Health inspection·May 16, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete must be worn when handling HD including during: . handling, preparation/mechanical manipulation, and administration . Review of the CDC's NIOSH Safety and Health document, titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 12/2024, last accessed on 5/22/25 via https://www.cdc.gov/niosh/docs/2023-130/default.html and https://www.cdc.gov/niosh/docs/2025-103/default.html, the documents indicated: Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes. Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years. NIOSH suggests careful precautions and safeguards to protect workers, fetuses, and breastfed infants. Further review of the document indicated to use single glove for handling intact tablet form and double gloves for handling oral liquid form of the hazardous medications as directed. The NIOSH list included finasteride as HD and should have been handled with gloves during medication administration. Event ID: Facility ID: 555399 If continuation sheet Page 2 of 15 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 05/16/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to document disposition and destruction of the non-narcotic (non-opioid) prescription medications with resident census of 35. Residents Affected - Few This failed practice could contribute to the risk of drug diversion (unlawful use of prescription drug by unauthorized individuals) and unsafe disposition practices. Findings: During a concurrent inspection of the facility's medication room and interview with Licensed Vocational Nurse (LVN) 2, on 5/13/25, at 9:50 AM, LVN 2 could not locate any documentation record for prescription drug destruction and was not sure how non-narcotic prescription medications were stored and/or destroyed. LVN 2 stated the medication room did not have a storage section for resident's discontinued medications. In an interview with the Director of Nursing (DON) on 5/14/25 at 9:42 PM, the DON stated the facility allowed the nurses to destroy the discontinued prescription medications. The DON stated the facility did not have a system of documentation with a witnessed signature. The DON stated the facility did not have an option to return unused drugs to the pharmacy, so any nurse could destroy the discontinued or discharged medications without documentation. In a telephone interview with facility's Consultant Pharmacist (CP) on 5/16/25 at 11:05 AM, the CP stated she helped with destruction of narcotic drugs and was not involved with non-narcotic drug disposition. The CP stated the facility should follow their policy on discontinued drug disposition and the Nurse Consultant (a nurse that advised facility on proper policy and regulation compliance) may have addressed this with the facility. Review of the facility's policy, titled Discarding and destroying Medications, dated 1/2022, the policy indicated Medication that cannot be returned to the dispensing pharmacy . are disposed of in accordance with federal, state and local regulation governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances . Non-controlled substances . are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. The policy did not address the documentation for accountability of non-narcotic medication destruction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 3 of 15 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 05/16/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews the facility failed to address and prevent duplicate use of two similar medications used to treat severe form of stomach heartburn known as Gastro-Esophageal Reflux Disease (GERD-a condition of stomach acid flowing back into the esophagus and can contribute to stomach bleeding) in one out of five sampled residents reviewed for unnecessary drugs (Resident 28) when: Residents Affected - Few Resident 28 received two drugs called pantoprazole (or Protonix) and omeprazole (or Prilosec) simultaneously, which had belonged to the same class of drug called Proton Pump Inhibitors (PPIs-medications that reduce the production of stomach acid and help relieve symptoms like heartburn or GERD). The duplicate use of two PPI could contribute to adverse drug consequences and cause further health problems. Findings: During a review of Resident 28's electronic medical record (HER), titled Diagnosis, dated 5/14/25, the record indicated Resident 28 had GERD with recent hospitalization, diabetes (blood sugar disease), kidney disease, and heart issues among others. During a concurrent interview and record review on 5/14/25 at 4:06 p.m., with Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1, Resident 28's Order Summary Report (an electronic document listed medications and nursing orders) for May 2025 was reviewed. The Order Summary Report indicated that Resident 28 had been taking Prilosec orally every day for GERD since 12/11/24 and resumed the medication after hospitalization on 4/29/25. The record indicated that the Medicator Director (MD) ordered Protonix on 4/27/25 when Resident 28 returned to the facility from the hospital. RN 1 stated the duplicate drugs were not flagged when the second drug was added to the medical record. LVN 1 stated Prilosec should have been discontinued to prevent duplicate therapy. LVN 1stated nurses should notify the MD about Resident 28 receiving two PPIs. During a phone interview with facility's Consultant Pharmacist (CP), on 5/15/25 at 11:05 a.m., the CP stated it's a hard no for Resident 28 to take both Prilosec and Protonix. The CP stated the duplicate PPI would not have provided any additional benefit to Resident 28. A phone call and message to the MD caring for Resident 28, on 5/14/25, at 3:50 p.m., were not returned during the survey. Review of the facility's Policy and Procedure (P&P), titled Drug Regimen Review, revised 9/2017, the policy indicated The physicians, all other medical practitioners, and staff will follow the approaches discussed in the policy on Medication Utilization and Prescribing to guide decisions about using medications to treat any condition or symptom. As part of everyday care, this should include extensive ongoing efforts to review medications in individual residents/ patients for indications, doses, duration, and potential or actual adverse consequences. Review of the facility's policy, titled Medical Director Roles and Functions, dated 9/2017, the policy indicated Resident/patient care will be consistent with pertinent clinical standards of practice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 4 of 15 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 05/16/2025 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a Centers for Medicare & Medicaid Services (CMS) Medicaid Integrity Group document, dated 10/2015, titled Proton Pump Inhibitors Use in Adults, last accessed on 5/22/25 via https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/pharmacy-education-m the document indicated the FDA has issued several warnings regarding the long-term use of PPIs, including the risk of fractures, hypomagnesemia (low magnesium level), C. difficile infection (a type of bowel infection), and potential kidney problems. The FDA also recommends using the lowest effective dose and shortest duration of therapy. Event ID: Facility ID: 555399 If continuation sheet Page 5 of 15 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 05/16/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with resident census of 35. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 43 opportunities which resulted in a facility wide medication error rate of 9.52% in three out of 7 residents (Resident 26, Resident 29, and Resident 31) observed for medication administration as follows: Residents Affected - Few 1. Resident 26 was administered wrong cough medication called Robitussin DM (a brand name combinations liquid medicine containing Guaifenesin [an expectorant that helped loosen and thin mucus] with Dextromethorphan [a cough suppressant]) when the doctor's order indicated to give plain Robitussin (or guaifenesin, which thin and loosen mucus and made it easier to clear chest congestion). 2. Resident 29 was given a laxative drug called Senna (a natural stimulant laxative acts by creasing activity of the intestines to cause a bowel movement) when the doctor's orders asked for a combination of Senna plus Docusate (or DSS, a stool softener). 3. Resident 31 was given the wrong strength of a pain patch (also called transdermal patch, an adhesive medicated patch applied to the skin to deliver a specific dose of medication through the skin and into the bloodstream) called Lidoderm 4% (or Lidocaine patch, a product containing numbing agent applied to skin to reduce pain sensation) when the doctor's order asked for Lidoderm 5% (which was a stronger patch dosage). These failures may result in unsafe medication use affecting residents' health and well-being. Findings: 1. During a medication administration observation in facility's hallway B, accompanied by Registered Nurse 1 (RN 1), on 5/13/25, at 8:01 AM, RN 1 after giving Resident 26's routine morning medication, contacted the doctor for resident's complaint of allergy and cough symptoms. RN 1 received orders from MD for Robitussin liquid 10mL (mL is milliliter, a measure of volume) three times a day as needed for 7 days. RN 1 went into the facility's medication room to look for Robitussin and could not find it. RN 1 then went to nearby unit and used Hallway A's bottle of Robitussin DM. RN 1 administered Robitussin DM 10mL to Resident 26. During the review of Resident 26's Medication Administration Record (or MAR, a legal document that listed doctor's order and the nursing administering the drugs), dated 5/14/24, the record indicated RN 1 marked that Resident 26 received 10mL of the Robitussin. In an interview with RN 1, in hallway B, on 5/14/24, at 9:17 AM, RN 1 stated the facility did not stock the plain Robitussin liquid medication and she should have clarified Resident 26's order with the doctor. In an interview with the Director of Nursing (DON) in her office on 5/14/25 at 9:42 AM, the DON stated the nursing staff should have clarified the order with the doctor. The DON stated the house supply (a set of nonprescription medications the facility stocked) should have been reviewed for the availability of the products. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 6 of 15 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 05/16/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. During a medication administration observation in facility's hallway B, accompanied by Registered Nurse 1 (RN 1), on 5/13/25 at 8:28 AM, RN 1 administered a laxative medication called Senna to Resident 29 along with 7 other morning medications. During the review of Resident 29's Medication Administration Record (MAR), dated 5/14/24, the record indicated an order for morning administration of the laxative as follows: Sennosides-Docusate Sodium Tablet 8.6-50 MG (MG is milligram, a unit of measure); Give 1 tablet by mouth two times a day for BOWEL MANAGEMENT . -Start Date 4/17/2025 (Sennosides-Docusate tablet a combination of Senna and Docusate) Further review indicated the RN 1 gave a laxative with only Senna as its ingredient and did not follow the MAR order of the doctor. In an interview with RN 1 on 5/14/24 at 9:17 AM, RN 1 stated she overlooked giving the correct pill and the two bottles looked alike in terms of bottles color and letters. 3. During a medication administration observation in hallway A, accompanied by Licensed Nurse 2 (LVN 2) on 5/13/25 at 9:04 AM, LVN 2 applied a lidocaine 4% pain patch to Resident 31's back in addition to six other oral medications. During the review of Resident 31's Medication Administration Record (MAR) dated 5/14/24, the record indicated an order for morning administration of lidocaine patch as follows: Lidocaine Patch 5 % Apply to lower back topically one time a day for pain management . -Start Date: 5/13/2025 Further MAR review indicated LVN 2 marked the MAR for administration of lidocaine 5% when a 4% strength patch, a lower dosage of the pain patch, was administered. LVN 2 was not available for interview after MAR review. In an interview with the Director of Nursing (DON) on 5/14/25 at 10:16 AM, the DON stated the nursing staff should have followed the doctor's order and should have given the right dosage of medication as noted in the MAR. The DON stated the prescription strength of the lidocaine patch could have been ordered through the provider pharmacy. Review of the facility's policy titled: Administering Medications dated 4/2019, the policy indicated Medications administered in accordance with prescriber orders . The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, . of administration before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 7 of 15 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 05/16/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure safe storage of medication and medical supplies in the active storage areas of treatment cart (a mobile cart where medication and supplies for wound and skin care are stored) and the medication room (a locked room used to store medications and supplies) with census of 35 when: 1. Facility's medication room stored expired vaccine, expired testing products, expired supplies, and co-mingled supplies for IV (Into the Vein) medication use on residents that were no longer in the facility. 2. Treatment cart stored expired supplies and opened products that were marked sterile and for one time use in the active storage areas. These failures could contribute to unsafe storage and use of spoiled medication and supplies that could affect the well-being of vulnerable elderly residents. Findings: 1. During a concurrent interview and inspection of the facility's medication room on 5/13/25 at 9:30 AM, accompanied by Licensed Vocational Nurse and Director of Staff Development (DSD), the small room stored both medications and supplies for resident care with expired items as follows: a. The open shelf stored two boxes of multiple Covid testing product (test for respiratory infection) marked as iHealth Covid-19 Antigen Rapid Test (Brand name for the covid testing product) with expiration date of 3-3-2025. DSD could not find a newer expiration date for this product. b. The refrigerator stored two syringes of Covid vaccine (a product that protected from getting Covid respiratory disease) in the refrigerator with no clear expiration date and was marked as follows: Covid-19 Vaccine mRNA, Spikevax 2024-2025 formula (a brand name for the vaccine), the pharmacy label on the Ziploc bag indicated it was a house supply (means it could be used on any resident). The labels indicated the product was issued by provider pharmacy on 1/19/25 and there was another label indicating 3/17/25. There were two labels one the Ziploc bag indicating: 1. Refrigerate and 2.Store in freezer. Thaw before using per package direction. Do not Shake, Protect from Light . The label was not clear on exact Beyond Use Date (the date after which the product should not be used). DSD used his smart phone and searched for the vaccine's stability once out of the freezer, and it showed it was stable for 60 days after thawing. The label was not clear when it was thawed or when it was the beyond use date. Review of the drug information for Spikevax vaccine, accessed via DailyMed (a website by National Library of Medicine and Food and Drug Administration or FDA, a federal government entity that provides information about approved drugs), last accessed on 5/22/25 via https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f96b315c-fa57-4876-a7e5-a9b584d8e6e6 , the manufacturer information on safe storage indicated Store frozen between -50°C to -15°C (-58°F to 5°F) ( C stand for Celsius and F stands for Fahrenheit scale , both are scales for temperature recording). After thawing, SPIKEVAX may be stored refrigerated between 2°C to 8°C (36°F to 46°F) for up to 60 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 8 of 15 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 05/16/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few days or up to the expiration date printed on the carton, whichever comes first. After thawing, SPIKEVAX may be stored between 8°C to 25°C (46°F to 77°F) for up to 12 hours. c. A plastic drawer sitting on the counter in the medication room had a large stock of various supplies for IV use co-mingled with supplies for foley Catheter (a tube inserted into the bladder to drain urine) in addition to expired (outdated on 1-5-2025) swabs for testing for throat infection labeled as Starswab II (brand name of manufacturer). The plastic drawer stored labeled containers of supplies and saline flush (salt solution used to clean IV line) for residents that were no longer in the facility. DSD acknowledged the findings. 2. During a concurrent interview and inspection of the facility treatment cart located in the main hallway, accompanied by DSD, on 5/13/25 at 10:40 PM, the treatment cart stored multiple opened wound care products that were marked sterile and one-time use as follows: a. Multiple opened sterile Iodoform Packing strips (used as an antiseptic and disinfectant for wound healing) marked on the label as Sterile unless seal is tampered with, or jar is opened or damaged and Do Not Reuse. b. Opened packets of Non-adherent Pad by Dukal (manufacturer) marked as sterile noted on the label Sterility guaranteed unless package is damaged or opened. c. Opened packets of Calcium Alginate dressing (used to manage various types of wounds, particularly those that produce moderate to heavy exudate) marked as sterile. d. Opened packets of Comfort Foam by DermaRite (manufacturer, used for management of exuding wounds) marked with sterile and Do Not Reuse and Do not use if damaged e. Multiple expired (outdated on 1-5-2025) swabs for testing for throat infection labeled as Starswab II (brand name of manufacturer) DSD acknowledged the findings and removed the products from active storage. In an interview with Director of Nursing (DON) on 5/14/25 at 10:16 AM, the DON stated they had a small medication room, and it needed to be continuously re-organized for safer storage. The DON also stated every month the nurses and pharmacy consultant checked the storage areas, and they needed to be more detailed in checking the active storage areas. Review of the facility's policy titled: Storage of Medications dated 4/2019, the policy indicated The facility stores all drugs and biologicals in a safe, secure and orderly manner . The nursing staff is responsible for maintaining the medication storage and preparation area in a clean, safe and sanitary manner . Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing . Discontinued, outdated or deteriorated drugs or biologicals are returned to dispensing pharmacy or destroyed. Review of the facility's policy titled: Medication Labeling and Storage dated 2/2023, the policy indicated medications are stored in an orderly manner in cabinets, drawers, carts, . Labeling of medications and biologicals dispensed by pharmacy is consistent with applicable federal state requirements and currently accepted pharmaceutical practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 9 of 15 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 05/16/2025 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement their policy regarding food for residents brought in by family or other visitors for one of 27 sampled residents (Resident 31) when Resident 31's two bottles of outdated apple juice were stored in the facility refrigerator. Residents Affected - Few This deficient practice had the potential for Resident 31 to consume drinks that were out of date which could cause avoidable gastrointestinal upset. Findings: During a review of the facility's policy and procedure (P&P) titled: Bringing in Food for a Resident, dated 3/24/25, the P&P indicated .Food or beverages that are past the manufacturer's expiration date will be thrown away. Food or beverage items without a manufacturer's expiration date will be dated upon arrival in the facility, and thrown away three days after the date marked, or if frozen in 30 days .Refrigeration can occur in the designated resident food refrigerator. Unused food will be discarded within three days, and if kept frozen, within 30 days . During a concurrent observation and interview on 5/13/25 at 3:14 p.m., with director of staff development(DSD), in the staff break room, two frozen bottles of apple juice were found in the freezer of the refrigerator designated for staff usage, with the markings A R and RM [ROOM NUMBER] written in both bottles. The first bottle of the two bottles of apple juice had an expiration of 2/13/25, and the second bottle of apple juice had no written expiration date. On interview, DSD acknowledged that the two frozen bottles of apple juice belonged to Resident 31 in room [ROOM NUMBER]. DSD confirmed that one bottle of apple juice was expired, and the other bottle of apple juice had no expiration date. DSD stated, residents' food or drinks should not be placed in the staff refrigerator. Review of Resident 31's Facesheet (information containing contact details, brief medical history at-a-glance) indicated: Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's physician's order dated 4/25/25 indicated a diet order of regular diet and thin liquids (A regular diet is a standard, unrestricted diet that allows individuals to eat a wide variety of foods without specific limitations. Thin liquids refer to liquids that are typically considered normal in consistency, like water, juice, or coffee). During an interview on 5/14/25 at 2:59 p.m., with Director of Nursing(DON), DON stated the two bottles of apple juice should have been stored in the facility's refrigerator designated to store the residents' food and drinks from home. DON further stated that Resident 31's outdated two bottles of apple juice should have been thrown, because Resident 31 could have drunk the expired juice and could have gotten sick with an upset stomach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 10 of 15 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 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper infection prevention and control practices when: Residents Affected - Some 1. Shared Hoyer Lift used by 7 of 7 sampled residents was not maintained in the designated clean and dirty area in Utility Room. 2. The facility failed to properly clean and disinfect the glucometer (a device used to measure blood sugar) according to the manufacturer's guidelines, and facility's policies and procedures (P&P) between resident use. 3. Enhanced Barrier Precautions (EBP) protocol was not followed when providing direct care to Resident 239. These failures had the potential to result in transmission of infection to Residents and Staff throughout the facility. Findings: 1. During a concurrent observation and interview on 5/14/25 at 3:15 p.m. with Infection Preventionist (IP) in the Utility Room, there were 2 Hoyer Lifts (a mechanical device used to safely transfer individuals with limited mobility). One of the two Hoyer Lift base was within a red taped rectangular area labeled DIRTY AREA on the wall, and to the right, there was a cabinet labeled CLEAN AREA that contained various unopened residents' medical supplies. IP stated, it was unclear whether the Hoyer Lift was clean or dirty but the expectation is that after each resident use, it is supposed to be wiped down and cleaned with a disinfecting solution. Additionally, the IP also stated that the Hoyer Lift would not fit in the DIRTY AREA spot and I could see the potential for cross contamination issues with this. During a review of the electronic health records of Residents 5, 9, 19, 20, 21, 25, and 239, their electronic health records all indicated they used the Hoyer Lift. During a review of the facility's policy and procedure (P&P) titled: Cleaning and Disinfection of Resident-Care Items and Equipment dated September 2022, the P&P indicated, 5. Reusable items are cleaned and disinfected or sterilized between residents .6. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturer's instructions .7. Only equipment that is designated reusable is used by more than one resident .9. Durable Medical Equipment (DME-category of medical devices designed to assist individuals with disabilities, injuries, or chronic health conditions; can withstand repeated use) is cleaned and disinfected before reuse by another resident. During a review of the website https://www.cdc.gov/infection-control/media/pdfs/strive-ec102-508.pdf publication titled, Cleaning and Disinfection Strategies for Non-Critical Surfaces and Equipment, [undated], the article, indicated, Daily Cleaning and Disinfection- .Clean and Disinfect all surfaces. This includes horizontal, vertical and contact surfaces .Special Isolation Procedures- .Disinfect cleaning equipment Non-Critical Equipment-disinfect all non-critical patient care equipment before using it with another patient Assure staff responsible for device cleaning receive training on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 11 of 15 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 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 cleaning procedures and follow the equipment manufacturer's instructions Level of Harm - Minimal harm or potential for actual harm 2. During a review of Resident 239's admission Record (a document used to communicate basic information about a resident) printed on 5/14/25, the record indicated Resident 239 was admitted to the facility on [DATE] with a Pressure Ulcer of the Sacral Region, Stage 4 (a wound in the lower part of the spine, just above the tailbone that extends deep into the muscle, tendon, ligament, cartilage, or even bone, caused by prolonged pressure, shear forces, and friction, often in patients with limited mobility). Residents Affected - Some During a review of Resident 239's Physician order dated 5/09/25, the order indicated to start the Enhanced Barrier Precautions (EBPs, are infection control measures designed to expand the use of gowns and gloves beyond standard precautions to reduce the spread of multidrug-resistant organisms (MDROs) in long-term care facilities) during high contact time secondary to chronic wound with wound vac (A wound vac is a Vacuum-Assisted Closure device which is a type of negative pressure wound therapy that helps wounds heal by applying gentle suction to remove excess fluid, reduce swelling, and promote tissue growth). During an observation on 5/12/25 at 10:48 a.m., Resident 239 was lying in her bed. Certified Nursing Assistant 1 (CNA 1) was fixing Resident 239's blankets. CNA 1 did not have a gown on. There was a signage titled Enhanced Barrier Precautions outside Resident 239's door. The signage read as . Providers and Staff must wear gloves and a gown for the high-contact resident care activities . The Director of Nursing (DON) was standing outside Resident 239's door and asked CNA 1 to don a gown while providing care to Resident 239. During a phone interview with CNA 1 on 5/13/25 at 8:31 a.m., CNA 1 stated on 5/12/25, she plugged in Resident 239's wound vac to the electrical outlet in the wall and was tidying up Resident 239's blankets. CNA 1 stated she was aware that Resident 239 was on enhanced barrier precautions, however she did not have a gown on when she provided direct care to her. CNA 1 stated it was important to follow the precautions so the infection wouldn't spread to the other staff and residents. During an interview with DON on 5/13/25 at 8:41 a.m., the DON stated since Resident 239 had an open wound, staff were required to follow enhanced barrier precautions to decrease the risk of cross-contamination, potentially exposing other residents and staff to harmful pathogens. The DON stated since CNA 1 was in close contact with Resident 239 on 5/12/25 and did not wear a gown, she did not follow enhanced barrier precautions. During a record review of the Care Plan for Resident 239, the Care Plan, Enhanced Barrier Precautions required was initiated on 5/09/25. The Goal of the Care Plan indicated the EBPs will be followed during high contact activities through the next review date on 8/06/25. During a review of facility's Policy and Procedure (P&P) titled Enhanced Barrier Precautions dated 9/18/2024, the P&P indicated, EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use during the high contact resident care. 3. During a medication pass observation of Registered Nurse (RN) 1, on 5/13/25 at 8:28 a.m., Registered Nurse (RN) 1 brought the glucometer into Resident 29's room and placed the glucometer directly on the overbed table. RN 1, with gloved hand, poked Resident 29's left index finger to get blood to measure the blood sugar. After checking Resident 29's blood sugar, RN 1 took the glucometer out of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 12 of 15 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 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm the room, wiped it once with a Sani-Cloth wipe (disinfecting wipes used in healthcare settings to clean and sanitize surfaces) for less than 10 seconds, and then put it back in the medication cart drawer. During an interview on 5/14/25 at 9:17 a.m., in hallway B, RN 1 stated she thought using one wipe was enough to clean the glucometer. Residents Affected - Some During an interview with RN 1, on 5/14/2025 at 9:20 a.m., and concurrent record review of the manufacturer's instructions for Sani-Cloth germicidal disposable wipes, the instructions indicated a two-step process for cleaning and disinfecting a glucometer after use: 1. Use one wipe to remove dirt, blood, and other bodily fluids from the (glucometer) surface. 2. Use a new wipe to disinfect the (glucometer) surface and the surface must remain wet for recommended contact time of two minutes, then let it air dry. RN 1 acknowledged she did not follow manufacturer's instructions for cleaning and disinfecting the glucometer. During an interview with the Director of Nursing's (DON) in her office on 5/14/25 at 9:42 a.m., the DON stated that cleaning the glucometer is a two-step process. Staff must use two separate wipes and ensure the glucometer stays wet for two minutes, as required by the Sani-Cloth manufacturer's specification. During an interview with the Infection Preventionist (IP) on 5/15/25 at 11:57 a.m., the IP stated he was new to the role and expected the nursing staff to follow facility's policy on the two-step process of cleaning and disinfecting the shared glucometer between resident use. During a review of facility's P&P titled Cleaning and Disinfection of Resident -Care Items and Equipment, revised on 9/2022, indicated reusable resident care equipment is decontaminated and /or sterilized between residents' use according to manufacturers' instructions. Review of the manufacturer of Assure Platinum glucometer (a brand name by ARKRAY, the manufacturer of glucometer used by the facility), titled ARKRAY Technical Brief: Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System , dated 9/2024, last accessed on 5/22/25 via https://cdn.pepperapps.io/arkray/public/6372938c5d3664788b179794?signature=eyJhbGciOiJkaXIiLCJlbmMiOiJBMTI4Q0 [NAME]-zPbrA4UpWqmrx5CWqVA.j0hN7RTIwDlhn_ddmUxUrPoDtoekFW0hVi__otLAHk7yUDrnxRNXLd0MmggoJGQKJ8 , the documents under Cleaning and Disinfecting FAQ (Frequently Asked Questions) indicated Can cleaning and disinfecting be accomplished with one wipe? No, Each time the cleaning and disinfecting procedure is performed, two wipes are needed. One wipe to clean the meter and the second wipe to disinfect the meter. What will happen if a blood glucose meter is not cleaned and disinfected after use? . It is important that the long term care facility establish a program for infection control . Program include addressing the cleaning and disinfecting of blood glucose meters along with other equipment and environmental surfaces . It is also important to provide education on infection control and the proper use of products. Review of the glucometer manufacturer's, with brand name Assure Platinum Blood Glucose Monitoring System, with revision date of 9/2019, last accessed via (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 13 of 15 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 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm https://medaval.ie/docs/manuals/Arkray-Assure-Platinum-Manual.pdf, the section on Cleaning and Disinfecting . indicated The meter should be cleaned and disinfected after use on each patient . The cleaning procedure is needed to clean dirt, blood, and other body fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens (means germs in the blood). Residents Affected - Some A review of the Center for Disease Control (A federal agency responsible for the health and safety of people) guideline, titled Considerations for Blood Glucose Monitoring and Insulin Administration, last accessed on 5/22/25 via https://www.cdc.gov/injection-safety/hcp/infection-control/index.html, the guideline indicated Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place. The guideline further indicated Dedicated meters should be cleaned and disinfected per the manufacturer's instructions and, at a minimum, anytime the device is reassigned to a different person . If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, it should not be shared. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 14 of 15 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 05/16/2025 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 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** This requirement is NOT MET as evidenced by: Residents Affected - Some Based on observation and interview, the facility had two resident rooms (rooms [ROOM NUMBERS]) that measured less than 80 square feet (sq. ft.) per resident for the eight residents (Resident 3, 5, 22, 9, 25, 8, 19, and 14) who occupied the rooms. This failure had the potential to result in a lack of adequate space for the delivery of care to each of the residents in room [ROOM NUMBER] and 18, or for storage of these residents' belongings. Findings: During an observation and interview with the Maintenance Director (MOD) on 05/14/25 at 11:36 a.m., MOD measured the size of the room. The following rooms and the corresponding square footage per resident were identified: room [ROOM NUMBER]: 19.83 feet x 15.58 feet = 308.95 sq. ft. The room was occupied by four residents giving each resident 77.24 square feet of living space. room [ROOM NUMBER]: 14.42 feet x 20 feet = 288.4 sq. ft. The room was occupied by four residents giving each resident 72.1 square feet of living space. MOD stated no residents in room [ROOM NUMBER] and 18 had complained about the size of the room or requested to be transferred to another room. During an interview with Resident 3 on 05/14/25 at 11:48 a.m., Resident 3 stated she liked the room, and she could look out to the hallway. She had no concerns with the size of the room. She stated the staff had no problem maneuvering in the room to assist her and her roommates and had enough room to store her clothes and belongings. During observation of care and services on 05/14/25, there was sufficient space to move around without obstruction or interference from furniture or closets. Residents in room [ROOM NUMBER] and 18 had privacy as well as storage space for personal possessions. The facility staff were able to provide nursing services to meet the individual needs of each resident within room [ROOM NUMBER] and 18. There was no heavy equipment kept in the rooms that might interfere with residents' care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555399 If continuation sheet Page 15 of 15