Health inspection·March 25, 2022

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 14's MAR for 3/1/22 to 3/31/22, indicated nursing staff had not administered the eye drop solution brimonidine tartrate on 3/23/22 at 9 a.m. or 1 p.m. 2. During a concurrent observation and interview on 3/23/22, at 10:30 a.m., with LVN 1, the medication cart contained a pill cutter (a device for cutting pills into fractional pieces) and a pill crusher (a device for crushing pills into a powder). The pill cutter had white powder residue in all the cutter compartments. The pill crusher had a white powder residue at the tip of the blue handlebar and a dry brown spot on the right side of the base. LVN 1 stated the white powder residues could potentially result in the mixing of medications not prescribed to a resident. A review of the facility policy and procedure, Cleaning and Disinfection of Resident-Care Items, dated 2001, indicated, Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 2 of 9 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 555399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review the facility failed to ensure the recommendations from the January 2022 medication regimen review (MRR, a review of all medications prescribed to each resident to check for provision of pharmaceutical services not consistent with accepted professional standards) for five (Resident 5, 6, 7, 11, 12) of 13 sampled residents were reviewed by the attending physician. This failure had the potential to result in the administration of unnecessary medications for the five residents during January 2022. Findings: A review of Resident 5's admission Record, undated, indicated he was admitted in 2021 with a diagnosis of depressive disorder (a mood disorder resulting in sadness and loss of interest in life). A review of Resident 6's admission Record, undated, indicated he was admitted in 2021 with a diagnosis of end stage renal disease. (ESRD, the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplant to maintain life.) A review of Resident 7's admission Record, undated, indicated she was admitted in 2021 with a diagnosis of major depressive disorder. A review of Resident 11's admission Record, undated, indicated she was admitted in 2018 with a diagnosis of cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area) and major depressive disorder. A review of Resident 12's admission Record, undated, indicated he was admitted in 2021 with a diagnosis of cerebral infarction and chronic pain. A review of the facility MRR binder on 3/24/22 contained no documentation for a completed MRR in January 2022. During an interview on 1/24/22 at 11:06 a.m., with the Director of Nursing (DON), the DON stated she had not ensured the MRR had been completed in January 2022; she had missed it. The DON stated the MRR was completed on 12/29/21, and the next completed MRR was dated 2/6/22. The DON stated the monthly MRR was a review of all the medications and lab work for every resident in the facility. During a concurrent interview and record review on 3/25/22 at 9:40 a.m., with the DON, the DON provided a copy of MRR documents dated 1/21/22. The MRR documents included forms titled, Note to Attending Physician/Prescriber, with Printed: 1/21/22, on the bottom right- hand corner of the form, for the following residents: A review of Resident 5's Note to Attending Physician/Prescriber, dated 1/21/22, indicated the pharmacist recommended the physician re-evaluate the order for Resident 5's prescribed antidepressant medications. A review of Resident 5's form area designated, Physician/Prescriber Response, had a handwritten note with the name of the physician and the DON, and the date of 3/22/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 3 of 9 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 555399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 6's Note to Attending Physician/Prescriber, dated 1/21/22, indicated the pharmacist recommended the physician re-evaluate the order for Resident 6's continuous allergy medication. A review of Resident 6's form area designated, Physician/Prescriber Response, had no entries. A review of Resident 7's Note to Attending Physician/Prescriber, dated 1/21/22, indicated the pharmacist suggested the physician consider reducing the prescribed antidepressant medications from two medications to one medication. A review of Resident 7's form area designated, Physician/Prescriber Response, had a handwritten note with the name of the physician and the DON, and the date of 3/22/22. A review of Resident 11's Note to Attending Physician/Prescriber, dated 1/21/22, indicated the pharmacist recommended the physician re-evaluate the order for Resident 11's prescribed antidepressant medication. A review of Resident 11's form area designated, Physician/Prescriber Response, had a handwritten note with the name of the physician and the DON, and the date of 3/24/22. A review of Resident 12's Note to Attending Physician/Prescriber, dated 1/21/22, indicated the pharmacist suggested the physician consider reducing the prescribed antidepressant medications from two medications to one medication. A review of Resident 12's form area designated, Physician/Prescriber Response, had a handwritten note with the name of the physician and the DON, and the date of 3/22/22. The DON stated she had called the physician and entered the physician response on 3/22/22, for Residents 5, 7, and 12, and had called the physician and entered the physician response on 3/24/22 for Resident 11. During a review of the facility policies and procedures (P & P), titled Consultant Pharmacist Services Provider Requirements, dated 2007, the P & P indicated The Consultant Pharmacist, or designee, provides pharmaceutical care services, including but not limited to the following: .Medication Regimen Review (MRR) for each Skilled Nursing (SNF) resident at least monthly, or more frequently under certain conditions, incorporating the facility mandated standards of care in addition to other applicable professional standards. Communicate to the responsible prescriber and the director of nursing potential or actual problems detected and other findings related to medication therapy orders at least monthly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 4 of 9 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 555399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550 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 ensure one of two kitchen staff wore a head covering while working in the kitchen. Residents Affected - Few This failure had the potential to result in food contamination from hair shed by staff and cause food to be less palatable and/or spread food borne illness. Findings: During an observation and concurrent interview on 3/24/22, at 10:36 a.m., in the kitchen, [NAME] 1(CK 1) was in the kitchen with no head covering. CK 1 stated he forgot to put on a hairnet when he entered the kitchen. CK 1 stated residents could get sick from hair shed onto their food. During an interview on 3/24/22, at 10:43 a.m., with the Dietary Manager (DM), DM stated, all staff were required to wear a hairnet upon entry into the kitchen. During a telephone interview on 3/24/22, at 12:14 p.m., with Registered Dietician (RD), RD stated all staff must wear a hairnet when inside kitchen so hair does not get on food. RD stated hair in resident food was both a potential source of foodborne illness, and was very unsanitary, unappetizing, and unappealing. A review of the facility's policy and procedure (P&P) for kitchen staff titled, Dress Code for Women and Men, dated 2018, indicated, Appropriate dress in the Food & Nutrition Department .Men: .Hat for hair, if hair is short. Hair net for hair, if hair is long (over the ears or longer). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 5 of 9 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 555399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550 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 Based on observation, interview, and record review, the facility failed to ensure infection control policies and procedures were followed when: Residents Affected - Some 1. Two scheduled nursing staff (Licensed Vocational Nurse 1, Certified Nursing Assistant 1), had no documented completion of pre-entry screening for symptoms of COVID-19 (COVID-19, a respiratory infection which can result in breathing difficulty and other complications, including death. Symptoms include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea). Licensed Vocational Nurse 1 had no documented screening for 3/15/22, 3/16/22, 3/17/22, or 3/20/22. Certified Nursing Assistant 1 had no documented screening for 3/17/22. 2. Certified Nursing Assistant 3 (CNA 3) failed to perform hand hygiene after doffing gloves, and properly dispose of the soiled gloves, for one of 14 sampled residents (Resident 14). 3. For two of 14 sampled residents (Resident 10, Resident 14), nursing staff moved an open bag of bathing supplies (disposable towelettes) from Resident 10's bed and used the towelettes for Resident 14's bath. 4. Nursing staff failed to disinfect a wrist blood pressure cuff (a cloth or plastic band which is wrapped around the wrist and inflated to obtain a measurement of blood pressure) and a pulse oximeter (a device, usually secured or taped around a finger, used to measure the percentage of oxygen dissolved in the blood) between use by different residents. These failures had the potential to result in infection or spread of infection, including COVID-19 infection. Findings: 1. A review of the facility document titled, [facility name] Nursing Schedule March 1-31, 2022, indicated Certified Nursing Assistant 1 (CNA 1) was scheduled to work 3/17/22 and Licensed Vocational Nurse 1 (LVN 1) was scheduled to work 3/15/22, 3/16/22, 3/17/22, and 3/20/22. A review of the facility document titled, COVID-19 Screening Vaccinated Employees, revised 8/18/21, indicated a line for the date, and instructions at the top of the page, All employees must be screened and wear a mask before entering the facility. The form had lines for individual names, and columns for each name to indicate temperature, proof of vaccination, whether or not the individual had travelled outside the country in the last two weeks, whether or not the individual had been in contact with a COVID positive person in the last two weeks, presence or absence of cough/fever/chills/shortness of breath/loss of smell or taste/diarrhea/nausea or vomiting/sneezing or cold-like symptoms, and verification of use of hand sanitizer before entry to the facility. A review of the screening forms dated 3/15/22 through 3/20/22 indicated no entries to document completion of the screening process for COVID-19 by Certified Nursing Assistant 1 (CNA 1) on 3/17/22, or by Licensed Vocational Nurse 1 (LVN 1) on 3/15/22, 3/16/22, 3/17/22, or 3/20/22. During an interview on 3/23/22 at 11:14 a.m., with the Director of Nursing (DON), the DON stated staff were required to document completion of a daily screening for symptoms of COVID-19 on the COVID-19 Screening Vaccinated Employees form. The DON stated CNA 1 had worked on 3/17/22, and LVN 1 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 6 of 9 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 555399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550 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 worked on 3/15/22, 3/16/22, 3/17/22, or 3/20/22. The DON was unable to provide documentation CNA 1 had completed the screening process on 3/17/22, or that LVN 1 had completed the screening process on 3/15/22, 3/16/22, 3/17/22, or 3/20/22. The DON stated it was important the screening process be completed daily to help prevent staff from exposing residents to COVID-19. 2. A review of Resident 14's admission Record indicated she was admitted in 2017 with a diagnosis of diabetes mellitus (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs). A review of Resident 14's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 12/9/21, indicated Resident 14 was totally dependent on one person for assistance with personal hygiene and bathing. A review of Resident 10's admission Record indicated she was admitted in 2018 with a diagnosis of Parkinson's disease (a disease of progressive deterioration of the brain and muscular systems). A review of Resident 10's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 1/20/22, indicated Resident 10 was totally dependent on one person for assistance with personal hygiene and bathing. During an observation on 3/21/22 at 10:25 a.m., in the shared room of Resident 10 and Resident 14, Certified Nursing Assistant 3 (CNA 3) wore gloves while she gave a bed bath to Resident 14, while Resident 14 lay in her bed. CNA 3 doffed her soiled gloves and placed them on Resident 14's bedside table. CNA 3 did not perform hand hygiene after she removed the used gloves and left Resident 14's bedside to get supplies. A review of facility's policy and procedure (P & P), titled Bed Bath, revised February 2018, indicated when staff completed the bath, gloves should be removed and discarded in the designated container, immediately followed by wash and dry your hands thoroughly. 3. During an observation and concurrent interview on 3/21/22 at 10:27 a.m., in the shared room of Resident 10 and Resident 14, CNA 3 went to Resident 10's bedside and picked up an open packet of bathing towelettes which were on top of the blanket covering Resident 10's feet. CNA 3 carried the towelettes to Resident 14's bedside, placed the towelettes on top of Resident 14's bedside table, wet the packet with a rinse-less wash solution (a cleansing solution that does not require rinsing), and stated she was going to complete Resident 14's bed bath. During an interview on 3/21/22 at 11:01 a.m., with the Director of Nursing (DON), the DON stated each resident had their own bathing supplies, and there was no reason wipes should be moved from one resident to another. The DON stated sharing bathing supplies could lead to the spread of infection between residents. 4. During a concurrent observation and interview on 3/23/22, at 8:10 a.m., Licensed Vocational Nurse 1 (LVN 1) placed a wrist blood pressure monitor and a pulse oximeter on a medication tray and entered Resident 234's room. When LVN 1 left the room, LVN 1 wiped the blood pressure monitor and pulse oximeter using a sanitizing wipe but did not thoroughly wet the surface or ensure it remained wet for two minutes, per manufacturers specifications to adequately disinfect. LVN 1 stated the blood pressure monitor and oximeter should be cleaned for two minutes since the equipment was shared between residents and could spread germs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 7 of 9 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 555399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550 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 FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated October 2018, indicated, Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. A review of the [brand name] sanitizing wipe directions for use, To disinfect and deodorize: To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry. Event ID: Facility ID: 555399 If continuation sheet Page 8 of 9 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 555399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide seven of seven residents in multiple resident rooms [ROOM NUMBERS] with at least 80 square feet per resident. This had the potential to result in inadequate space for resident needs and care provision. Findings: During an observation on 3/21/22 at 10 a.m., there were four beds each in rooms [ROOM NUMBERS]. During an interview and concurrent record review on 3/21/22 at 9:38 a.m., with the Administrator and Director of Nursing (DON), the previous approved room waiver was reviewed. The DON stated resident rooms [ROOM NUMBERS] each had four beds and that a request for a room waiver needed to be submitted to the Centers for Medicare and Medicaid Services. The DON stated the room measurements were as follows: Resident room [ROOM NUMBER] measured 20 feet by 16 feet. Usable resident space for four residents would provide 304.6 square feet or 76.1 square feet per resident. Resident room [ROOM NUMBER] measured 20 feet 6 inches by 17 feet. Usable resident space for four residents would provide 287 square feet or 71.75 square feet per resident. During random observations on 3/21/22 through 3/25/22 there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident's care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed the decreased space and/or safety concerns in the two rooms. There was sufficient space for the provision of care and emergency access in both rooms. Granting of room size waiver recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 9 of 9