Health inspection·June 20, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) assessment for one of one sampled residents (Resident 1) was completed and coded accurately. Residents Affected - Few This failure to accurately code Resident 1's PASRR assessments placed Resident 1 at risk to not receive care and services appropriate to his needs. Findings: During a review of Resident 1's admission Record, dated 6/19/25, the admission Record indicated Resident 1 has a diagnosis of major depressive disorder (MDD, a mental condition with a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and an eating disorder. During a review of the facility's provided letter titled Department of Health Care Services (DHCS) from Clinical Assurance Division, PASRR Section, Unable to complete PASRR II, dated 2/23/23, indicated Resident 1 had a positive PASRR I and PASRR II was not completed as Resident 1 was isolated as a health or safety precaution. During a concurrent interview and record review on 6/29/25 at 12:30 p.m. with Minimum Data Set Coordinator (MDSC) 1, MDSC 1 stated their role is to complete and update the PASRR assessments in Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) for residents at the facility. When reviewing the Minimum Data Set, Section A, dated 4/29/23, under A1500 Preadmission Screening and Resident Review, MDSC 1 stated the form indicated Resident 1 is currently considered by the state PASRR II process to have a serious mental illness and or intellectual disability or a related condition. While reviewing the DHCS letter, MDSC 1 stated she had not seen this letter and believed the PASSR II assessment had been completed. MDSC 1 confirmed that a PASRR II was never completed as Resident 1 was on isolation precautions as indicated by the DHCS letter. During a concurrent interview and record review on 6/19/25 at 12:30 p.m. with MDSC 1, the record review of the Minimum Data Set, Section A dated 4/29/25 under A1500 Preadmission Screening and Resident Review, MDSC 1 stated the form indicates No that Resident 1 is not currently considered by the state Level II PASRR process to have a serious mental illness and or intellectual disability or a related condition. MDSC 1 stated a PASRR II had not been done for Resident 1 and that they should review the documents every year to update and correct them in the MDS system. During an interview on 6/20/25 at 9:20 a.m. with the Medical Director (MD), MD stated PASRR II Page 1 of 4 555905 555905 06/20/2025 Serenethos Care Center, LLC 22822 Myrtle Street Hayward, CA 94541

F 0641 Level of Harm - Minimal harm or potential for actual harm screening was important to ensure residents receive the care, treatment, and services to help treat their illness. MD stated that he was not aware a PASRR II had never been completed for Resident 1, and stated the facility should be monitoring and tracking this information. MD stated that the facility should be reporting this information to the physician. Residents Affected - Few 555905 Page 2 of 4 555905 06/20/2025 Serenethos Care Center, LLC 22822 Myrtle Street Hayward, CA 94541

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for one out of four sampled residents (Resident 23) when nursing staff administered 4% lidocaine patch to Resident 23's knees on two separate days, instead of to the back as prescribed by the physician. Residents Affected - Few These failures resulted in two medication errors being identified out of 27 opportunities during an observation of medication administration leading to a medication error rate of 7.41%. These deficient practices had the potential to result Resident 23 not having pain relief. Findings: During review of Resident 23's admission Record, dated 6/19/25, the admission Record indicated Resident 23 was admitted in September 2021 with a diagnosis of heart failure (when the heart does not pump as well as it should) and osteoarthritis (a breakdown of cartilage in joints, leading to pain and stiffness) with current pathological fracture (break) of the vertebrae (spine.) During a medication pass observation on 6/17/25 at 11:49 a.m., with Registered Nurse (RN) 1, RN 1 administered a 4% lidocaine patch (A topical skin analgesic for pain relief) to Resident 23's left knee. During a medication pass observation on 6/18/25 at 9:15 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 administered a 4% lidocaine patch to Resident 23's right knee. During a review of Resident 23's Order Summary Report, dated 6/19/25, The Order Summary Report, indicated a physician's order to apply a lidocaine 4% patch to the lower back once daily for pain management. During an interview on 6/19/25 at 1:40 p.m. with the Nursing Supervisor (NS), NS stated the nurse must contact the physician before applying the lidocaine patch to a different location than prescribed, and the physician must change the order. 555905 Page 3 of 4 555905 06/20/2025 Serenethos Care Center, LLC 22822 Myrtle Street Hayward, CA 94541

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interviews and record review, the facility failed to ensure that when it hired a part-time registered dietitian, the person designated to serve as the director of food and nutrition services met both the federal and/or state educational qualifications for the position. This failure had the potential for lack of competency and skill set necessary to carry out all the functions of the food services. Findings: During an interview on 6/17/25 at 10:01 a.m. with the Dietary Manager (DM), DM stated she was not the dietary supervisor for the facility. DM stated she covers for the sister facility, another building, but recently was orienting a new dietary supervisor who was on his way to the facility. During an interview on 6/17/25 at 10:24 a.m. with the Dietary Supervisor (DS), DS stated he was the DS. DS stated he worked at the facility as the Dietary Supervisor and Maintenance Director. DS stated his duties included checking the refrigerators and making sure supply of food items are done. DS provided a food handler certification. During an interview on 6/19/25 at 10:56 a.m. with Registered Dietician (RD), RD stated she worked part time. RD stated she worked on site at the facility once a month. During a review of the food handler certificate, titled ServeSafe, the certificate indicated national restaurant association certification. During an interview on 6/17/25 at 11:23 a.m. with the Administrator (Admin), Admin stated she will review with RD the type of certification required for DS position. 555905 Page 4 of 4