Health inspection·March 1, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete baseline care plans were not completed within 48 hours by the interdisciplinary team members (IDT). DON further stated she was aware the summaries of the baseline care plan were not provided to the residents and representatives. During a review of the facility's policy and procedures (P&P) titled, Care Plan - Baseline, revised March 2022, the P&P indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand). Provision of the summary to the resident and/or resident representative is documented in the medical records. Event ID: Facility ID: 555399 If continuation sheet Page 2 of 39 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 03/01/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review, for one (Resident 6) of two sampled resident, the facility failed to implement its Care Plans, Comprehensive Person-Centered policy and procedure when there was no care plan developed to address Resident 6's risk of aspiration with appropriate interventions This failure had the potential to result in Resident 6 develop aspiration, pneumonia and respiratory infection and for residents' not receiving appropriate care and treatment. Findings: Review of Resident 6's admission record, dated 9/1/21, indicated Resident 6 was admitted to the facility with multiple diagnoses included dysphagia orophapharryngeal phase (difficulty in swallowing). Review of Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 12/22/23, indicated Resident 6's Basic Interview of Mental status (BIMS) score was 05 (meaning poor cognition). Resident 6 had swallowing disorder related to holding food in mouth/cheeks or residual food in mouth after meals. Resident 6 diagnoses included dysphagia and Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). During an observation on 2/26/24 at 12:56 a.m., Resident 6 was sited up at the dining table in the dining area and fed by Restorative Nursing Assistant (RNA 1). Resident 6 coughed repeatedly when fed corn bread and salad. When Resident 6 coughed RNA 1 gave Resident 6 water to drink from a plastic cup and Resident 6 coughed after the drink. During an interview on 2/27/24 at 10:01 a.m., RNA 1 stated Resident 6 coughed from time to time when fed. RNA 1 stated Resident 6 used to use a special cup but get frustrated because the special cup limited the amount of water to drink at a time. RNA 1 said Resident 6 did not like to use the specialized cup. Review of physician order dated 10/1/21 indicated the physician prescribed Resident 6 to received provale cup during meals. (The provale cup helps prevent choking and aspiration pneumonia while allowing the patient to eat and drink independently). During an interview on 2/27/24 at 10:01 a.m., Director of Nursing (DON), DON stated Resident 6 did not like the provale cup and get frustrated when drinking water so staff stopped using the special cup. DON said Resident 6 used regular plastic cup to drink water and cough frequently. DON stated Resident 6 was high risk for aspiration. DON said coughing help Resident 6 to prevent aspiration. DON said she did not inform the speech therapist or referred resident for speech evaluation. During an interview on 2/29/24 at 10:50 a.m., DON accompanied by the MDS coordinator (MDS), DON stated there no active care plans to address Resident 6 risk from aspiration and dysphagia diagnosis. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated: The comprehensive, person-centered care plan that includes measurable objectives and timetables to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 3 of 39 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 03/01/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm meet the resident's physical, psychological and functional needs is developed and implemented for each resident; The comprehensive, person-centered care plan is developed within (7) days of the completion of the required MDS assessment and no more than 21 days after admission. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 4 of 39 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 03/01/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent falls and implement appropriate interventions for one (Resident 16) of 12 sampled residents when, Resident 16 had repeated unwitnessed falls. The facility did not implement Resident 16's need for supervision with stand-by assistance during transfers. These failures caused Resident 16 to sustain repeated falls and had the potential to result in injuries. Findings: Review of the Interdisciplinary Team (IDT, consists of staff members from different departments) progress notes, dated 2/26/24, indicated Resident 16 had an unwitnessed fall in the dining/activity room. Resident 16 called out for help and was seen sitting on the dining room floor in front of a wheelchair and facing a regular chair that he was previously sitting in. Review of the Significant Change in Status-Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 9/8/23, indicated Resident 16 was admitted to the facility on [DATE]. Resident 16's diagnoses included stroke and Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). Resident 16's Basic Interview of Mental status (BIMS) score was 02 (meaning poor cognition). Resident 16 needed extensive assistance and one person physical assistance with how resident moves to and from lying position, transfers, movements between surfaces, including to or from bed, chair, wheelchair, standing position, use of toilet, transfer on/off toilet, cleanses after elimination, and personal hygiene. Resident 16 had impairment with limited range of motion to bilateral lower extremities (hip, knee, ankle and foot). Resident 16 had history of falls since admission and unsteady balance with moving from a seated to standing position, transfer between bed and chair or wheelchair, and only able to stabilize with staff assistance. During an observation on 2/29/24 at 11:21 a.m., Resident 16 was seated in a wheelchair with no cushion or device to alert staff with self transfer attempts to get up. Resident 16 could self propel the wheelchair up and down the hallways dragging his right leg along. Review of the IDT progress notes indicated Resident 16 was a high risk for falling and had the following documented falls: On 2/21/24 at 2200 (10:00 PM), Resident 16 was assisted to the floor in the hallway when he tried to stand up and lost his balance. On 1/13/24 at 10:00 AM, Resident 16 was sitting in dining/activity room, stood up, lost balance CNA (certified nursing assistant) assisted Resident 16 to sit on the floor. On 12/7/23 at 19:45 (7:45 PM), Resident 16 had an unwitnessed fall, found yelling, hey helpnext to his bed in his room. On 11/28/23 at 2020 (8:20 PM), Resident 16 was found on the floor in the hallways beside his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 5 of 39 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 03/01/2024 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 0689 wheelchair in front of nursing station trying to transfer from wheelchair to regular chair. Level of Harm - Minimal harm or potential for actual harm On 10/28/23 at 2020 Resident 16 found on the floor inside the room by his bed. Resident tried to transfer from his wheelchair to his bed. Residents Affected - Some On 10/16/23 at 18:15 (6:15 PM,) Resident 16 was found on the floor at the end of the hallway. Resident 16 seemed to try to transfer from his wheelchair to another wheelchair. On 9/13/23 at 10:05 AM, Resident 16 was found on the floor in the hallway, laid on his right side with head on the floor. Resident 16 usual function was wheeling self in entire facility; On 8/28/23 at 10:47 AM, Resident 16 had unwitnessed fall inside the activity/dining room. Resident impulsive, has no safety awareness. Review of the care plan initiated 4/17/23 indicated Resident 16 was at risk for continued falls, sub-[NAME] hemorrhage (bleeding in the brain) and injuries related to continued gradual physical weakness. The intervention included physical therapy (PT) evaluation and treatment as ordered. Review of the PT Discharge summary dated [DATE] indicated Resident 16 will safely perform functional transfers with SBA (stand-by assist) and needed supervised assistance with bed mobility in order to reduce risk of fall. {SBA : Stand-by assist. The resident still required caregiver to stand-by them for safety}. During an interview on 3/1/24 at 9:14 a.m., CNA 4 stated she was Resident 16's caregiver for at least twice a week. CNA 4 stated Resident 16 transfers himself from bed to wheelchair and chair to bed CNA 4 stated Resident 16 sometimes goes to the bathroom by himself and does not call for assistance. Further review of the care plan revised 4/20/21 indicated Resident 16 had impaired cognitive function, impaired thought processes, dementia with progressive gradual decline and does not use call light. Care plan interventions included cue, orient and supervise as needed, provide adaptive/safety equipments as needed. During an observation and concurrent interview on 3/1/24 at 11:10 a.m., Resident 16's was not in his room. Resident 16's bed was in the lowest position with landing mat on the floor. There was no device on the bed to alert staff of unassisted transfers. The Director of Nursing (DON) stated the facility is concerned about his repeated falls. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised March 2018, the P&P indicated; Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 6 of 39 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 03/01/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess one sampled resident (Resident 16) when the resident experienced a severe weight loss. This failure had the potential to result in continuous, unplanned weight loss for one of 13 sampled residents. Residents Affected - Few Findings: Review of the document titled, Weight Change Protocol dated 2023, showed Early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner . Residents will be weighed monthly and weekly for those newly admitted and those deemed to be at high risk for weight changes . Variances are calculated from monthly and weekly weights that are obtained by facility staff. Residents who experience significant changes in weight or insidious (continuous weight loss that does not necessarily meet the significant/severe weight loss guidelines) weight loss will be assessed by the Facility RD [Registered Dietitian]. The following criteria define significant or insidious weight changes . 5 # [pound] weight loss or gain in 1 month . 10% weight loss or gain in 6 months. The Facility RD will assess, nutritionally diagnosis, suggest interventions, monitor, and evaluate the success of interventions . A care plan is to be developed stating problems, the goal, and the approaches, interventions to accomplish the goal . The care plan must be revised as the goals and interventions change. The goals, interventions in the care plan should match the latest assessment . Review of Resident 16's admission Record showed he was [AGE] years old and admitted on [DATE]. The diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting right dominant side, dementia (a group of conditions characterized by at least two brain functions, such as memory loss and judgement), dysphagia (difficulty swallowing), depressive disorder, and acquired absence of digestive tract. A review of the document titled, Weights and Vitals Summary showed weights recorded for Resident 16 included but were not limited to: 6/5/23 191 pounds (lbs) 11/4/23 178 lbs 12/4/23 170 lbs This document showed in 6 months from 6/5/23 (191 lbs) to 12/4/23 (170 lbs), Resident 16 had a 21 lb/11 percent (%) weight loss. In addition, Resident 16 had an 8 lb weight loss in one month from 11/4/23 (178 lb) to 12/4/23 (170 lb). A record review for Resident 16 showed the last nutrition related documentation by an RD in Resident 16's Electronic Medical Record (EMR) included a Quarterly Nutrition assessment dated [DATE], and a Progress Note dated 9/14/23. A record review for Resident 16, showed the last revised Care Plan in relation to weight loss was on 10/21/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 7 of 39 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 03/01/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Review of the document titled, MDS [Minimum Data Set] 3.0 Nursing Home Quarterly . dated December 8, 2023, showed Resident 16 had a BIMS (Brief Mental Status) score of 4 (a BIMS score from 0-7 suggests severe cognitive impairment). This document also showed under Section K - Swallowing/Nutritional Status, Resident 16 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regimen. Residents Affected - Few During an interview on 3/1/24 at 9:30 a.m., the licensed vocation nurse MDS Coordinator (LVN 1) stated the RD filled out section K of the MDS, and herself and the Director of Nursing (DON) reviewed the MDS when it was completed. LVN 1 stated when reviewing Section K of the MDS, she looked for weight loss or weight gain. During an interview on 3/1/24 at 9:50 a.m., DON stated when the RD marked yes in section K for unplanned weight loss/gain, the facility started the process for weight variance. DON stated the RD needed to do an assessment and brought the assessment to the Interdisciplinary Team (IDT). DON stated the IDT discussed things, such as the necessity to reweigh a resident and the interventions recommended by the RD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 8 of 39 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 03/01/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two (Resident 2, 16 ) of five sampled residents were free from unnecessary drug when psychotropic medications were administered without adequate clinical indication and monitoring for its use when; 1. Resident 2 was administered Ziprasidone HCL (hydrochloride), an antipsychotic medication at bedtime for dementia and depression manifested by hitting, striking out during care and mobility. Resident 2 was administered Ziprasidone without adequate monitoring of target behaviors. 2. Resident 16 was administered Zyprexa, an antipsychotic medication for altered sensorium (inability to think clearly or concentrate), throwing objects, hitting/punching staff. Resident 16 was administered Trazadone, an antidepressant for sleep without adequate monitor of hours of sleep. Resident 16 was administered PRN (as needed) Lorazepam (Ativan), an antianxiety medication without the implementation of non-pharmacological interventions first before offering PRN medication. Resident 16's PRN Ativan was extended beyond 14 days without the physician documentation of the clinical rationale for continued use. (Note: Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior). According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa can increase the risk of death in elderly people who have memory loss and is not approved for use in psychotic conditions related to dementia. [Reference: www.[NAME].com]. These failures had the potential for residents to receive unnecessary drugs and adverse medication side effects. Findings: 1. During an observation and concurrent interview with Certified Nursing Assistant (CNA 3), on 2/27/24 at 7:42 a.m., Resident 2 laid in bed in her room awake and was nonverbal. CNA 3 stated Resident 2 had no behavior or agitation, and when care was explained, Resident 2 was cooperative, nice and sweet. CNA 3 further stated Resident 2 had a left leg contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) and may agitate when turned and reposition. Review of admission Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 12/28/23, indicated Resident 2 had short and long-term memory problems. Resident 2 had no physical, verbal or other behavioral symptoms directed towards others e.g. hitting, kicking, pushing, scratching, grabbing, rejection of care or wandering. Resident 2 had no behavioral symptoms of feeling down, depressed or hopeless, feeling tired or having little energy or pleasure in doing things. Resident 2 had diagnoses that included depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 9 of 39 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 03/01/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physician order dated 1/30/24 indicated the physician prescribed Resident 2 to receive Ziprasidone HCL oral capsule 40 mg (milligram) give one capsule by mouth at bedtime for antipsychosis (prevents or minimizes hallucinations, like seeing or hearing things that are not there). Review of the Medication Administration Record (MAR), dated 1/1/24 to 1/31/24, indicated Resident 2 received Ziprasidone HCL oral capsule 60 mg, one capsule at bedtime for depression and dementia. Review of the MAR, dated 2/1/24 to 2/26/24, indicated Resident 2 received Ziprasidone 40 mg one capsule by mouth at bedtime for antipsychosis. Further review of the MAR, dated 1/1/24 through 2/25/24, indicated no documentation of target behavior monitoring for Resident 2's use of Ziprasidone. During an interview on 2/27/24 at 12:53 p.m., Licensed Vocational Nurse (LVN 2), LVN 2 stated Resident 2 used to be agitated when first admitted to facility. LVN 2 further said Resident 2 was now calm with no behavior of hitting or striking out. During an interview on 2/28/24 at 8:58 a.m., CNA 2 stated she provided care for Resident 2, two to three times a week. CNA 2 stated Resident 2 was cooperative when care was explained. Review of the Consultant Pharmacist's (CP) Medication Regimen Review (MRR), dated 1/3/24, indicated Resident 2 has been receiving the antipsychotic medication Ziprasidone that requires behavior and side effect monitoring. Please evaluate for gradual dose reduction. Review of Resident 2's Preadmission Screening and Resident Review (PASRR), dated 12/21/23, indicated a negative (no mental illness) Level 1 screening (a tool that helps identify possible serious mental illness or intellectual/developmental disability-ID/DD). If Level I is negative, no advance screening to Level II occurs. A Level II evaluation helps determine placement and specialized services. 2. Review of the Significant Change in Status-Minimum Data Set, dated [DATE], indicated Resident 16's Basic Interview of Mental status (BIMS) score was 02 (meaning poor cognition). Resident 16 was not oriented to correct year, month, and day of the week. Resident 16 had unclear speech and was usually understood and understand others. Resident 16 had no serious mental illness or exhibited other behavioral symptoms directed towards others, such as hitting or scratching and screaming. Resident 16's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). Review of the impaired behavioral patterns initiated 6/19/23, indicated Resident 16 had behavior manifestation with period of aggressiveness related to dementia. Review of the order summary report, dated 6/27/2023, indicated the physician prescribed Resident 16 to receive Zyprexa 5 mg one tablet by mouth, one time daily for altered sensorium with behavioral disorder manifested by hitting, punching staff, and throwing objects. Review of the MAR, dated 1/1/24 to 1/31/24, indicated Resident 16 received Zyprexa 5 mg tablet one tablet by mouth one time a day for altered sensorium, hitting/punching staff. Review of the Consultant Pharmacist's (CP) MRR dated 1/5/24, indicated for Resident 16 to please update Zyprexa order to include indication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 10 of 39 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 03/01/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and concurrent interview on 2/29/24 at 11:00 a.m., Resident 16 was seated in wheelchair in the dining room playing with puzzles. Resident 16 stated he was doing well. During an interview on 2/29/24 at 11:02 a.m., CNA 1 stated he was a regular caregiver for Resident 16. CNA 1 stated Resident 16 had no behavior of hitting or punching staff. CNA 1 stated he started work at the facility eight months ago, and at that time, Resident 16 was aggressive when care was provided, but no more. CNA 1 stated Resident 16 was up in the wheelchair daily, and able to mobilize himself up and down the hallways. Review of the order summary report, dated 7/6/2023, indicated the physician prescribed Resident 16 to receive Lorazepam oral tablet 1 mg, give one tablet by mouth every 6 hours PRN for anxiety and aggressive behaviors. Review of the MAR, dated 2/1/2024 to 2/26/2024, indicated Resident 16 received PRN Lorazepam 1 mg one tablet by mouth for anxiety and aggressive behavior more than 14 days without a physician reevaluation for continued use. Further review of the MAR, dated 1/1/24 to 1/30/24, and 2/1/24 to 2/26/24, indicated Resident 16 was administered PRN Lorazepam 1 mg tablet by mouth 17 times in January 2024 and nine times in February 2024 without implementation of no- pharmacological interventions first before offering PRN medication. Review of CP's MRR, dated 1/5/24, regarding Resident 16 to please be aware there needs to be a review of PRN psychotropic medications by Medical Doctor (MD) every 14 days unless stated on the order otherwise. During a telephone interview on 3/01/24 at 9:51 a.m., Medical Doctor (MD 1), MD 1 stated she was not aware of the need to reevaluate and document Resident 16's use of PRN Ativan after 14 days. Further review of order summary report, dated 8/26/2023, indicated the physician prescribed Resident 16 to receive Trazodone HCL 100 mg, give one tablet by mouth in the evening for sleep. Review of the MAR, dated 1/1/24 to 1/30/24, and 2/1/24 to 2/26/24, indicated Resident 16 was administered Trazodone 100 mg one tablet by mouth in the evening sleep. Resident 16's hours of sleep was not monitored. During a review of Resident 16's clinical records and MRR, and concurrent interview, on 2/29/24 at 2:53 p.m., with DON, DON stated the facility's expectation was for licensed nurses to first offer nonpharmacological interventions before the administration of PRN psychotropic medications. DON said hours of sleep were not monitored for the use of Trazodone HCl, and the attending physician did not document the rationale for the extended time use of Lorazepam PRN in Resident 16's medical records. Furthermore, DON stated she was aware that hitting and striking out were not appropriate indications for use of antipsychotic medications and PRN psychotropic medications need to be reevaluated every 14 days. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, the P&P indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications. Psychotropic medications are not prescribed or given on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 11 of 39 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 03/01/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical records. PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are NOT antipsychotics if the prescribe or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 12 of 39 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 03/01/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm 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 observation, interview, and record review, the facility failed to employ a qualified nutrition professional to manage the food and nutrition services when; Residents Affected - Many 1. The Dietary Services Supervisor (DSS) did not work in the facility on a full-time basis and the Registered Dietitian (RD) worked part-time. 2. DSS did not know the cool down method for a leftover meat sauce and Pozole soup. 3. DSS did not ensure that time and temperature monitoring was performed by kitchen staff during thawing of frozen food items. 4. DSS did not ensure residents were served palatable food when food was served at a low temperature, tasted bland, and was a poor texture. 5. DSS did not ensure food was fortified (adding protein, fat, and/or carbohydrate to foods) for 15 out of 15 residents on fortified diet. 6. DSS did not ensure six out of six residents on Consistent Carbohydrate (CCHO - a diet that helps keep blood sugar levels stable) diet received a Regular diet instead of the CCHO diet. 7. DSS had not communicated to RD 1 that most residents did not like milk for lunch and for other meals which resulted in the facility not providing a substitute of equal nutritive value. 8. DSS did not effectively maintain a system to ensure that resident's food preferences were accurately recorded on individual tray cards. These failures had the potential for food and nutrition services staff to be inadequately trained and supervised to carry out food and nutrition services for 30 out of 30 residents in a safe and sanitary manner. Findings: 1. During a concurrent kitchen observation and interview on 2/26/24 at 9:25 a.m, with DSS, there were multiple unlabeled and undated food items, thawed and refrozen food items, and 10 tomatoes had areas of white fuzzy material and dark spots resembling mold was in the freezer and refrigerator. DSS stated that cooks are responsible for checking food items in the refrigerator and freezer. DSS further stated, I should be monitoring the refrigerator and freezer too, but I am not here full time. I am also working in the facility next door. During an interview on 2/26/24 at 11:20 a.m. with RD 1, RD 1 stated she worked for the facility for only a month and, I work 8 hours in this facility and once a week for the other facility next door. RD 1 further stated there was another RD (RD 2) that works for the facility. 2. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the policy indicated 1. The Food & Nutrition Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 13 of 39 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 03/01/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's undated DSS Job Description which indicated, The DSS duties and responsibilities included: To enforce food safety and sanitation policies by performing regular inspections of facilities and employees. According to the 2022 Federal Food Code, safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety (TCS) foods has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, TCS foods are subject to the growth of a variety of pathogenic microorganisms. A longer time near ideal bacterial incubation temperatures (70 ºF - 125 ºF), is to be avoided. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness. The Food Code provision for cooling provides for cooling from 135ºF to 41°F or 45°F in 6 hours, with cooling from 135ºF to 70°F in 2 hours. The 6-hour cooling parameter, with an initial 2-hour rapid cool, allows for greater flexibility in meeting the Code. The initial 2- hour cool is a critical element of this cooling process. During an observation on 2/26/24 at 10:12 a.m., in the kitchen refrigerator was a container lid labeled meat sauce dated 2/24/24, and another container labeled Pozole soup dated 2/23/24. During a review of the meat sauce recipe, dated Week 4 Saturday, the recipe indicated it contained ground beef. During a review of the Pozole soup recipe, dated Week 4 Friday, the recipe indicated it contained pork meat. During concurrent interview and record review on 2/27/24 at 11:02 a.m, with DSS, an undated and blank Cool Down Log was reviewed. The log indicated, the leftover meat sauce and Pozole soup temperature was not monitored during the cool down process.DSS stated, The leftover meat sauce and Pozole soup in the refrigerator doesn't necessarily need a cool down log since the meat was mixed with other ingredients. On 2/28/24 at 11:50 a.m., the surveyor requested DSS to provide the staff training related to food safety. As of 3/1/24, at the time of exit, the facility failed to provide documented staff training. 3. During a review of facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the policy indicated, 1. The Food & Nutrition Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques. During a review of the facility's undated DSS Job Description, the document indicated, The DSS duties and responsibilities included: To enforce food safety and sanitation policies by performing regular inspections of facilities and employees; To monitor records of food temperatures, . cool down logs. If incomplete, identify responsible employee and enforce compliance. According to the 2022 Federal Food Code, an important duty of the Person in Charge is to make sure that any required temperatures are achieved or maintained when foods are thawed. The Person in Charge ensures that employees are monitoring food temperatures to verify the critical temperature limits, the likelihood of temperature abuse is reduced. This includes oversight of temperature monitoring to ensure that temperatures for Time/Temperature Control for Safety (TCS) foods are routinely (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 14 of 39 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 03/01/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm monitored during thawing to ensure that the growth of bacterial pathogens and toxin production is prevented and that foods that require temperature control for safety are being held at temperatures that adequately prevent pathogen growth and toxin production. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. If the food is then refrozen, significant numbers of bacteria and/or all preformed toxins are preserved. Residents Affected - Many During a concurrent kitchen observation and interview on 2/26/24 at 9:25 a.m., with [NAME] 1, multiple thawed and refrozen food items were in the freezer. [NAME] 1 stated that received frozen food items were generally thawed by staff in the food production sink by running water over the product and that it was likely the product was thawed and refrozen. [NAME] 1 further stated there was no time and temperature monitoring of this process. During a concurrent follow up observation and interview on 2/26/24 at 3:06 p.m., with [NAME] 2, there were two frozen pieces of cooked roast beef in a cardboard box on the counter next to the food production sink. [NAME] 2 stated he recently pulled them from the freezer and would begin thawing under water shortly. [NAME] 2 further stated there was no time or temperature control monitoring of this process. During an interview on 2/27/24 at 10:45 a.m., DSS stated they (kitchen staff) thaw frozen meat under running water without time and temperature monitoring and that it was okay not to monitor since the meats are already cooked. The facility's P&P manual was requested from DSS. DSS stated the manual was kept in the facility next door. On 2/28/24 at 11:50 a.m., the surveyor requested DSS to provide staff training related to food safety. As of 3/1/24, at the time of exit, the facility failed to provide documented staff training. 4. During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the policy indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperature; 3. The hot food served on tray line must be at or above minimum holding temperature of 140 ºF; 7. Temperature of the food when the resident receives it is based on palatability. The goal is to serve hot food hot. The recommended hot food temperature for an entrée, starch, and vegetable at delivery to resident was greater than or equal to (?) 120 ºF. During a review of the undated Regular Pureed Diet document from the facility's Diet Manual, the document indicated The texture of pureed food should be of smooth and moist. During a review of facility's undated DSS Job Description, the document indicated The DSS duties and responsibilities included to supervise receiving of food to ensure correct items, temperatures and amounts; When on duty, be present at each meal services, monitoring for compliance in food temperatures and texture modification; Communicate with dietitian regarding resident changes or request. During an interview on 02/26/24 at 11:00 a.m., with Resident 5, Resident 5 stated that a lot of times she receives cold food and does not get much in terms of variety of choices and chooses what she thinks will taste ok and not give her nausea. During tray line observation on 2/26/24 at 11:30 a.m., pureed chili had the texture of a thickened cream soup and pureed cornbread was a thin pudding texture. Both foods did not hold their shape and spread out when placed on the resident lunch plate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 15 of 39 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 03/01/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a follow up tray line observation on 2/27/24 at 11:23 a.m., pureed beef roast and zesty spinach were plated, both were runny and spread out on the plate. During a concurrent tray line observation and interview on 2/28/24 at 12:05 p.m., with RD 1, the temperature of the food served was measured with a calibrated thermometer. A tray of regular fish Italiano was 113 degrees Fahrenheit (ºF). RD 1 stated temperature of hot foods during tray line should be at least 141 ºF. Temperature of the food on a resident's pureed tray, placed on a food service cart number 2 used to carry food to resident rooms, was also checked. Pureed fish was 121.8 ºF, pureed broccoli with garlic was 119.3º F, and pureed risotto was 106.5 ºF. Test trays with pureed and regular textured food were also placed on cart number 2. It was noted the kitchen did not have a piece of equipment to hold food hot on the tray line, which is the standard in licensed facilities for holding hot food during a tray line food service. During a concurrent observation and interview on 2/28/24 at 12:45 p.m. with Registered Dietitian (RD) 1, the regular and pureed food test tray were sampled. The temperature of the regular textured food was as follows: fish Italiano was 97 ºF, creamy risotto style rice was 118.3 ºF and broccoli with garlic was 102.1 ºF. The temperature of the pureed broccoli with garlic was 119.6 ºF. The regular risotto and broccoli tasted bland (no or very little flavor), and the pureed risotto, broccoli, and fish had a very sticky and gummy mouth texture. RD 1 stated the fish and broccoli was cold and that the risotto was at room temperature when she tasted it. RD 1 further stated she would like the food to be a little warmer to at least 120 ºF when served to the residents. She also acknowledged that the risotto tasted bland, and the pureed food was sticky. During an interview on 2/29/24 at 8:37 a.m. with the Activity Director, AD stated DSS was notified and aware of resident's cold food complaints that was discussed during the resident council meeting. During an interview on 2/29/24 at 8:42 a.m., with DSS, DSS stated he provided education to kitchen staff related to cold food complaints however did not follow up. During an interview on 2/29/24 at 8:58 a.m. with RD 1, the RD 1 stated resident's complaints of cold food was not communicated to her when she started working for the facility. 5. During a review of facility's policy and procedure (P&P) titled, Fortification of Food: Increasing Calories and/or Protein in the diet, dated 2023, indicated, The goal of fortification of food is to increase the calorie and/or protein density of the foods commonly consumed by the resident to promote improvement in their nutritional status; Adding calories by 1. Adding extra ½ oz or 1 tablespoon (Tbsp) melted margarine to one food item at breakfast, two at lunch, and one at dinner will add 100 calories per ½ oz, 2. Adding extra 2 oz of gravy to foods designated to receive gravy will add 20-50 calories per item; Identification of the residents in need of fortification will be done by the RD or the Food and Nutrition Services Director. The physician will then order a Fortified Diet. During a review of the facility's P&P titled, Diet Orders, dated 2023, indicated, Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department. During a review of facility's undated DSS Job Description, the document indicated, The DSS duties and responsibilities included to when on duty, be present at each meal service, monitoring for compliance in . therapeutic diet (a diet order as part of treatment for a disease or clinical condition to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 16 of 39 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 03/01/2024 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 0801 decrease or increase specific nutrients in the diet). Level of Harm - Minimal harm or potential for actual harm During tray line observation on 2/26/24 at 12:11 p.m., margarine was not served on lunch trays for all residents including residents on a fortified diet (Cross-reference F803). Residents on a fortified diet did not receive any additional items to increase the nutrient content of the food served. A review of the Winter Menus, dated 2/26/24, indicated 1 tsp of margarine should be included at lunch tray for all diets excluding lowfat/low cholesterol. Residents Affected - Many During a follow up tray line observation on 2/27/24 at 11:23 a.m., [NAME] 1 used a two ounce (oz) red, spoodle (a utensil, cross between a ladle and a spoon) to spread gravy between the mashed potatoes and beef roast for each meal plate. Extra gravy was not served for residents with fortified diet order. Residents on a fortified diet did not receive any additional items to increase the nutrient content of the food served. A review of the Winter Menus dated 2/27/24, showed regular and therapeutic diets received 1-2 oz of brown gravy on the herb crusted beef roast. During a review of the Diet Type Report, dated 2/28/24, the document indicated 15 residents were on a Fortified diet order. 6. During a review of the facility's P&P titled, Diet Orders, dated 2023, indicated Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department. During a review of the facility's undated DSS Job Description, which indicated, The DSS duties and responsibilities included: When on duty, be present at each meal service, monitoring for compliance in . therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet). During a concurrent tray line observation and interview on 2/26/24 at 11:30 a.m., with [NAME] 2, [NAME] 2 dished the citrus chiffon delight dessert. [NAME] 2 stated the dessert was the same for all the residents. When the desserts were placed on Resident trays, regular citrus chiffon delight was placed on Regular and CCHO diet trays. In addition, one whole piece of cornbread was served on Regular diet and CCHO diet lunch trays. A review of the Winter Menus, dated 2/26/24, indicated Regular diets should receive Citrus Chiffon Delight and CCHO diet should receive Diet Citrus Chiffon Delight. The menu also showed Regular diets should receive one piece of Cornbread with [NAME] Chilis, and CCHO diets should receive one half piece of Cornbread with [NAME] Chilis. During a concurrent observation, interview, and record review on 2/27/24 at 10:15 a.m., [NAME] 2 was dishing the Triple Fruit Crisp and stated he had prepared it earlier using the regular recipe. The Citrus chiffon delight recipe and Triple fruit crisp recipe, concurrently dated Week 1 Monday and Tuesday was reviewed with [NAME] 1 and [NAME] 2. The recipe indicated diet gelatin was to be substituted for regular gelatin for the diet Citrus chiffon and brown sugar was not an ingredient for making a diet Triple fruit crisp. [NAME] 1 and [NAME] 2 stated they used the regular recipe for desserts and did not make a separate diet dessert. During a tray line observation on 2/27/24 at 11:23 a.m., Regular and CCHO diets received one garlic stick, and regular triple fruit crisp. A review of the Winter Menus dated 2/27/24 indicated, Regular diets should receive one slice of garlic bread and Triple Fruit Crisp.In addition, CCHO diets should receive ½ slice of garlic bread and Diet Triple Fruit Crisp. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 17 of 39 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 03/01/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm During a review of Diet Type Report, dated 2/28/24, the document indicated, 6 residents were on CCHO diet. 7. During a review of the facility's undated DSS Job Description, the document indicated, The DSS duties and responsibilities included: To Communicate with dietitian regarding resident changes or request. Residents Affected - Many During a review of the winter menus, dated 2/26/24 and 2/27/24, the menu indicated, milk was the beverage to be served to residents on all diets. During tray line observation on 2/26/24 at 12:11 p.m., meal trays were prepared, placed on a food delivery cart, and were transported to residents for lunch. One 4 oz cup of water and one 4 oz cup of cranberry juice were on 29 lunch trays. One meal tray had one 4 oz cup of water and one 4 oz cup of yellow sugar free beverage. Over 20 trays did not include milk. During a follow up tray line observation on 2/27/24 at 11:36 a.m., DSS, Dietary Aide (DA) 2, and [NAME] 2 were placing one 4 oz cup of water and one 4 oz cup of cranberry juice on each lunch tray. Again, over 20 trays did not include milk. During an interview on 3/1/24 at 12:10 p.m. with DSS and RD 1, DSS stated that most residents do not like milk for lunch and for other meals. The DSS further stated that when residents were not getting milk on a regular basis, there was no substitution made. RD 1 stated she was not aware that most of the residents did not like milk and she did not make sure a substitution was provided when a resident preferred not to drink milk when it was on the planned menu. 8. During a review of the facility's P&P titled The Dietary Profile, dated 2023, the policy indicated The FNS [Food and Nutrition Services] Director or other designated personnel will update the profile card. The policy also indicated the profile card would include information obtained by visiting the resident and should include food and beverage preferences, food dislikes, appetite, and swallowing ability. During a review of facility's undated DSS Job Description, the document indicated The DSS duties and responsibilities included: To maintain correct tray cards and supplement labels for correct food service; Input food preferences into computer system; When on duty, be present at each meal service, monitoring for compliance in . food preferences. During an interview on 02/26/24 at 11:00 a.m. with Resident 5, Resident 5 stated that they do not get much in terms of variety of choices so that she just choses what she thinks will taste ok and not give her nausea. During a concurrent interview and document review on 2/28/24 beginning at 11:20 a.m., the Dietary Services Supervisor (DSS) demonstrated the system for maintaining food preferences. It was noted the administrative documents for the facility were not maintained within the licensed building of the facility, rather were maintained at an affiliated separately licensed facility. Concurrent review of the resident profile cards (a document that documents the residents' physician ordered diet, allergies, as well as likes and dislikes). Resident profile cards are also intended to provide special instructions to food production staff. The surveyor asked how food production staff would be able to accurately check resident preferences or any specialized instructions, since the profile cards were not accessible to them. He stated there was a printed diet report that was updated weekly and posted in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 18 of 39 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 03/01/2024 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 0801 the food production kitchen. Level of Harm - Minimal harm or potential for actual harm The DSS also indicated the profiles cards were currently not updated as there continued to be resident profile cards that were no longer at the facility. Random review of the resident profile card for Unsampled Resident 3 revealed while she listed multiple dislikes including zucchini, broccoli, fish, bread, or rolls, none of these dislikes were listed on her tray card. Similarly, there were greater than 15 profile cards where no likes/dislikes or preferences were listed. Review of facility document titled Diet Type Report dated 2/28/24, revealed there were 32 listed residents, however the facility's current census was listed as 30. It was also noted except for Resident 6's preference for iced cold or hot beverages there were no other listed preferences. Similarly for Resident 5 the listed the nursing instructions for the nurse to check the tray every Sunday. There were no food preferences listed on the diet report. Concurrent review of Resident 5's tray card listed only cheese as a dislike. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 19 of 39 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 03/01/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure food and nutrition staff had the appropriate competencies and skills set when: 1. Staff did not follow correct procedure for thawing frozen food item. 2. Staff did not appropriately demonstrate how to check the sanitizer strength used for the dish machine. 3. Staff recorded dish wash machine temperature inaccurately. These failures had the potential for inappropriate food preparation and dishwashing procedure that could result in food borne illness. Findings: 1. During a concurrent kitchen observation and interview on 2/26/24 at 9:25 a.m., with [NAME] 1, an unlabeled plastic package of tan colored frozen meat was in the freezer. It was also noted in the bottom of the plastic bag there was a frozen clear, pink tinged fluid. [NAME] 1 identified the item as frozen chicken and stated that product was received frozen and staff generally thawed meat in the food production sink by running water over the product. [NAME] 1 acknowledged it was likely the product was thawed and was refrozen and stated there was no time or temperature monitoring of this process. During a concurrent follow up observation and interview on 2/26/24 at 3:06 p.m., with [NAME] 2, there were two frozen pieces of cooked roast beef in a cardboard box on the counter next to the food production sink. [NAME] 2 stated he recently pulled them from the freezer and would begin thawing under water shortly. [NAME] 2 further stated there was no time or temperature control monitoring of this process. According to the 2022 Federal Food Code, an important duty of the Person in Charge is to make sure that any required temperatures are achieved or maintained when foods are thawed. The Person in Charge ensures that employees are monitoring food temperatures to verify the critical temperature limits, the likelihood of temperature abuse is reduced. This includes oversight of temperature monitoring to ensure that temperatures for time/temperature control for safety (TCS) foods are routinely monitored during thawing to ensure that the growth of bacterial pathogens and toxin production is prevented and that foods that require temperature control for safety are being held at temperatures that adequately prevent pathogen growth and toxin production. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. If the food is then refrozen, significant numbers of bacteria and/or all preformed toxins are preserved. 2. During an observation on 2/27/24 on 10:13 a.m., Dietary Aide (DA) 2 was washing dishes using the dish machine. DA 2 demonstrated how to check the chlorine strength by dipping a sanitizer strip in water pooled in the dish machine. [NAME] 2 noticed that the sanitizer strip used by DA 2 was the improper strip. [NAME] 2 then handed DA 2 the correct strip which was the chlorine strip and retested the dish machine sanitizer concentration. [NAME] 2 guided DA 2 through the testing process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 20 of 39 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 03/01/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of facility's undated Dietary Aide Job Description, the document indicated, Duties and Responsibilities: Perform dishwashing/cleaning procedures in timely fashion; Follow established safety procedures and infection control policies and procedures when performing daily task. During a review of facility's policy and procedure (P&P) titled Sanitation, dated 2023, the policy indicated No Food & Nutrition Services employee shall operate any major piece of equipment without knowing how to operate it correctly. 3. During a concurrent observation and interview on 2/27/24 at 10:13 a.m., with DA 2, DA 2 completed a dish wash cycle. DA 2 stated she checked and recorded the temperature earlier in the Dish Machine Temperature Log. During a concurrent interview and record review on 2/27/24 at 10:20 a.m., with DA 2, the Dish Machine Temperature Log, dated [DATE] was reviewed. The log indicated, 2/27/24 lunch dish wash temperature was recorded when lunch was not served yet. The log further indicated the temperatures are consistently the exact same number for multiple cycle on multiple days. During a review of the facility's undated, Dietary Aide Job Description, the document indicated. Duties and Responsibilities: Maintain accurate and timely logs of temperature, chemical level, etc. as directed; Perform dishwashing/cleaning procedures in timely fashion. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the policy indicated, 1. The Food & Nutrition Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques. On 2/28/24 at 11:50 a.m., the surveyor requested the Dietary Services Supervisor (DSS) to provide staff training related to food safety. As of 3/1/24, at the time of exit, the facility failed to provide documented staff training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 21 of 39 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 03/01/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation and record review, the facility failed to provide food items according to the menu when nine of 30 sampled residents receiving a regular diet order (Residents 4, 6, 13, 15, 16,17, 29, 186, and 188) were not served with one teaspoon (tsp) of margarine at lunch. This failure had the potential for residents to receive and/or consume inadequate caloric intake. See also tag F 808. Findings: During a review of the facility document, Diet Type Report, dated 2/28/24, the document indicated Residents 4, 6, 13, 15, 16,17, 29, 186, and 188 were on a regular textured diet that allowed margarine consumption. During a lunch tray line observation, on 2/26/24 at 12:11 p.m., there was no margarine served on any resident lunch tray, including the lunch trays of Residents 4, 6, 13, 15, 16,17, 29, 186, and 188. During a review of the facility document, Winter Menus, dated 2/26/24, the Menu indicated one tsp of margarine should be included on the lunch tray for all regular textured diets, excluding the low/fat, low cholesterol diet. During a review of the facility's P&P titled, Diet Orders, dated 2023, the P&P indicated, Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 22 of 39 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 03/01/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 residents were served palatable food when food was served at a low temperature, tasted bland, and had poor texture. Residents Affected - Many These failures had the potential for 30 of 30 residents to consume a decreased amount of nutrients leading to weight loss and/or nutrient related medical complications. Findings: During an interview on 2/26/24 at 10:28 a.m., Resident 1 stated the meals served at the facility were often cold and not palatable. Resident 1 stated the same menu was served repeatedly. Review of the Minimum Data Set (MDS), a Resident Assessment and care guide tool, dated 1/25/24, indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's Basic Interview of Mental status (BIMS) score was 13 (meaning cognitively intact). Resident 1's diagnoses included hypothyroidism (a condition in which the thyroid gland that regulates metabolism doesn't produce enough thyroid hormone). Review of the resident council meetings' minute,s dated 5/24/23 and 1/30/24, indicated residents discussed how come food was cold and the cycle of menus was discussed. During an interview on 2/27/24 at 9:58 a.m., the Activity Director (AD), AD stated residents complained of cold food, dietary issues, and (food) flavor. AD stated she reported (complaints) to the Dietary Supervisor (DS). During an interview on 2/29/24 at 8:50 a.m., the Dietary Services Supervisor (DSS) stated he was aware that residents complained of cold food. DS stated his expectation was for food to reach the residents at 120-degree temperature. DSS said he did not do a follow-up check of the food temperature. During a concurrent tray line observation and interview, on 2/28/24 at 12:05 p.m., with Registered Dietitian (RD) 1, temperature of the food served was measured with a calibrated thermometer. A tray of regular fish Italiano was 113 degrees Fahrenheit (ºF). RD 1 stated the temperature of hot foods during tray line should be at least 141 ºF. The temperature of the food on a resident's pureed tray placed on food service Cart # 2 used to carry food to resident rooms, was checked. The pureed fish was 121.8 ºF, pureed broccoli with garlic was 119.3ºF, and pureed risotto was 106.5 ºF. Test trays with pureed and regular textured food were also placed on Cart # 2. It was noted the kitchen did not have the equipment to hold food hot on the tray line, which is the standard in licensed facilities for holding hot food during the tray line food service. During a concurrent observation and interview, on 2/28/24 at 12:45 p.m., with RD 1, the regular and pureed food test trays were sampled. The temperature of the regular textured food were: fish Italiano was 97 ºF, creamy risotto style rice was 118.3 ºF, and broccoli with garlic was 102.1 ºF. The temperature of the pureed broccoli with garlic was 119.6 ºF. The regular risotto and broccoli tasted bland (no or very little flavor), and the pureed risotto, broccoli, and fish had a very sticky and gummy mouth texture. RD 1 stated the fish and broccoli was cold and the risotto was at room temperature when she tasted it. RD 1 further stated she would like the food to be a little warmer to at least 120 ºF when served to the residents. RD 1 also acknowledged the risotto (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 23 of 39 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 03/01/2024 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 0804 tasted bland and pureed food was sticky. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the policy indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperature; 3. The hot food served on tray line must be at or above minimum holding temperature of 140 ºF; 7. Temperature of the food when the resident receives it is based on palatability. The goal is to serve hot food hot. The recommended hot food temperature for an entrée, starch, and vegetable at delivery to resident was greater than or equal to 120 ºF. Residents Affected - Many During a review of undated Regular Pureed Diet document from the facility's Diet Manual, the document indicated The texture of pureed food should be of smooth and moist. During a review of the facility's admission Record dated 03/01/23, Resident 5 was admitted to the facility on [DATE]. During an interview on 02/26/24 at 11:00 a.m. with Resident 5, Resident 5 stated a lot of times, she receives cold food and she is lactose intolerant. Resident 5 indicated they do not get much in terms of variety of choices and she chooses what she thinks will taste ok and not give her nausea. During a concurrent interview and record review, on 02/27/24 at 1:34 p.m., the Resident Council President stated the food is sometimes ok and sometimes not. Also, the food would be late and cold, and these issues were addressed on 11/'23 during the Resident Council Meeting. A review of the last three months of the Resident Council minutes meeting, dated 11/27/23, it was reported the food was ok, sometimes tasty, sometimes not. Further review indicated the facility will give verbal in-service on the importance of following recipes, using herbs and spices and signed by DS on 11/27/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 24 of 39 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 03/01/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation and record review, the facility failed to ensure pureed food was the appropriate consistency for six out of 30 residents. Residents Affected - Some This failure had the potential for residents on pureed diet to aspirate (draw food into the lungs) and/or negatively impact the resident's dining experience resulting in poor food intake and compromising their nutritional status. Findings: During the tray line observation, on 2/26/24 at 11:30 a.m., the pureed chili had the texture of a thickened cream soup and pureed cornbread was a thin pudding texture. Both foods did not hold their shape and spread out when placed on the resident lunch plate. During a follow up tray line observation, on 2/27/24 at 11:23 a.m., the pureed beef roast and zesty spinach were plated. Each were runny and spread out on the plate. During a review of the Diet Type Report, dated 2/28/24, the document indicated, six residents were on pureed diet order. During a review of the undated Regular Pureed Diet document from the facility's Registered Dietician (RDs) for Healthcare diet manual, the document indicated, The texture of pureed food should be of smooth and moist and able to hold its shape. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 25 of 39 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 03/01/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to: 1. Offer a substitute of equal nutritive value when milk on the planned menu was routinely not provided when milk was on the planned menu for all diets. 2. Effectively maintain a system to ensure the resident's food preferences were accurately recorded on their individual tray cards. These failures had the potential for 30 of 30 residents who received food from the kitchen to not receive the nutrients intended by the planned menu and not receive foods according to resident preferences. Findings: 1. During a review of the winter menus, dated 2/26/24 and 2/27/24, the menu indicated, milk was the beverage to be served to residents on all diets. During the tray line observation, on 2/26/24 at 12:11 p.m., meal trays were prepared, placed on a food delivery cart, and were transported to residents for lunch. One 4 oz cup of water and one 4 oz cup of cranberry juice were on 29 lunch trays. One meal tray had one 4 oz cup of water and one 4 oz cup of yellow sugar-free beverage. Over 20 trays did not include milk. During a follow up tray line observation, on 2/27/24 at 11:36 a.m., the Dietary Services Supervisor (DSS), Dietary Aide (DA) 2 and [NAME] 2 were placing one 4 oz cup of water and one 4 oz cup of cranberry juice on each lunch trays. Over 20 trays did not include milk. During an interview on 3/1/24 at 12:10 p.m., with DSS and Registered Dietitian (RD) 1, DSS stated that most residents do not like milk for lunch and for other meals. DSS further stated when residents were not getting milk on a regular basis, there was no substitution made. RD 1 stated she was not aware that most of the residents did not like milk and she did not make sure a substitution was provided when a resident preferred not to drink milk when it was on the planned menu. 2. During an interview on 02/26/24 at 11:00 a.m., with Resident 5, Resident 5 stated a lot of times she receives cold food and she is lactose intolerant (not able to digest the sugar lactose in milk or dairy products). Resident 5 indicated they (residents) do not get much in terms of variety of choices and chooses what she thinks will taste ok and not give her nausea. During an interview and concurrent document review, on 2/28/24 beginning at 11:20 a.m., DSS demonstrated the system for maintaining food preferences. It was noted the facility's administrative documents for the facility were not maintained within the licensed building of the facility, and were maintained at an affiliated, separately licensed facility. The concurrent review of the resident profile cards (document of the residents' physician ordered diet, allergies, and likes and dislikes), and also intended to provide special instructions to food production staff. The surveyor asked how food production staff would be able to accurately check resident preferences or any special instructions, since the profile cards were not accessible to them. DSS stated there was a printed diet report updated weekly and posted in the food production kitchen. DSS also indicated the profile cards were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 26 of 39 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 03/01/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some currently updated because there continued to be resident profile cards that were no longer at the facility. A random review of the resident profile card for Unsampled Resident 3 showed she listed multiple dislikes, including zucchini, broccoli, fish, bread, or rolls, none of these dislikes were listed on her profile card. Similarly, there were greater than 15 profile cards with no likes/dislikes or preferences listed. Review of facility document titled, Diet Type Report dated 2/28/24, showed there were 32 listed residents. However the facility's current census was listed as 30. Except for Resident 6's preference for iced cold or hot beverages, there were no other listed preferences. Similarly for Resident 5 guidance was limited to nursing instructions for the nurse to check the tray every Sunday and no food preferences listed on the diet report. Resident 5's tray card listed only cheese as a dislike. During a review of the facility's policy and procedure (P&P) titled, The Dietary Profile, dated 2023, the policy indicated, The FNS [Food and Nutrition Services] Director or other designated personnel will update the profile card. The policy also indicated the profile card would include information obtained by visiting the resident and should include food and beverage preferences, food dislikes, appetite, and swallowing ability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 27 of 39 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 03/01/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, the facility failed to provide the physician- prescribed therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet) when: 1. Six of six sampled residents (Residents 4, 6, 13, 15, 16,17) on a Fortified diet (a diet with added protein, fat, and/or carbohydrate to increase calories) did not receive supplemental food items as ordered. 2. Three of three sampled residents (Residents 5, 28, 21) on a Consistent Carbohydrate diet (CCHO - a diet that promotes stable blood sugar levels) received a regular diet instead of the CCHO diet. 3. One of one sampled resident (Resident 16) with a diet order for extra protein did not receive extra meat as ordered. These failures had the potential to result in weight loss and/or unstable blood sugar for the residents who did not receive their therapeutic diets as ordered. See also tag F 803. Findings: 1. During a review of the facility document, Diet Type Report, dated 2/28/24, the document indicated Residents 4, 6, 13, 15, 16, and 17 had orders for a Fortified diet. During a lunch tray line observation on 2/26/24 at 12:11 p.m., there was no margarine served on any resident lunch tray, including the lunch trays of Residents 4, 6, 13, 15, 16, and 17. The lunch trays of Residents 4, 6, 13, 15, 16, and 17 included the food items provided to residents on a Regular diet without provision of any additional food items, such as additional margarine. During a review of the facility, Winter Menus, dated 2/26/24, the Menus indicated one teaspoon (tsp) of margarine should be included on lunch trays for all diets excluding low fat/low cholesterol diets. During a lunch tray line observation on 2/27/24 at 11:23 a.m., [NAME] 1 used a two ounce (oz), red spoodle (a combination utensil used as a ladle and a spoon) to spread gravy between the mashed potatoes and beef roast on each resident meal plate, including the lunch trays of Residents 4, 6, 13, 15, 16, and 17. The lunch trays of Residents 4, 6, 13, 15, 16, and 17 included the food items provided to residents on a Regular diet without provision of any additional food items such as extra gravy. During a review of the facility, Winter Menus, dated 2/27/24, the Menus indicated regular and therapeutic diets were to receive one to two ounces of brown gravy on herb crusted beef roast during the lunch service. 2. During a review of the facility, Diet Type Report, dated 2/28/24, the Report indicated Residents 5, 28, and 21 were on a CCHO diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 28 of 39 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 03/01/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent lunch tray line observation and interview on 2/26/24 at 11:30 a.m., with [NAME] 2, all resident lunch trays received a 2 inch by 2.5-inch piece of cornbread, and a serving of Citrus Chiffon Delight Dessert, including the lunch trays of Residents 5, 28, and 21. [NAME] 2 stated the same dessert was provided to all the residents. During a review of the facility document, Winter Menus, dated 2/26/24, the Menus indicated residents on Regular diets were to receive Citrus Chiffon Delight and residents on CCHO diet were to receive Diet Citrus Chiffon Delight. The Menu also indicated residents on a Regular diet were to receive one piece of cornbread with green chilis, and residents on CCHO diets were to receive one-half piece of cornbread (a half piece of the regular 2 inch by 2.5-inch cornbread) with green chilis. During a concurrent interview and record review on 2/27/24 at 10:15 a.m., in the kitchen, with [NAME] 1 and [NAME] 2, the recipes for Citrus Chiffon Delight and Triple Fruit Crisp were reviewed. The recipes indicated changes from the Regular diet items of Citrus Chiffon Delight and Triple Fruit Crisp should be made for CCHO diets as follows: diet gelatin was to be substituted for regular gelatin for preparation of the Diet Citrus Chiffon and brown sugar should be omitted from the ingredients in the Diet Triple Fruit Crisp. [NAME] 2 stated he had prepared the Triple Fruit Crisp earlier in the day using the Regular recipe. [NAME] 1 and [NAME] 2 both stated they had used the Regular diet recipes for Citrus Chiffon Delight and Triple Fruit Crisp and had not made a separate diet dessert as indicated in the recipes. During a lunch tray line observation on 2/27/24 at 11:23 a.m., each resident lunch tray received one garlic stick, and a serving of the regular Triple Fruit Crisp, including the lunch trays of Residents 5, 28, and 21. A review of the facility document, Winter Menus, dated 2/27/24, the Menus indicated residents on a Regular diet were to receive one slice of garlic bread and a serving of Triple Fruit Crisp. The Menus indicated CCHO diets were to receive half of a garlic stick and a Diet Triple Fruit Crisp. During a review of the facility's P&P titled, Diet Orders, dated 2023, the P&P indicated, Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department. 3. During a review of Resident 16's Physician's order, dated 9/18/23, the order indicated Resident 16's diet was Regular, Fortified, Extra Calorie, Extra Protein. During tray line observation on 2/27/24 at 11:40 a.m., Resident 16's lunch tray was plated with one 3-ounce slice of beef roast, mashed potatoes, zesty spinach, and a garlic stick. The lunch tray had a copy of Resident 16's meal card; the meal card indicated Resident 16 was to receive extra meat. Resident 16 did not receive any additional items to increase the nutrient/caloric content of the food served. During a review of the facility's Winter Menu, dated 2/27/24, the menu indicated residents on regular diets were to receive three ounces of Herb Crusted Beef Roast. During a review of facility's policy and procedure (P&P) titled, Fortification of Food: Increasing Calories and/or Protein in the diet, dated 2023, the P&P indicated, The goal of fortification of food is to increase the calorie and/or protein density of the foods commonly consumed by the resident to promote improvement in their nutritional status; Adding calories by 1. Adding extra ½ oz or 1 tablespoon (Tbsp) melted margarine to one food item at breakfast, two at lunch, and one at dinner (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 29 of 39 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 03/01/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm will add 100 calories per ½ oz, 2. Adding extra 2 oz of gravy to foods designated to receive gravy will add 20-50 calories per item. During a review of the facility's P&P titled, Diet Orders, dated 2023, the P&P indicated, Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 30 of 39 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 03/01/2024 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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 consider alternative recommendations for the use of the provale cup assistive device (helps prevent choking by delivering a measured amount of liquid. Cups vary with different delivery amounts) while allowing the patient to eat and drink independently, for one (Resident 6) of 12 sampled residents. Resident 5 was identified at risk for aspiration (food or liquids enters the windpipe). Residents Affected - Few This failure resulted in staff not using an assistive device with meals or consulting with the Speech Therapist for recommendations when Resident 5 refused using the provale cup. This had the potential to result in aspiration and the development of pneumonia. Findings: During an observation on 2/26/24 at 12:56 a.m., Resident 6 was seated at the dining table in the dining area and fed by the Restorative Nursing Assistant (RNA 1). Resident 6 coughed repeatedly when fed corn bread and salad. When Resident 6 coughed, RNA 1 gave Resident 6 water to drink from a plain plastic cup. Review of the Minimum Data Set (MDS), a resident assessment and care guide tool, dated 12/22/23, indicated Resident 6's Basic Interview of Mental status (BIMS) score was 05 (meaning poor cognition). Resident 6 also had a swallowing disorder related to holding food in the mouth/cheeks or residual food in mouth after meals. Resident 6 diagnoses included dysphagia (difficulty swallowing foods or liquids) and Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). During an interview on 2/27/24 at 10:01 a.m., RNA 1 stated Resident 6 coughed from time to time when fed. RNA 1 stated Resident 6 used to use a special cup but got frustrated because the cup limited the amount of water to drink at a time and did not like using the special cup. Review of the physician order dated 10/1/21 indicated the physician prescribed Resident 6 to receive a provale cup during meals of mechanical soft ground texture, thin liquid consistency. Review of the speech therapy (ST) Discharge summary dated [DATE] indicated Resident 6 had therapy for dysphagia. Resident 6 had excessive coughing. ST requested Resident 6 to have provale cup to restrict her sip size during meals. During an interview on 2/27/24 at 10:01 a.m., with the Director of Nursing (DON), DON stated Resident 6 did not like the provale cup and got frustrated when drinking water so staff stopped using the special cup. DON said Resident 6 used a regular plastic cup to drink water and coughs frequently. During an interview on 2/27/24 at 11:52 a.m., with the Speech Therapist ST), ST stated Resident 6 had an order to use provale cup for drinks and was not informed Resident 6 refused the use of the provale cup. During an interview on 2/29/24 at 10:12 a.m., DON stated Resident 6 has a high risk for aspiration. DON further stated she did not inform ST or referred Resident 6 for speech re-evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 31 of 39 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 03/01/2024 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 store, prepare, distribute, and serve foods in a sanitary manner that prevents foodborne illness for the facility when: Residents Affected - Many 1. Cool down method was not performed for a leftover meat sauce and Pozole soup in the refrigerator. 2. Frozen food items were incorrectly thawed and refrozen. 3. A box of cherry tomatoes in the refrigerator was covered with white fuzzy material and dark spots. 4. A bag of cooked chicken was stored together in the same compartment with frozen raw meat and poultry. 5. Multiple unlabeled and undated food items were found in the freezer. 6. Staff did not handle drinkware in a manner to protect the drinkware from contamination. 7. The ice machine evaporator plate had black build-up residue, the evaporator cover had white mineral build-up, and the cleaning and sanitizing procedures was not followed according to the manufacturer's instruction. These failures had the potential for residents to be exposed to food borne illness. Findings: 1. During an observation on 2/26/24 at 10:12 a.m., in the kitchen refrigerator, there was a covered container labeled, meat sauce dated 2/24/24, and another covered container labeled, Pozole soup, dated 2/23/24. During a review of the meat sauce recipe, dated Week 4 Saturday, the recipe indicated the meat sauce contained ground beef. During a review of the pozole soup recipe, dated Week 4 Friday, the recipe indicated the pozole soup contained pork meat. During concurrent interview and record review on 2/27/24 at 11:02 a.m., with the Dietary Services Supervisor (DSS), the Cool Down Log was reviewed. The log had columns and rows. The written instructions on the Cool Down Log indicated, log the menu or item on the first column; log the temperature upon removal from the oven on the second column; log the date, time and temperature once food drops to 140 degrees Fahrenheit (ºF) on the third column; log the temperature at two hours or less and time (If 70 ºF or less, you have four more hours to get temperature 41 ºF or less. If more than 70 ºF, take corrective action per policy) and staff signs their initials on the fourth column; log temperature at four hours or less and time (If 41 ºF or less cooling done) and staff signs their initials on the fifth column; log temperature by six hours and time, must be 41 ºF or less (If more than 41 ºF, take corrective action per policy) and staff signs their initials (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 32 of 39 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 03/01/2024 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 Residents Affected - Many on the sixth column. The Cool Down Log had no entries in any of the columns or rows. The DSS stated the leftover meat sauce and pozole soup had no temperature monitoring completed during the cool down process because the meat was mixed with other ingredients. During a review of the facility's policy and procedure (P&P) titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, the document indicated, Cooked Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) food (food that requires time/temperature control for safety to limit the growth of pathogens [i.e., bacterial or viral organisms capable of causing a disease or toxin formation]) shall be cooled . in a method to ensure food safety. PHF or TCS food include: a food of animal origin that is raw or heat-treated. Also included would be soups and gravies made with any of the above PHF or TCS food; When cooling down food, use the Cool Down Log to document proper procedure; During the cooling process, use a clean, sanitized, and calibrated probe thermometer to measure the internal temperature of the food at the center of the product. Note menu item, date, time, temperature, and cook's initials on the cool down log used. 2. During an observation on 2/26/24 at 9:25 a.m., in the kitchen walk-in freezer, on the bottom shelf, there was an unlabeled, resealable plastic bag which contained a tan-colored frozen item with pink liquid. During a concurrent interview with [NAME] 1, [NAME] 1 stated the frozen tan-colored item was a frozen chicken part. [NAME] 1 stated the chicken had been received frozen and staff generally thawed frozen meat in the food production sink by running water over the frozen meat. [NAME] 1 stated the chicken had likely been thawed and then placed back in the freezer to refreeze. [NAME] 1 stated there was no date or time or temperature monitoring documentation of the thawing/refreezing process. During an observation on 2/26/24 at 3:06 p.m., the kitchen counter next to the food production sink had a cardboard box with two frozen pieces of cooked roast beef. During a concurrent interview with [NAME] 2, [NAME] 2 stated he had recently pulled the frozen roast beef from the freezer, and was preparing to thaw the meat under running water. [NAME] 2 indicated he did not monitor for time/temperature control during the thawing process. During an interview on 2/27/24 at 10:45 a.m., with [NAME] 2 and the DSS, [NAME] 2 stated he had thawed the two frozen pieces of cooked roast beef for about an hour yesterday under running water. The DSS stated he had thawed the two frozen pieces of cooked roast beef again for about an additional hour earlier on 2/27/24. The DSS stated the kitchen staff would thaw frozen meat under running water without time and temperature monitoring since the meats were already cooked. During a review of the facility's P&P titled, Procedure for Freezer Storage, dated 2023, the document indicated . Estimated time for thawing meat: 1 day (24 hours) for every 5 pounds (lbs) frozen meat in the refrigerator at approximately 40 degrees Fahrenheit (ºF); 8. Frozen food should be left in the refrigerator to thaw. Once thawed, uncooked meats are to be used within 2 days. During a review of the facility's P&P titled, Thawing of Meats, dated 2023, the document indicated . Submerge under running, potable water at a temperature of 70 ºF or lower, with a pressure sufficient to flush away loose particles; The food product cannot remain in the temperature danger zone (41 ºF to 140 ºF) for more than four hours, which includes the time the food is thawed. 3. During a concurrent observation and interview on 2/26/24 at 9:55 a.m. with DSS, on a shelf in the refrigerator, there was a closed lid cardboard box which contained ten cherry tomatoes, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 33 of 39 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 03/01/2024 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 Residents Affected - Many tomatoes were covered with white fuzzy material and dark spots. The side of the cherry tomato box had a sticker which indicated a delivery date of 1/26/24; the top of the box lid had a handwritten date of 1/7/24. The DSS stated cherry tomatoes are good for one week at room temperature. The DSS stated he relied on the cooks to check food items in the refrigerator and freezer. During a review of the facility's P&P titled, Storing Produce, dated 2023, the document indicated, Check boxes of fruit and vegetables for rotten, spoiled items. One rotten tomato, . in a box can cause the rest of the produce to spoil faster. Throw away all spoiled items. 4. During a concurrent kitchen observation and interview on 2/26/24 at 9:25 a.m., with [NAME] 1, the freezer had one bag of chopped cooked chicken stored in the same compartment as frozen raw meat. During a review of the facility's P&P titled, Storage of Frozen Food, dated 2023, the P&P indicated, Store raw meat, poultry, .separately from cooked and ready-to-eat food to prevent cross contamination; Store cooked or ready-to-eat food above raw meat, poultry, . if these items are stored in the same unit. 5. During a concurrent kitchen observation and interview on 2/26/24 at 9:25 a.m., with Dietary Services Supervisor (DSS) and [NAME] 1, on a shelf in the freezer was one bag of opened, unlabeled frozen patties dated 2/24/24. The DSS stated the patties were pork sausages and used a black marker pen to label the bag, Pork Sausage. On another shelf in the freezer were the following items: one resealable plastic bag of undated and unlabeled frozen chicken; one package of undated frozen cauliflower; and a package of unlabeled brown ground meat. During a review of the facility's P&P titled, Procedure for Freezer Storage, dated 2023, the P&P indicated, .All frozen food should be labeled and dated. During a review of the facility's P&P titled, Labeling and Dating of Foods, dated 2023, the P&P indicated, All food items in the refrigerator and freezer need to be labeled and dated. 6. During an observation on 2/28/24 at 12:05 p.m., in the kitchen, Diet Aide 3 (DA 3) filled a cup with juice and filled a second cup with water with ungloved hands. DA 3 placed both filled cups on a resident lunch tray, picked up a plastic lid while touching the side, top, and bottom surfaces of the lid, and placed the plastic lid on a filled cup. DA 3 touched the top drinking surface of the cup when the lid was placed on the cup. The process was repeated for the second cup of liquid. During a review of the P&P titled, Sanitation, dated 2023, the P&P indicated, Food and Nutrition Services employees are to employ the following methods in handling dishes and utensils. Cups and glasses are to be grasped firmly in the middle when picking up or by the handle. Hands must not contact food surface. The eating portion which comes into contact with the food must never be touched. During a review of the 2022 Federal Food Code, the Food Code indicated cleaned and sanitized utensils were to be handled so that the contamination of food-and lip-contact surfaces was prevented. 7. During a concurrent observation and interview on 2/26/24 at 2:44 p.m. with [NAME] 2, a blue ice chest cooler filled with ice was on the floor in front of the ice machine. [NAME] 2 stated the ice machine had been broken for two weeks and the facility was being provided by a near-by affiliated skilled nursing facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 34 of 39 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 03/01/2024 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 Residents Affected - Many During a concurrent observation and interview, and record review on 2/28/24 at 11:30 a.m., with the Maintenance staff person (Maintenance), at the affiliated skilled nursing facility, the ice machine was inspected. Maintenance stated he was the maintenance provider for both facilities, and his duties included cleaning of the ice machine. The Maintenance stated he cleaned the ice machine once a month by spraying bleach germicidal cleaner into a hot damp washcloth and wiping the inside of the ice bin (the area where formed ice is stored) and the chute (the part of the ice machine where formed ice is transferred from the top of the ice machine where the ice is made into the bin). Maintenance stated this was all he did to clean the ice machine. The Maintenance stated he did not have the manufacturer's cleaning instructions and had never opened the top of the ice machine to clean the inside of the ice machine, and had never removed the evaporator plate (a metal grid where water runs over and ice is formed) cover/curtain, or removed any parts from the machine to clean. The Maintenance opened the top of the ice machine to inspect the area where ice was made and removed the evaporator cover. The inside surface of the evaporator cover, which faced the evaporator plate and running water, had areas with rough white residue. The Maintenance stated the white residue was calcium build-up from exposure to water. The plastic frame around the evaporator plate had black residue in the upper left and right corners, and in the frame on the right-side seam. The ice sensor, upper left and right corners of the evaporator plate had black residue build up. The black residue was able to be removed when wiped with a paper towel. The Mainenance stated the spray bottle labeled, [Brand Name], Healthcare Bleach Germicidal Cleaner, was the product he used to clean the ice machine. The brand of the spray cleaner was not the same company as the ice machine manufacturer. The directions on the spray cleaner indicated for food contact surfaces, a potable water rinse was required. During a review of the ice machine's manufacturer manual titled, [Company name], [Model Name], Air/Water/Remote Condenser Ice Machines, Technician's Handbook, dated 2018, the manual indicated, You are responsible for maintaining the ice machine in accordance with the instructions in this manual. Clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment . [Company Name] Ice machine Cleaner and Sanitizer are the only products approved for the use in [Company Name] ice machines (the manual provided specific information on the company's cleaner and sanitizer) . the handbook indicated, bleach germicidal cleaner was not the cleaner and sanitizer product approved for the ice machine The ice machine and bin must be disassembled, cleaned and sanitized; remove sanitized; remove mineral deposits from areas or surface that are in direct contact with water . Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime . Step 1 Open the front door to access the evaporator compartment. The cleaning instructions included 16 detailed steps for cleaning the evaporator compartment, the dispenser, and the bin. During a review of the facility's policy and procedure titled, Sanitation, dated 2023, indicated 14. Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. During a review of the 2022 Federal Food Code, the Food code indicated equipment food-contact surfaces are to be smooth and clean to sight and touch. The Food Code indicated nonfood-contact surfaces of equipment were to be cleaned at a frequency necessary to preclude accumulation of soil residues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 35 of 39 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 03/01/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accurate documentation of medication administration for three (Residents 5, 13, and 16) of five sampled residents when two nursing staff (Director of Nursing and Licensed Vocational Nurse 3) failed to document multiple medications' administration on four separate days (2/2/24, 2/11/24, 2/14/24, 2/17/24) These failures had the potential to result in unnecessary duplication of medication administration, and prevented accurate analysis of effectiveness of medication due to lack of clarity as to whether or not the medication was administered. Findings: During a review of the facility admission Record, undated, the admission Record indicated Resident 5 was admitted to the facility in 2022. During a review of Resident 5's Medication Administration Record (MAR) dated February 2024, the MAR indicated no entries for administration of the following scheduled medications: 2/11/24 at 9 a.m.: amiodarone (to treat high blood pressure), amlodipine (to treat high blood pressure); jardiance (to treat high blood sugar); fluoxetine (to treat depression); metoprolol (to treat high blood pressure). 2/11/24 at 5 p.m.: Xarelto (to prevent blood clots); metoprolol. 2/17/24 at 9 p.m.: rosuvastatin (to treat high cholesterol); vraylar (to treat depression). During a review of Resident 13's admission Record, undated, the admission Record indicated an admission date in 2021. During a review of Resident 13's MAR dated February 2024, the MAR indicated no entries for administration of the following scheduled medications: 2/2/24 at 5 p.m.: metoprolol. 2/2/24 at 9 p.m.: lantus (to treat high blood sugar). 2/11/24 at 8 a.m.: metformin (to lower blood sugar). 2/11/24 at 9 a.m.: aspirin (to prevent blood clots); Lexapro (to treat depression); valsartan (to treat high blood pressure); Eliquis (to prevent blood clots); metoprolol. 2/11/24 at 1 p.m.: metformin. 2/11/24 at 5 p.m.: Eliquis. 2/11/24 at 6 p.m.: metformin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 36 of 39 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 03/01/2024 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 0842 2/11/24 at 9 p.m.: atorvastatin (to treat high cholesterol). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 16's admission Record, undated, the admission Record indicated an admission date in 2021. Residents Affected - Some During a review of Resident 16's MAR dated February 2024, the MAR indicated no entries for administration of the following scheduled medications: 2/11/24 at 9 a.m.: aspirin; fluoxetine; furosemide (to treat high blood pressure); metolazone (to treat high blood pressure); potassium chloride (to replenish body electrolytes); senna (to prevent constipation); Zyprexa (a mood stabilizer); Depakote (a mood stabilizer and anti-seizure medication); metoprolol. 2/11/24 at 5 p.m.: atorvastatin; Depakote; trazadone (to promote sleep). 2/14/24 at 9 p.m.: metoprolol. During a concurrent interview and record review on 2/29/24 at 3:25 p.m. with Licensed Vocational Nurse (LVN) 3, the February MARs of Resident's 5, 13, and 16 were reviewed. LVN 3 stated the missing MAR entries between 5 p.m. and 9 p.m. for Residents 5, 13, and 16 had been medications she had administered to the residents. LVN 3 stated she had been too busy to document the medication administration during the shifts, and then had fallen ill and forgotten to document the medications when she returned to work. During a concurrent interview and record review on 3/1/24 at 3:11 p.m., with the Director of Nursing (DON), the February MARs of Resident's 5, 13, and 16 were reviewed. The DON stated the missing MAR entries between 8 a.m. and 1 p.m. for Residents 5, 13, and 16 had been medications she had administered to the residents, but she had been too busy to document the administration in the residents' MARs. The DON stated the expectation was for a medication to be charted when the medication was administered. A review of Fundamentals of Nursing: The Art and Science of Nursing Care, 3rd Edition, by [NAME], Lillis and Lemone; copyright 1997, p. 656, indicated, Documenting Medication Administration: The medication record is a legal document. Recording each dose of medication as soon as possible after it is given provides a documented record that can be consulted if any questions as to whether the client received the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 37 of 39 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 03/01/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure one out of the one facility dishwashing machine was able to maintain water temperatures during the wash and rinse cycles within the manufacturer's recommended water temperature range of 120 degrees Fahrenheit (ºF) and 140 ºF. Residents Affected - Some This failure had the potential for dishware used by residents to not be sanitized sufficiently to prevent food borne illness. Findings: During a continuous observation on 2/27/24 at 10:13 a.m., in the kitchen, Dietary Aide (DA) 2 placed dishes in the dishwashing machine and began the dishwashing cycle. During the wash cycle, the dishwashing machine water temperature gauge reached a maximum of 106 degrees Fahrenheit (ºF), the water temperature gauge remained at a temperature of 106 ºF during the rinse cycle. During an interview on 2/27/24 on 10:15 a.m. with DA 2, DA 2 stated she had checked and recorded the dishwashing machine water temperature earlier in the Dish Machine Temperature Log. During a concurrent interview and record review on 2/27/24 at 10:20 a.m. with DA 2, the Dish Machine Temperature Log dated February 2024 was reviewed. The Temperature Log indicated that the dishwashing machine was a low temperature dishwasher (uses chemical sanitization to wash and sanitize dishware) and indicated instructions to, Please record wash and rinse temperatures, and chlorine parts per million (ppm is a unit used to describe very small concentrations of a substance in a larger solution) before each meal. Run empty racks through machine until proper temperatures and chlorine level are reached. Wash temperature must be at least 120 ºF for the dishwashing machine. (Use manufacturers guidelines on machine for range of wash and rinse temperature.). The log further indicated that on 2/27/24, the breakfast dishwasher wash cycle water temperature was 120 ºF, and the dishwasher rinse cycle water temperature was 140 ºF. During an observation on 2/27/24 at 10:25 a.m. with DA 2, a water-proof digital holding thermometer (A holding thermometer is intended to record and demonstrate the highest water temperature during all cycles in a dish machine.) was placed inside the dishwashing machine. At the end of the dishwashing wash and rinse cycles, the thermometer indicated the maximum temperature of the water was 147.8 ºF, and the minimum water temperature was 74 ºF. During an observation on 2/27/24 at 2:29 p.m., the information plate on the dishwashing machine showed the minimum wash and rinse temperature was 120 ºF, and the maximum recommended incoming water temperature was 140 ºF. During a review of facility's policy and procedure (P&P) titled Sanitation, dated 2023, the P&P indicated, All equipment shall be maintained as necessary and kept in working order. During a review of the dishwashing machine manufacturer guidelines, dated December 5, 2007, the guidelines indicated, The minimum wash and rinse water temperature was 120 ºF and the recommended maximum wash and rinse temperature was 140 ºF. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 38 of 39 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 03/01/2024 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 and interview, the facility had two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) with multiple beds that provided less than 80 square feet (sq ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings. Findings: During an observation on 3/1/24 at 8:02 a.m., with the Administrator (Admin) and the Maintenance Designee (Maintenance) room [ROOM NUMBER] and room [ROOM NUMBER] each had four resident bed spaces: room [ROOM NUMBER] measured 280 sq ft to equal 70 sq ft per resident; room [ROOM NUMBER] measured 286.6 sq f. to equal 71.65 sq ft per resident. During an interview on 2/28/24 at 8:29 a.m., with Certified Nursing Assistant (CNA 2), CNA 2 stated there was enough space to provide care for residents. CNA 2 stated she had no problems going in and out with necessary care equipment. During an interview on 2/28/24 at 8:34 a.m., with Resident 13, Resident 13 stated there was enough room space for his belongings and he had no concerns about space. During an observation and concurrent interview on 2/28/24 at 8:38 a.m., with Certified Nursing Assistant (CNA 3), CNA 3 stated there was enough space to conveniently provide care for residents in the rooms including residents that required mechanical lifting devices for determining body weight. CNA 3 stated there was no heavy equipment kept in the rooms that might interfere with residents' care and each resident had adequate personal space and privacy. There were no negative consequences attributed to the decreased space in the two rooms. Granting of room size waiver recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 39 of 39