents receiving PRN (meaning as needed) controlled medications were requested for review during the survey. During a concurrent interview and record review with the Charge Nurse (CN) on 3/14/23 at 11:00 a.m., she stated any time a controlled medication was needed for a resident, the nurse would remove the medication from the medication cart, sign it out on the CDR (or the count sheet) to indicate it was removed, and document the administration on the MAR. a. Resident 31 had two (2) physician's order, dated 4/16/22, for Norco (hydrocodone -acetaminophen (a potent controlled medication for moderate to severe pain) 5-325 mg, . 1 Tablet by mouth every 6 hours as needed for Moderate Pain (4-7) (A pain scale where 0 means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain.) . 2 tablets by mouth every 6 hours as needed for severe pain (8-10). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 2 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 During a concurrent interview and record review with the CN on 3/14/23 at 11:15 a.m., a review of Resident 31's CDR for Norco and the November 2022, December 2022, and March 2023 MARs reflected the following were removed but not documented on the MARs: - Residents Affected - Some Two tablets on 11/4/22 at 6:25 a.m. One Norco tablet on 12/11/22 at 1 a.m. One Norco tablet on 3/3/23 at 5:30 a.m. The CN verified the findings and acknowledged 4 Norco tablets were not accounted for. b. Resident 50 had a physician's order, dated 5/9/22, for Oxycodone (a potent controlled medication for moderate to severe pain) 10 mg, 1tablets by mouth for Moderate - Severe Pain (4-10) During a concurrent interview and record review with the CN on 3/14/23 at 11:31 a.m., a review of Resident 50's CDR for Oxycodone and the May 2022 MAR reflected the nursing staff signed out Oxycodone on the CDR but did not document the respective administrations on the MAR on One Oxycodone tablet on 5/10/22 at 9:00 a.m. One Oxycodone tablet on 5/15/22 at 8:30 p.m. One Oxycodone tablet on 5/16/22 at 7:42 p.m. One Oxycodone tablet on 5/19/22 at 3:00 p.m. The CN verified this finding and acknowledged 4 Oxycodone tablets was not accounted for. CN stated nursing staff are supposed to document in the CDR and the MAR, as the physician will look in the MAR to check if a medication has been administered, not in the CDR [count sheet]. c. Resident 25 had a physician's order, dated 1/13/23, for Promethazine-codeine (a controlled medication for cough) syrup 6.25 -10 mg milligrams (mg, unit of measurement)/5 mL milliliters (mL, unit of measurement), to give 5 mL by gastric tube (a tube inserted through the belly that brings nutrition directly to the stomach) 4 times a day as needed for cough. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 3 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 On 3/14/23 at 11:38 a.m., a review of Resident 25's CDR for Promethazine- Codeine 5 mL 4 times a day as needed for cough and the January 2023 MAR with the CN indicated licensed nursing staff signed on the CDR - Residents Affected - Some 5 mL on 1/13/23 at 2:00 p.m., 5 mL on 1/18/23 at 9:50 p.m., 5 mL on 1/21/23 at 9:00 p.m., 5 mL on 1/22/23 at 9:00 p.m., 5 mL on 1/25/23 at 9:00 p.m., but did not document on the MARs to show they were administered to the resident. The CN verified 5 missing documentations on the MAR to account for 25 mL of Promethazine - Codeine syrup. d. Resident 45 had a physician's order, dated 2/22/23, for hydrocodone - acetaminophen (a potent controlled medication for moderate to severe pain) 5-325 mg, 1.5 tablets by mouth 30-60 minutes prior to PT (Physical Therapy) for pain management. During a concurrent interview and record review with the CN on 3/14/23 at 11:44 a.m., a review of Resident 45's CDR for Hydrocodone - Acetaminophen and the February 2023 MAR reflected the nursing staff signed out two tablets on the CDR on 2/24/23 at 4:15 p.m. and documented they gave it at that time but did not document the waste of the half tablet. The CN verified this finding and acknowledged ½ (0.5) tablet was not accounted for. During a concurrent interview and record review with the director of nursing (DON) on 3/14/23 at 3:18 p.m., she stated when the nurse is pulling a controlled medication from the medication cart, she is to confirm the order, and then prep the medication in the MAR. As soon as the controlled medication is administered, the nurse is to sign the MAR 'as given. She stated, All medications must be documented in the MAR, if it is not documented, it is not given. During a review of facility's policy and procedure titled Administering Medication, dated April 2019 it indicated, The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 4 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure expired medications were removed, and medications were labeled and stored according to manufacturer's instructions, and medication refrigerator temperature log was complete, for one out of one medication room and two out of two medication carts, when: 1. Expired and discontinued controlled drugs were not removed from the medication carts. 2. Expired drugs were not removed from the medication room. 3. Expired drugs were not replaced or removed from the emergency Kit (eKit -a kit containing medications for emergency situations) in the medication refrigerator. 4. Medication refrigerator temperature logs were incomplete. These deficient practices had the potential for residents to receive medications with reduced potency and had the potential to result in medication errors. Findings: 1A. During an inspection of the [NAME] Wing Medication Cart with licensed vocational nurse 2 (LVN 2) on 3/13/23, at 2:34 p.m., Four expired and discontinued medications were identified in the locked compartment of the medication cart, as follows: a. a. An opened bottle containing Furosemide Oral Solution 10 mg per mL without an open date. The manufacturer's label indicated it was good for 90 days after opening. b. An opened and expired bottle containing Miacalcin (A drug used to treat bone disease in women) 200 Unit Nasal Spray without an open date. The manufacturer's label indicated it was good for 35 days after opening. c. A discontinued bubble pack containing 26 tablets of Tramadol (a potent controlled medication for moderate to severe pain) 50 mg Tablet. LVN 2 stated the medication was discontinued on 3/3/23 (2 weeks ago). d. A medicine pill bottle containing 14 tablets of Zolpidem Titrate (a drug used for temporary sleep problems in adults) 10 mg tablet for a Resident who was discharged on 3/2/23 (2 weeks ago). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 5 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 - Some During an interview on 3/13/23 at 2:50 p.m., with LVN 2, she verified the findings above and stated she did not know how long the controlled medications were in the cart or in the Medication room and did not know who was responsible for the rotating and removing of the expired medication. LVN 2 verified the above medications were expired and/or discontinued. During an interview with the DON on 3/14/23 at 2:52 p.m., she stated the staff nurse was supposed to give expired and discontinued controlled medications to her right way. The DON verified the above bubble packs should have been removed from the medication cart to prevent loss or medication errors. During a review of the facility's policy and procedure titled Discontinued Medications, dated 10/2007, it indicated, If a prescriber discontinues a medication, the medication container is removed from the medication cart immediately. 1B. During an inspection of the South Wing Medication Cart with licensed vocational nurse 3 (LVN 3) on 3/14/23 at 10:44 a.m., five expired medications were identified in the locked compartment of the medication cart, as follows: a. An opened bottle containing Sodium Chloride (Normal Salt tablets) 1 gm tablets with an expiration date of 01/2023. b. An undated and opened bottle of Breo Ellipta (a drug to treat lung disease) 200-25 mcg (microgram, unit of measurement) inhaler without an open date. The manufacturer's label indicated, Discard 42 days after opening. c. An opened bottle of Brimonidine Tartrate Ophthalmic Solution (a drug used to treat high fluid pressure in the eye) 0.2% 10 ml bottle had an open date of 1/2023. LVN 3 stated it was good for 28 days after opening. d. An opened bottle of Latanoprost (a drug used to treat high pressure in the eye) 0.005% eye drop with a date open labeled 01/13/23. The pharmacy label indicated: Refrigerate until opened, Discard 42 days after opening. e. An unopened, undated, and un-refrigerated bottle of Latanoprost 0.005%. The pharmacy label indicated: Refrigerate until opened, Discard 42 days after opening. During an interview on 3/14/23 at 11:03 p.m., with LVN 3, she verified the above findings, and the sodium chloride tablets had expired; the brimonidine eye drops was good for 28 days after opening; and the Breo inhaler and the latanoprost eye drops should have been dated or kept in the refrigerator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 6 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 until opened. Level of Harm - Minimal harm or potential for actual harm According to Lexi-comp (www.[NAME].com, a nationally recognized drug information resource), store unopened bottle of latanoprost solution in the refrigerator and once opened, the container may be stored at room temperature for 6 weeks (https://online.[NAME].com/lco/action/doc/retrieve/docid/pated, assessed on 3/3/23). Residents Affected - Some 2. During an inspection of the medication room with Licensed vocational nurse 2 (LVN 2) on 3/13/23 at 3:37 p.m., four expired medications were identified in the medication room, as follows: a. An unopened bottle containing Vitamin B-6 100 mg with an expiration date of 07/2022 b. A second unopened bottle containing Vitamin B-6 100 mg, with an expiration date of 07/2022 c. A third unopened bottle containing Vitamin B-6 100 mg, with an expiration date of 05/2022 d. An opened bottle of Aspirin 81 mg Tablet an expiration date of 01/2023. During an interview with the LVN 2 on 3/13/23 at 4:15 p.m., LVN 2 stated that she was not aware of who is responsible for the removal of expired medication from the medication cart or how often the expired medications are removed. During an interview with the Charge Nurse (CN) on 03/13/23 at 4:20 p.m., the CN verified the medications were expired and should have been removed from active stock. 3. During an inspection of the medication refrigerator at the nurse's station with the CN on 3/13/23 at 03:12 p.m., 3 expired medications were identified in the medication refrigerator as follows: a. A controlled medication E-kit (an emergency kit which contains medications for use in emergency situations) was identified with expiration date of 1/2023. Inside the E-kit were Novolog R (A rapid acting Insulin) that expired on 1/2023. The CN verified the E-kit was expired. b. A Latanoprost eye drop with an opened date of 1/1/2023. The manufacturer's label indicated, Discard 42 days after opening. c. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 7 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 A Miacalcin nasal spray undated with open date. The manufacturer's instructions indicated it is good for 35 days once opened. During an interview with the CN on 03/13/23 at 03:15 p.m., the CN verified the above findings and confirmed the Ekit expired on 01/2023. Residents Affected - Some 4. During a concurrent record review and interview with the CN on 03/13/23 at 03:15 p.m., the temperature logs for the medication refrigerator from October 2022 to March 2023 were reviewed. The logs of December 2022 and February 2023 were identified to be incomplete. CN stated that it is the responsibility of the AM and PM shift licensed staff to check the medication refrigerator temperature and log accordingly. The CN verified that the logs did not have any entries for PM shift on December 30, 2022, AM and PM shifts on December 31, 2022, and PM shifts for February 24, 25, 26, 27 and 28, 2023. The CN stated that no documentation means the temperature check was not done. The CN stated, It's important to make sure the temp is correct, otherwise the medications will go bad. A review of the facility's policy and procedure titled EMERGENCY PHARMACY SERVICE AND EMERGENCY KITS, dated 2007, indicated, The consultant pharmacist and provider pharmacy designee checks the emergency kits monthly for expiration dating of the content. A review of the facility's policy and procedure titled Storage of Medication, dated 2007, indicated, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stocks, disposed of according to procedures for medication disposal . and reordered from pharmacy . if a current order exists. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 8 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: Residents Affected - Some 1. water temperature in hand washing station in the kitchen was cold. 2. two dietary staff did not cover facial hair while inside the kitchen. 3. food items in upstairs kitchen refrigerator was not labeled, undated and was stored beyond used by date. 4. food stored in upstairs freezer was not labeled and dated. 5. vegetables in downstairs walk-in refrigerator was stored beyond use by date. 6. automatic ice machine dispenser had white and yellowish build up residue. 7. automatic ice machine filter was not changed according to manufacturer's guidelines. These failures had the potential to cause food contamination and food borne illness. Findings: 1. During an initial tour of the upstairs kitchen and concurrent interview on 3/13/23, at 9:39 a.m., with MS (Maintenance Director) 1, water in hand washing sink was cold after running it for 45 seconds. MS 1 checked water temperature with a thermometer (a measuring device), water temperature reached 88.3 °F (degrees Fahrenheit - temperature scale). MS 1 stated, water temperature for hand washing should be between 105 °F - 120 °F. During a review of facility's policy and procedure (P&P) titled, Personal Hygiene, (undated), the P&P indicated, .Hand washing ust take at least (20) seconds with hot water.All hand washing stations must have: Hot water. 2. During an observation and concurrent interview on 3/13/23, at 9:28 a.m., CK (Cook) 1 walked across the kitchen without hair protection to cover his facial hair. CK 1 stated he was in the kitchen getting supplies and ingredients, therefore, he did not need facial hair covering. A review of the United States Food and Drug Administration Food Code 2017, under section titled, Hygienic Practices, Hair Restraints, section 2-402.11 indicated, FOOD EMPLOYEES shall wear hair restrains such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; AND UNWRAPPED SINGLESERVICE and SINGLE-USE ARTICLES. During a review of facility's policy and procedure (P&P) titled, BWC Uniform Policy dated, 9/2016, the P&P indicated, .3. Hair restraints: .Food employees with high risk of contaminating exposed food must wear a hat or hair covering, a beard restraint, and clothing that covers body hair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 9 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 3. During an observation and concurrent interview on 3/13/23, at 9:53 a.m., with ECDM (Executive Chef Dietary Manager), of the upstairs kitchen, the following items were stored unlabeled and undated, as follows: 1-gallon barbecue sauce, large clear plastic squeeze bottle with solidified green content, 18-ounce jar of mint jelly. ECDM stated, green content in squeeze bottle was 4-cups herb oil that should have been labeled. ECDM further added, mint jelly should have labeled with use-by date. Residents Affected - Some The following items were stored beyond use-by date, as follows: One 8.16 lbs (pound) jar of whole grain mustard labeled open 12/1/22 use-by 02/01/23, romaine lettuce in silver container covered with clear plastic wrap labeled open 3/8/23 use-by 3/10/23, small clear plastic squeeze bottle labeled burger sauce marked with preparation date 3/8/23, use-by 3/11/23, clear bin labeled red onion, marked with preparation date 3/8/23 and use-by 3/11/23. ECDM stated, burger sauce and red onion was beyond use by date and should have been removed from the refrigerator. 4. During an observation on 3/13/23, at 10:03 a.m., CK 3 was observed without hair protection to cover facial hair while cooking food. A review of the United States Food and Drug Administration Food Code 2017, under section titled, Hygienic Practices, Hair Restraints, section 2-402.11 indicated, FOOD EMPLOYEES shall wear hair restrains such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENES; AND UNWRAPPED SINGLESERVICE and SINGLE-USE ARTICLES. During a review of facility's policy and procedure (P&P) titled, BWC Uniform Policy dated, 9/2016, the P&P indicated, .3. Hair restraints: .Food employees with high risk of contaminating exposed food must wear a hat or hair covering, a beard restraint, and clothing that covers body hair. 5. During an observation and concurrent interview on 3/13/23, at 10:15 a.m., with ECDM of the upstairs freezer, the following items were stored unlabeled and undated, as follows: open clear plastic bag of cubed potatoes, open clear plastic bag of fish filets, open clear plastic bag of frozen peas, one 4-pound bag of green beans, one 3.4 frozen garden burger patties, frozen peas and carrots in a blue plastic bag, tater tots in an open light brown bag. 6. During an observation and concurrent interview on 3/13/23, at 10:35 a.m., of downstair produce refrigerator with ECDM, the following items were stored undated; petite carrots in clear plastic wrap. The following items are stored beyond use-by date; 35 wrinkled green peppers with dark black and brown spots marked received date 3/1/23. A review of facility's Produce Storage Guidelines, (undated) indicated, green peppers are stored in the refrigerator for one week. 7. During an observation and concurrent on 3/14/23, at 11:50 a.m., in the downstairs kitchen, with Dietary Supervisor (DS), the following was observed as follows: ice machine had white-yellowish build up residue above liquid reservoir and ice dispenser machine. DS wiped residue with her fingers but build up residue did not come off. Water filter attached to wall and connected to the automatic ice machine was marked 2/2/22. DS stated, date marked on the filter was the last time it was replaced. During a review of facility's planned maintenance report, dated 10/28/22, indicated the need for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 10 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 water filter replacement. The report also indicated, the recommendation to replace water filter was declined. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 3/15/23, at 9:38 a.m., with DS, DS confirmed water filter was due to be replaced. DS stated she was not aware of who declined the recommended service filter replacement. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 11 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 label and provide a use by date on two of two food items kept in a refrigerator designated for food brought from outside the facility. Additionally, Facility did not ensure safe food handling practices for reheating food brought from outside the facility. Residents Affected - Few These failures placed the facility residents at risk for food borne illnesses. Findings: During a concurrent observation and interview on 3/16/23, at 12:30 p.m., Certified Nurse Assistant 6 (CNA 6) reached into a 3.7 cubic foot refrigerator in the facility's conference room. CNA 6 then opened the freezer section and removed a sandwich-sized resealable unlabeled and undated plastic bag with frozen mixed vegetables. CNA 6 stated the frozen mixed vegetables were for Resident 1. CNA 6 stated facility stored residents food brought from outside the facility in that refrigerator. During a concurrent observation and interview with Charge Nurse (CN) on 3/16/23, at 1:11 p.m., following items were found in the refrigerator designated for food brought from outside the facility. 1. An undated and unlabeled 14-ounce container of [NAME] Dazs vanilla ice cream, with thick ice crystals and yellow-colored leftovers of ice cream. CN stated she could not identify if the ice cream belonged to a resident or staff. CN then threw the ice cream away in a trash bin. 2. A gallon-sized resealable storage bag that contained four portioned sandwich-sized resealable bags of frozen vegetables. CN stated the vegetables were portioned for Resident 1 and nursing staff microwaved them for her. CN wrote Resident 1's name on the storage bag. CN stated food brought from outside the facility should be labeled and kept for 72 hours in the refrigerator. CN stated she did not know when the facility received those mixed vegetables packs for Resident 1. CN stated all food from outside the facility must be labeled with the resident's name, the date and time placed in the refrigerator, and the expiration or use by date on the container. During an interview with CNA 6 on 3/16/23, at 1:40 p.m., CNA 6 stated she put the frozen mixed vegetables in a bowl, microwaved them for two minutes prior to giving it to Resident 1. CNA 6 stated she did not check the temperature before giving them to Resident 1. CNA 6 stated she did not have a thermometer available at the nursing station. During an interview on 3/16/23, at 1:49 p.m., the Director of Staff Development (DSD) stated she was responsible for ongoing training and educating the certified nursing assistants. The DSD stated she did not provide a training or in-service to the nursing staff on safe food handling practices and or reheating resident's food. During a concurrent interview and record review with Director of Nursing (DON) on 3/16/23, at 1:50 p.m., facility's Policy and Procedures (P&P) titled Foods Brought by Family/Visitors revised 2017 was reviewed. The P&P showed, All personnel involved in preparing, handling, serving or assisting the resident with meals or snacks will be trained in safe food handling practices. The P&P also showed, Containers will be labeled with the resident's name, the item and the use by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 12 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 3a. During a review of Resident 10's Face Sheet dated 3/13/23, the record indicated Resident 10 was admitted to the facility 2/23. Residents Affected - Some During an observation on 3/13/23, at 11:50 a.m., Resident 10 had a red magnetic sign on the doorframe that read oxygen in use. Resident 10 was lying in her bed with glasses and a nasal cannula on. A green colored oxygen tubing dated 3/13/23, connected to the cannula tubing was coiled and lying on the floor. During an observation and interview on 3/13/23, at 1:06 p.m., IP stated facility used the green extension tubing for the residents who was were to use the bathroom. IP also stated facility kept the extended oxygen tubing on the floor only. IP then stated keeping the oxygen tubing on the floor could result in respiratory infections for Resident 10. 3b. During a review of Resident 19's Face Sheet dated 3/13/23, the record indicated Resident 19 was admitted to the facility 2/23. During an initial observation of Resident 19 on 3/13/23, at 11:42 a.m., a red magnetic sign was on the doorframe that read oxygen in use. Observed Resident 19 with a nasal cannula on and oxygen tubing dated 3/13/23 coiled on the floor. During an interview on 3/13/23, at 12:57 p.m., IP stated oxygen tubing was often made long enough for residents to be able to use the bathroom in their room and the excess tubing was coiled onto the floor. 3c. During a review of Resident 2's Face Sheet dated 3/13/23, the record indicated Resident 2 was admitted to the facility in 8/2012. During an initial observation on 3/13/23, at 12:30 p.m., observed Resident 2 lying in bed with nasal cannula on. Observed the oxygen tubing dated 3/12/23 lying on top of the base of the feeding pump pole (a portable metallic pole with a base, four wheels and feeding pump attached to it to provide liquid nutrition at a controlled rate). The feeding pump pole had pools of a tan-colored substance; visible dirt around the four bolts that held the wheels on, the center pole and over the base; and a small piece of white debris on it. During an observation and interview on 3/13/23 at 1:00 p.m., with Infection Preventionist (IP), observed the oxygen tubing on the base of Resident 2's feeding pump pole. The IP stated the feeding tube pole was dirty and used her right foot to move the tubing off the base of the pole, which fell to the floor. IP stated the risk of the tubing being on the floor was infection, such as respiratory infections and sepsis. 4. During a review of Resident Face Sheet for Resident 38 dated 3/15/23, the record showed Resident 38 was admitted to the facility 2/23 and returned on 3/23 after a hospitalization. During an observation and interview with IP on 3/13/23, at 12:57 p.m., Observed Resident 38 sitting in wheelchair their 3/4 full urinary bag touching the floor. IP stated catheter tubing should be below the bladder and not touching the floor to prevent risk of infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 13 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 - Some During a record review of Policy and Procedure (P&P), revised September 2014 and titled Catheter Care, Urinary, the P&P showed be sure the catheter tubing and drainage bag are kept off the floor. 5. During an observation and interview on 3/13/23 at 1:00 p.m., with Infection Preventionist (IP), Observed Resident 2 receiving feeding/nutrition through a gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach). Observed the pump for feeding/nutrition the attached to the feeding pump pole on her right side of the bed. The feeding pump pole had pools of a tan-colored substance; visible dirt around the four bolts that held the wheels on, the center pole and over the base; and a small piece of white debris on it. IP stated the feeding tube pole was dirty. IP pushed the feeding pump pole back toward the bedside table at the head of Resident 2's bed. During an interview with IP on 3/14/23, at 10:01 a.m., IP stated she tried to clean the feeding pump pole with a sponge and paper towel. IP stated she was able to scrape off some of the residue, which she thought was formula feeding, but could not get it all so had to change the pole for Resident 2. During a follow up interview with IP on 3/16/23, at 10:28 a.m., IP stated the risk of using dirty equipment for residents could result in cross contamination. IP stated the pole was connected to Resident 2 via tubing and pathogens could travel to Resident 2 via the tubing. IP stated staff was expected to clean the equipment daily or at least every 72 hours. IP stated visible dirt and residue should be cleaned immediately. 6. During an observation on 02/13/23, at 09:30 a.m., Licensed Vocational Nurse 4 (LVN 4) took the blood pressure measuring device from the medication cart to Resident 29's room, without cleaning or disinfecting LVN 4 applied the blood pressure cuff on Resident 29's left arm. LVN 4 did not disinfect the blood pressure measuring device after use and placed it on the medication cart. During an interview on 3/13/23, at 10:14 a.m., LVN 4 stated she did not wipe down the blood pressure measuring device before and after using it on Resident 29 to prevent cross contamination. During a record review of facility's Policy and Procedures titled Cleaning and Disinfection of Resident-Care Items and Equipment dated September 2022, indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected .non-critical resident-care items include bedpans, blood pressure cuffs .Reusable items are cleaned and disinfected or sterilized between residents. 7. During an observation on 3/13/23 at 10:03 a.m., after administering morning medication to Resident 29, LVN 4 was observed applying a cream on Resident 29's upper shoulder and back of the legs with gloved hands. LVN 4 then took off her gloves and put on a new pair without sanitizing her hands in between glove change. LVN 4 then administered a breathing inhaler to Resident 29 During an observation on 3/13/23, at 10:09 a.m., LVN 4 walked into Resident 29's room, put on new gloves, removed Resident 29's shirt, assessed the pain medication patch sticking on his upper back, put Resident 29's shirt back on, removed her gloves and without performing hand hygiene exited the room. During an interview on 3/13/23, at 10:15 a.m., LVN 4 stated she should have washed her hands prior to putting on new gloves and after taking off the gloves to prevent the spread of infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 14 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 During an observation on 3/13/23, at 11:01 a.m., LVN 2 prepared Resident 2's medications, walked into Resident 2's room, without performing hand hygiene put on new pair gloves, placed Resident 2's medications on the bedside table, picked up Resident 2's medications in her right gloved hand, walked into Resident 2's bathroom, and turned on the faucet with left gloved hand, filled three cups of water, came back to Resident 2, placed water and medications on the bedside table. Residents Affected - Some LVN 2 then removed the gloves, without performing hand hygiene, went out of Resident 2's room, placed Resident 2's medications in the medication cart, entered Resident 38's room, grabbed gloves, put on gloves, exited Resident 38's room, took out stethoscope from a drawer in the medication cart, picked up Resident 2's originally prepared medications and went back into Resident 2's room. LVN 2 then removed the gloves, without performing hand hygiene put on new gloves and administered Resident 2's medications via Gastronomy Jejunostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach) During an interview on 3/13/23 at 11:45 a.m., LVN 2 stated she should have sanitized her hands between gloves changes, after touching high touch surfaces, and prior to administering medications to Resident 2 to prevent spread of infection. During a record review of facility's Policy and Procedures titled, INFECTION CONTORL & PROCEDURE policy dated 04/2010, under section HANDWASHING/HANDHYGIENE showed Employee must wash their hands for twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: . Before and after direct contact with residents .After removing gloves . In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations .before and after direct contact with residents, .Before preparing or handling medications; .After removing gloves; The use of gloves does not replace hand washing/hand hygiene. Based on observation, interview and record review the facility failed to ensure infection control practices were implemented when following was noted: 1. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene after handling Resident 33's dirty linen, and prior to handling clean personal clothing for Resident 22. 2. CNA 3 folded Resident 50's clean personal clothing while it was in contact with their own clothing. 3. Residents 10, 19, and 2's oxygen tubing was on the floor. 4. Resident 38's urinary catheter bag and tubing were touching the floor. 5. Resident 2's feeding pump pole had visible dirt and dried matter sticking to the base. 6. Licensed Vocational Nurse (LVN) 4 did not sanitize blood pressure cuff before and after use on Resident 29. 7. LVN 2 and LVN 4 did not perform hand hygiene before and after gloves changes during medication administration for Resident 2 and Resident 29 respectively. These failures placed facility's residents at risk for healthcare-associated infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 15 of 16 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 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 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 Findings: Level of Harm - Minimal harm or potential for actual harm 1. During an observation on 3/14/23, at 11:17 a.m., in the laundry department, CNA 1 carried Resident 33's soiled linen in a clear plastic bag in her left gloved hand, from Resident 33's room to the laundry room. CNA 1 entered the laundry room and placed Resident 33's soiled personal belongings into the washing machine, started the washing machine, and removed her left-hand glove. CNA 1 proceeded to fold Resident 22's clean laundry without performing hand hygiene . Residents Affected - Some During a concurrent interview and record review with Infection Preventionist (IP) on 3/15/23, at 1:06 p.m., facility's Policy and Procedures (P&P) titled Departmental (Environmental Services)-Laundry and Linen dated January 2014 was reviewed. The P&P showed staff were to, wash hands after handling soiled linen and before handling clean linen. IP stated hand washing is important because laundry can be a source of infection. 2. During a concurrent interview and observation on 3/14/23, at 12:45 p.m., in the laundry room, CNA 3 folded Resident 50's clean laundry against her own clothing and placed the clothing in the Resident 50's closet located within their room. CNA 3 stated clothes should be held away from body or they'll be contaminated. During an interview on 3/14/23, at 1:17 p.m., IP stated facility staff did not wear gowns when sorting laundry. IP stated staff shouldn't put clean clothes on scrubs because staff's personal clothing was considered as contaminated. IP also stated clean clothes should be kept at least one arm's length away from body. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555855 If continuation sheet Page 16 of 16