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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555905 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 555905 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Serenethos Care Center, LLC 22822 Myrtle Street Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)