Inspection·June 4, 2024

F 0584 1. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 6/4/24 at 2:45 p.m., Unlicensed Staff A verified the following: RM [ROOM NUMBER]'s floor were sticky, there were 2 brownish stain/material on the bathroom floor which Unlicensed Staff A identified as probably poop , there were 3 clothes hanging on the towel rack in the bathroom and the tissue paper was touching the bathroom floor. Unlicensed Staff A stated this was a big infection control issue. Unlicensed Staff A stated the floor was sticky because it was probably not cleaned well enough. Unlicensed Staff A stated the floor should not be sticky, there should be no clothes hanging on the towel rack, no tissues touching the bathroom floor and the bathroom should be clean for infection control purposes. Unlicensed Staff A stated the clothes should not be hanging on the towel rack because they don't know if that was clean or dirty and resident might put the clothes back on. Unlicensed Staff A stated the tissue should not be touching the floor because the floor was dirty and contaminated and if a resident used the tissue, they might have cross contamination with the bacteria from the floor. Unlicensed Staff A stated it was a resident's right to ensure their environment was homelike, clean and safe. Residents Affected - Some During a concurrent observation in room [ROOM NUMBER]'s bathroom and interview on 6/4/24 at 2:54 p.m., Unlicensed Staff A verified there was a brownish material smeared on the toilet bowl seat which Licensed Staff A identified as definitely a poop , there was a stack of basin on top of the paper towel dispenser and there was a purplish colored pants on the floor. Unlicensed Staff A also verified room [ROOM NUMBER]'s bathroom reeked of urine smell and the bathroom floor was sticky. Unlicensed Staff A stated these were unacceptable. Unlicensed Staff A stated the bathroom floor should not be sticky, there should not be clothes on the bathroom floor and the toilet bowl seat should not have a smeared poop. Unlicensed Staff A stated this was a big infection control issue. During an interview on 6/4/24 at 2:55 p.m., Licensed Staff B stated the bathroom floor should not be sticky. Licensed Staff B stated if the bathroom floor was sticky, it could be an indication the floor was not cleaned thoroughly. Licensed Staff B also stated there should be no brownish stain/material on the bathroom floor which could be poop or poop smeared in the toilet bowl seat. Licensed Staff B stated this was disgusting and was a big infection control issue. Licensed Staff B stated there should be no stack of basin on top of the paper towel dispenser. Licensed Staff B stated those basin should not be used and should be discarded because it was now considered dirty. Licensed Staff B stated it was not acceptable to place clothes on the towel rack or on the floor because you would not know whether resident would put this on again which could result to possible cross contamination. Licensed Staff B stated it was important to ensure residents were in a clean environment and residents were protected from infection due to environmental factors such as dirty bathrooms and floors. Licensed Staff B stated it was also a resident's right to have a clean and safe environment. During an interview on 6/4/24 at 3:05 p.m., Resident 1 stated the facility over all cleanliness could be improved. During an interview on 6/4/24 at 3:10 p.m., Licensed Staff C stated sticky floor meant the floor was not cleaned thoroughly. Licensed Staff C stated the bathroom floor should not have any brownish stains or materials, no clothes on the floor or the towel rack, no stack of basin in the paper towel dispenser and the tissue paper was not supposed to touch the floor. Licensed Staff C also stated the toilet bowl seat should not have any smeared bowel movement. Licensed Staff C stated this was disgusting and should have been cleaned right away. Licensed Staff C stated these were big infection control issues and could lead to residents getting sick. Licensed Staff C stated it was a resident right to have a clean bathroom and to live in a clean and safe environment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 2 of 4 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 Residents Affected - Some During an interview on 6/4/24 at 3:15 p.m., Housekeeping D stated the floors should not be sticky. Housekeeping D stated a sticky floor could be an indication the floor was not thoroughly cleaned. Housekeeping D stated it was not acceptable to have a smeared poop on the toilet bowl seat. Housekeeping D stated the tissue should not touch the floor and there should be no clothes on the bathroom floor or on the towel rack. Licensed Staff D stated all of these were an infection control issue and residents could get sick and infected through contaminated and dirty items. During an interview on 6/4/24 at 3:25 p.m., the Director of Nursing (DON) stated it was not acceptable to have a sticky floor, to have the tissue touching the floor, to have a stack of basin on top of the paper towel dispenser, to have brownish stain/material on the bathroom floor or have a bowel movement smeared on the toilet bowl seat, to have clothes on the bathroom floor or have clothes hanging on the towel rack in the bathroom. The DON stated these were an infection control issue. When asked if it was a resident right to live in a clean and safe environment, the DON stated yes. When sked if a sticky floor, having a tissue touching the floor, having a stack of basin on top of the paper towel dispenser, having a brownish stain or material on the bathroom floor, having bowel movement smeared on the toilet bowl seat, having clothes on the bathroom floor and clothes hanging on the towel track meant the resident was living in a clean environment, the DON stated I get it. During an interview on 6/4/24 at 3:33 p.m., Unlicensed Staff E stated sticky floor meant it was not cleaned thoroughly. Unlicensed Staff E stated it was not acceptable to have tissue touching the floor, to have a stack of basin kept in the paper towel dispenser, to have a poop smeared in the toilet bowl seat or to have clothes hanging on the towel rack or left on the floor. Unlicensed Staff E stated these were all an infection control issue and residents could get sick if they use these contaminated items. During an interview on 6/4/24 at 3:35 p.m., Licensed Staff F stated it was not acceptable to have a sticky floor, to have tissue touching the floor, to have a stack of basin on top of the paper towel dispenser in the bathroom, to have clothes on the bathroom floor or hanging on the towel rack. Licensed Staff F stated it was not acceptable and it was disgusting to have a brown colored discoloration or material on the bathroom floor or a bowel movement smeared on the toilet bowl seat. Licensed Staff F stated it was a resident's right to live in a safe and clean environment. Licensed Staff F stated these were all an infection control issue and could result to cross contamination which could lead to residents getting sick. A review of the facility's policy and procedure (P&P) titled Cleaning and Disinfection of Environmental Surfaces revised 8/2019, the P&P indicated housekeeping surface will be cleaned in regular basis, when spills occurs and when these surfaces were soiled .spills of blood and other potentially infectious materials be promptly cleaned . 2. During a concurrent observation of room [ROOM NUMBER]'s bathroom door and interview on 6/4/24 at 2:45 p.m., Unlicensed Staff A stated the hole on room [ROOM NUMBER]'s bathroom door had been there for a while. When asked if this hole had been reported to the maintenance, Unlicensed Staff A stated she did not know. When asked if it was important to get this fixed, Unlicensed Staff A stated yes for safety purposes. Unlicensed Staff A stated residents might touch the hole in room [ROOM NUMBER]'s bathroom and have splinters on their hand. Unlicensed Staff A stated it was a resident right to live in a safe, clean and home like environment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 3 of 4 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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 Residents Affected - Some During a concurrent observation of room [ROOM NUMBER]'s bathroom door and interview on 6/4/24 at 3:30 p.m., the DON stated the hole in room [ROOM NUMBER]'s bathroom door appeared like it had been there for a while. The DON stated this should be repaired right away for residents' safety. The DON stated it was a safety risk for cuts and abrasion. During a concurrent observation of room [ROOM NUMBER]'s bathroom door and interview on 6/4/24 at 3:32 p.m., the Maintenance Director (MD) stated the hole on room [ROOM NUMBER]'s bathroom door hole did not look like it was recent. The MD stated the hole appeared like it had been there for a while. The MD stated it appeared like staff were trying to cover it with something based on the presence of tape around the hole. The MD stated staff did not report this to him, so it was not fixed. The MD stated for safety purposes, this hole should be fixed. The MD stated resident might put their hand on the hole which could result in cut and splinters. During a concurrent observation of room [ROOM NUMBER]'s bathroom door and interview on 6/4/24 3:33 p.m., Unlicensed Staff E stated the hole in room [ROOM NUMBER]'s bathroom door was not new and had been there for a while. Unlicensed Staff E stated this should be fixed for residents' safety. Unlicensed Staff E stated this hole put residents at risk for cuts and abrasions. During an interview on 6/4/24 at 3:35 p.m., Licensed Staff F stated the hole on room [ROOM NUMBER]'s bathroom door had been there for a while. Licensed Staff F stated she was not sure if anyone reported this to the maintenance yet. Licensed Staff F stated she was not sure why it had not been fixed yet. Licensed Staff F stated the hole should be fixed by maintenance because this hole put residents at risk for getting splinters or cuts. A review of the facility's policy and procedure (P&P) titled Maintenance Services , undated, the P&P indicated the maintenance department is responsible for maintaining the building, grounds and equipment in a safe and operable manner at all times .functions of the maintenance personnel include maintaining the building in good repair . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555184 If continuation sheet Page 4 of 4