Health inspection·October 19, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 10/17/23 at 12:32 p.m., in Resident 3's room, Resident 3's lunch tray had 3 individual thick red cups containing pureed food. During a record review on 10/19/23 at 1:11 p.m., of Resident 120 's electronic health record, the record indicate no assessments nor progress notes addressing preference for meals to be served in individual cups. A subsequent record review of Resident 3's health record also did not have assessments nor progress notes indicating a preference for meals to be served in individual cups. During an interview on 10/18/23 at 9:30 a.m., with Registered Dietician (RD), RD states that puree food needs to be served on a plate or else it can be a dignity issue. During a review of the facility's policy and procedure titled Resident Rights (undated), indicated residents have a right to .a. a dignified existence, b. be treated with .dignity . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555914 If continuation sheet Page 2 of 11 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 555914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE We Care Skilled Nursing Facility 21863 Vallejo 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)

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 physician orders when administering oxygen to one resident (Resident 170) out of 12 sampled residents. Residents Affected - Few This failure has the potential to cause Resident 170 to be given too much oxygen, which could result in hospitalization. Findings: During a review of Resident 170's admission Record, the admission Record indicated a readmission date of 7/26/23 with diagnosis including Chronic Obstructive Pulmonary Disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe). During an observation on 10/16/23 at 9:12 a.m., in Resident 170's room, Resident 170 was asleep with oxygen via nasal cannula (a device used to deliver supplemental oxygen) at 2.5L/min. During a follow up observation and interview on 10/18/23 at 10:54 a.m., with Resident 170, inside Resident 170's room, Resident 170 was observed with nasal cannula and supplemental oxygen was delivered at 2.5L/min. Resident 170 stated, he uses oxygen mostly at night. During a concurrent record review and interview on 10/18/23 at 10:55 a.m., with Licensed Vocational Nurse (LVN 1), Resident 170's physician orders dated 10/2023 and progress notes were reviewed. The physician orders indicated O2 @ 1L/min via NC to keep oxygen saturation >94% as needed. LVN 1 stated, resident 170 was having difficulty breathing yesterday (10/17) so she bumped up oxygen' to 2-3 (liters). LVN 1 also stated, that for any change of condition, there should be an SBAR (Situation, Background, Assessment, Recommendation - a way to clearly and concisely communicate a resident's situation), notify MD, and write progress notes. A review of Resident 170's progress notes did not show change of condition documentation and no SBAR documentation. During a record review of Resident 170's nursing progress notes from 8/2023 to 10/2023, nursing progress notes indicated Resident 170, was on supplemental oxygen at 2 liters per minute starting 10/2/23 through last progress note dated 10/9/23. A nursing progress note dated 8/10/2023 indicated a new order for oxygen to be given 1L/min via NC to keep oxygen saturation >94% as needed. During an interview on 10/19/23 at 9:09 a.m., with Director of Nursing (DON), DON stated if resident 170 is having difficulty breathing, put 1 liter of oxygen as ordered, if it is not enough, then turn up the oxygen until 3L until oxygen saturation is in acceptable range, then notify MD they had to change the amount of oxygen. Nurses will then document in skilled charting or progress note. DON stated that if there is a need to change orders, then nurses need to do SBAR and change of condition (COC) charting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555914 If continuation sheet Page 3 of 11 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 555914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE We Care Skilled Nursing Facility 21863 Vallejo 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)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure dialysis (a treatment to remove extra fluid and waste products from the blood when the kidneys cannot) communication records were completed for one (Resident 6) of one sampled resident. Residents Affected - Few This failure had the potential to miss signs of illness such as fever or bleeding, which could lead to hospitalization. Findings: A review of Resident 6s admission record, the admission record indicated, admission date of 7/23/23 with diagnoses including end stage renal disease (the last stage of long-term kidney disease where the kidneys no longer work) and dependence on renal dialysis. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated, Resident 6 had dialysis three times a week on Tuesdays, Thursdays, and Saturdays. During a record review of Resident 6's Hemodialysis Communication records dated 9/12/23 through 10/17/23, the Hemodialysis Communication records for hemodialysis treatment days on 9/12/23, 10/7/23 and 19/17/23 were not completed. During a concurrent interview and record review, on 10/18/23 at 8:51 a.m., of Resident 6's Hemodialysis Communication records, dated 9/12/23, 10/7/23, and 10/17/23, with Director of Staff Development (DSD), DSD confirmed Hemodialysis Communication records were missing. DSD further stated, it is important to check resident after treatment to monitor bleeding from the access site and check for signs of infection. DSD stated, it is important because staff need to know what is going on with the resident and they are expected to complete the hemodialysis communication record before the resident goes to dialysis and when the resident returns to facility. During a review of the facility's policy and procedure titled, Care of a Resident on Dialysis (undated), the policy indicated nursing services .monitor and assess the resident's condition, the effects of dialysis and .prevent complications .5.Nursing must complete dialysis communication form on dialysis days . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555914 If continuation sheet Page 4 of 11 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 555914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE We Care Skilled Nursing Facility 21863 Vallejo 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)

F 0759 Ensure medication error rates are not 5 percent or greater. 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 administer medications below a five percent (5%) error rate when: Residents Affected - Some 1. Licensed Vocational Nurse (LVN )1 gave Insulin Aspart (a drug used to treat diabetes; a condition that develops when a person's blood sugar is too high) 2 units, late to one (Resident 10) of 10 sampled residents. 2. LVN 1 gave Metformin 850 mg (a drug used to treat diabetes; a condition that develops when a person's blood sugar is too high), after lunch was finished and not with lunch, to one (Resident 12) of 10 sampled residents. These errors resulted in Resident 10 and 12, not receiving medication as prescribed by their physicians. Findings: During a review of Resident 10's admission Record (AR), dated 10/19/23, the AR indicated Resident 10 was originally admitted to the facility on [DATE], and had a diagnosis of Diabetes Mellitus (a condition that develops when a person's blood sugar is too high). During a review of Resident 12's admission Record (AR), dated 10/19/23, the AR indicated Resident 12 was originally admitted to the facility on [DATE], and had a diagnosis of Diabetes Mellitus. During a concurrent observation and interview on 10/17/23 at 1:08 p.m., with LVN 1, LVN 1 was observed giving the medication, Metformin 850 mg, to Resident 12. LVN 1 stated, Metformin was ordered to be given with lunch. Resident 12's lunch tray had already been removed and the tray cart taken back to the kitchen, when LVN 1 gave Metformin to Resident 12. LVN 1 stated, she gave Metformin after Resident 12 had eaten. During a concurrent interview and record review on 10/17/23 at 1:11 p.m., with LVN 1, Resident 12's medication administration record (MAR) was reviewed. The MAR indicated, metFORMIN HCL Oral Tablet 850 MG (Metformin HCL) Give 1 tablet by mouth with meals for DM (DM - Diabetes Mellitus). LVN 1 stated, she gave the Metformin, after Resident 12 had eaten. During an observation on 10/17/23 at 2:12 p.m., LVN 1 was observed giving the medication, Insulin Aspart 2 units, to Resident 10. During a concurrent interview and record review on 10/17/23 at 2:15 p.m., with LVN 1, Resident 10's MAR was reviewed. The MAR indicated, Insulin Aspart Injection Solution . inject as per sliding scale if 70 - 150 = No insulin . 151-200 = 2 units 201 - 250 = 3 units, 251 - 300 = 4 units . before meals and at bedtime for DM. LVN 1 stated, she checked Resident 10's blood sugar at 11:00 a.m. LVN 1 stated, the blood sugar was 166, and per the sliding scale she needed to give 2 units to Resident 10. LVN 1 stated, Resident 10 ate his lunch around noon. She stated, she usually gave Resident 10 his insulin between 11:00 a.m. and 11:30 a.m. LVN 1 stated, she gave the insulin after lunch because Resident 10 was in the physical therapy room before lunch and she couldn't give the medication to him there. LVN 1 stated, she had not checked the blood sugar again after 11:00 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555914 If continuation sheet Page 5 of 11 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 555914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE We Care Skilled Nursing Facility 21863 Vallejo 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 12's Order Summary Report (ORD), dated 10/19/23, the ORD indicated, Resident 12 was ordered metFORMIN HCL Oral Tablet 850 MG (Metformin HCL) Give 1 tablet by mouth with meals for DM. During a review of Resident 10's Order Summary Report (ORD), dated 10/19/23, ORD indicated, Resident 10 was ordered Insulin Aspart Injection Solution . inject as per sliding scale if 70 - 150 = No insulin . 151-200 = 2 units 201 - 250 = 3 units, 251 - 300 = 4 units . before meals and at bedtime for DM. During a review of Resident 10's Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart) Administration History (ADH), dated 10/19/23, the ADH indicated, Resident 10 was given 2 Units of Insulin Aspart by LVN 1 on 10/17/23 at 2:12p.m. During an interview on 10/18/23 at 3:35 PM with Director of Nursing (DON), DON stated, Resident 12 should have been given Metformin while she was eating lunch, not after she had eaten and the tray removed, as Metformin was ordered to be given with meals. DON stated, giving Metformin after lunch was an error and could have negatively affected the resident's blood sugar and health. DON stated, Resident 10's Insulin Aspart should have been given before lunch, as it was ordered to be given before lunch. DON stated, giving the Insulin Aspart after lunch was an error and could have negatively affected the resident's blood sugar and health. During a review of the facility's policy and procedure titled, Administering Medication, undated, indicated . 3. Medications must be administered in accordance with the orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555914 If continuation sheet Page 6 of 11 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 555914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE We Care Skilled Nursing Facility 21863 Vallejo 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)

F 0760 Ensure that residents are free from significant medication errors. 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 gave Insulin Aspart (a drug used to treat diabetes; a condition that develops when a person's blood sugar is too high) 2 units, late to one (Resident 10) of 10 sampled residents. Residents Affected - Few This failure resulted in Resident 10 not receiving medication as prescribed by the physician and placed Resident 10's health at risk due to risk of a negative effect on Resident 10s blood sugar. Findings: During a review of Resident 10's admission Record (AR), dated 10/19/23, the AR indicated Resident 10 was admitted to the facility on [DATE], and had a diagnosis of Diabetes Mellitus (a condition that develops when a person's blood sugar is too high). During an observation on 10/17/23 at 2:12 p.m., Licensed Vocational Nurse (LVN) 1 was observed giving the medication, Insulin Aspart 2 units, to Resident 10. During a concurrent interview and record review on 10/17/23 at 2:15 p.m., with LVN 1, Resident 10's Medication Administration Record (MAR) was reviewed. The MAR indicated, Insulin Aspart Injection Solution . inject as per sliding scale if 70 - 150 = No insulin . 151-200 = 2 units 201 - 250 = 3 units, 251 300 = 4 units . before meals and at bedtime for DM (DM - Diabetes Mellitus). LVN 1 stated, she checked Resident 10's blood sugar at 11:00 a.m. LVN 1 stated, the blood sugar was 166, and per the sliding scale she needed to give 2 units to Resident 10. LVN 1 stated, Resident 10 ate his lunch around noon. LVN 1 stated, she usually gave Resident 10 the insulin between 11:00 a.m. and 11:30 a.m. LVN 1 stated, she gave the insulin after lunch because Resident 10 was in the physical therapy room before lunch and she couldn't give the medication to him there. LVN 1 stated, she had not checked the blood sugar again after 11:00 a.m. During a review of Resident 10's Order Summary Report (ORD), dated 10/19/23, ORD indicated, Resident 10 was ordered Insulin Aspart Injection Solution . inject as per sliding scale if 70 - 150 = No insulin . 151-200 = 2 units 201 - 250 = 3 units, 251 - 300 = 4 units . before meals and at bedtime for DM (DM Diabetes Mellitus). During a review of Resident 10's Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart) Administration History (ADH), dated 10/19/23, the ADH indicated, Resident 10 was given 2 Units of Insulin Aspart by LVN 1 on 10/17/23 at 2:12 p.m. During an interview on 10/18/23 at 3:35 p.m., with Director of Nursing (DON), DON stated, Resident 10's Insulin Aspart should have been given before lunch, as it is ordered to be given before lunch. DON stated, giving the Insulin Aspart after lunch was an error and could have negatively affected the resident's blood sugar and health. During an interview on 10/19/23 at 12:15 p.m., with the Director of Staff Development (DSD), DSD stated, LVN 1 should have given Resident 10 Insulin Aspart before lunch as ordered by the doctor. DSD stated, LVN 1 should have removed Resident 10 from the physical therapy room, given Resident the Insulin Aspart, and returned Resident 10 to the physical therapy room. DSD stated, when LVN 1 gave the Insulin Aspart late, Resident 10's blood sugar and health were at risk of a negative effect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555914 If continuation sheet Page 7 of 11 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 555914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE We Care Skilled Nursing Facility 21863 Vallejo 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)

F 0760 During a review of the facility's policy and procedure titled, Administering Medication, undated, indicated . 3. Medications must be administered in accordance with the orders, including any required time frame. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555914 If continuation sheet Page 8 of 11 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 555914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE We Care Skilled Nursing Facility 21863 Vallejo 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)

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 food safely when food in the refrigerator, chest freezer, reach-in freezer, and dry storage were unlabeled and undated. Residents Affected - Many This failure has the potential of placing 21 out of 21 residents at risk for foodborne illnesses. Findings: During a concurrent observation and interview on 10/16/23, at 9:38 a.m., with Kitchen Supervisor (KS), during initial kitchen tour, in the chest freezer, 5 bags of broccoli had no date, two Ziploc bags of corn on the cob did not have label or date, and one package of turkey sausage with a date of 6/17/23. In the reach-in freezer, two bags totaling 24 veggie patties were without date and appeared with ice crystals inside the bag, two clear bags totaling 12 cheese pizzas were without label or date, 1 bag of frozen turkey was dated 6/23/23, 5 brown bags of French fries were unlabeled and undated, one package of frozen chopped meat was unlabeled and undated, and three bags of frozen raw chicken was unlabeled and undated. Inside the dry storage area, four 1-gallon containers of mayonnaise were not dated, two 5-lb bottles of Teriyaki Baste & Glaze dated 8-13-22. In the reach in-refrigerator, one 1-gallon jar of mayonnaise was without open date. KS stated canned goods are usually good for 6 months from the receive-by date then gets thrown away. KS also stated, it is important to have open dates and receive by dates because staff need to know when items need to be used. During an interview on 10/18/23 at 9:30 a.m., with Registered Dietician (RD), RD stated, all food items need to have dates. Her expectation is for the kitchen to be well organized and all food items labeled with dates. RD stated, it is important to have dates because food items can be kept a long time and staff need to know when to use them. During a review of the facility's policy and procedure titled Labeling and Dating of Foods, dated 2023, indicated All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555914 If continuation sheet Page 9 of 11 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 555914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE We Care Skilled Nursing Facility 21863 Vallejo 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)

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 ensure staff followed the infection control program designed to prevent the spread of infection for one of 10 sampled residents (Resident 10) when Licensed Vocational Nurse (LVN) 1 failed to perform hand hygiene after removing gloves, LVN 1 had put on to give eye drops. Residents Affected - Few This failure had the potential to cause infection or spread infection. Findings: During a review of Resident 10's admission Record (AR), dated 10/19/23, the AR indicated Resident 10 was originally admitted to the facility on [DATE]. During an observation on 10/17/23 at 1:18 p.m., in Resident 10's room, LVN 1 put on gloves. LVN 1 then put one drop of Dorzolamide-Timolol (a medication used to treat glaucoma, a condition in which the pressure inside the eye is abnormally high) in Resident 10's right eye. Then LVN 1 took off the gloves and left Resident 10's room. LVN 1 did not perform hand hygiene after taking off the gloves. During an interview on 10/17/23 at 1:21 p.m., LVN 1 stated, she had not performed hand hygiene after taking off the gloves. During an interview on 10/19/23 at 12:15 p.m., with the Director of Staff Development (DSD), DSD stated, LVN 1 was required to perform hand hygiene after LVN 1 removed the gloves she wore when she gave Resident 10 an eye drop. DSD stated, the failure to perform hand hygiene put Resident 10 at an increased risk of infection and the spread of infection. During a record review of Resident 10's Order Summary Report (ORD), dated 10/19/23, the ORD indicated, Dorzolamide HCL-Timolol Mal Ophthalmic Solution 22.3-6.8 mg/ml (Dorzolamide HCL-Timolol Maleate) Instill 1 drop in right eye three times a day for Glaucoma. During a review of Resident 10's Medication Administration Record (MAR), dated 10/1/23-10/31/23, the MAR indicated, LVN 1 gave one drop of Dorzolamide HCL-Timolol Mal in Resident 10's right eye on 10/17/23 at 2:00 p.m. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, undated, the P&P indicated, 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. When removing gloves . Hold the removed glove in the gloved hand and remove the other glove . Perform hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555914 If continuation sheet Page 10 of 11 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 555914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE We Care Skilled Nursing Facility 21863 Vallejo 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)

F 0921 Level of Harm - Potential for minimal harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide 80 square foot of space per resident for residents who occupied 3 multi-bed bedrooms. This condition had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside. Findings: During multiple room observations on 10/16/23 through 10/19/23, there were three residents in Rooms 3, 5 and 10, which are 4 bed rooms. 1. room [ROOM NUMBER] measured 20.4 feet by 14 feet which equaled 71.4 square feet per resident. 2. room [ROOM NUMBER] measured 20.4 feet by 14 feet which equaled 71.4 square feet per resident. 3. room [ROOM NUMBER] measured 20.4 feet by 14 feet which equaled 71.4 square feet per resident. During random observations of care and services from 10/16/23 to 10/19/23, there was sufficient space for the provision of care for the residents in all rooms. There were no heavy equipment in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. During an interview on 10/19/23, at 9:58 a.m., with Resident 178, Resident 178 stated, he had sufficient space in his room. Resident 178 stated, he liked his room. During an interview on 10/19/23, at 10:31 a.m., Resident 178, Resident 178 stated, he liked his room and had room for his personal belongings. There were no negative consequences from decreased space. No safety concerns for residents in the three rooms. Granting of room size waiver recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555914 If continuation sheet Page 11 of 11