Health inspection·December 11, 2025

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to follow the hemodialysis (treatment to remove waste products and excess fluid from the blood when kidneys are not functioning properly) care plan for one (Resident 50) of eight sampled residents reviewed. This failure did not ensure a hemodialysis resident received the service consistent with professional standards of practice and a person-centered care plan. Findings:During an observation and concurrent interview on 9/22/25, at 10:35 a.m., Resident 50 had bandages on her left upper arm. Resident 50 stated the bandages were put on at dialysis this past Saturday, two days ago. Resident 50 stated she did not know when they were to be removed.During an observation on 9/23/25, at 9:40 a.m., Resident 50 had the same bandages from yesterday on her left upper arm. Resident 50 stated she is going to dialysis after lunch today.During a review of Resident 50's facility Face Sheet, the Face Sheet indicated an admit date [DATE] with diagnoses of kidney failure and dependence on dialysis (a treatment that helps remove waste products and excess fluid from the blood when the kidneys are not functioning properly). During a review of Resident 50's Hemodialysis, ESRD, fistula to Left upper arm Care Plan, with a review date 7/18/25, the care plan indicated Resident 50's dialysis treatments were Tuesdays, Thursdays, and Saturdays from 3:00 p.m. to 6:00 p.m. Nursing interventions included checking the left upper arm fistula site dressing upon return from dialysis and leaving the dressing intact for 4 hours following dialysis treatments. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555710 If continuation sheet Page 2 of 7 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 555710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tice Valley Post Acute 1975 Tice Valley Blvd. Walnut Creek, CA 94595 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 Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to provide appropriate diet texture according to physician orders for two of three sampled residents (Resident 23 and 5) when both received a minced and moist meat texture instead of chopped.These failures resulted in Resident 5 and 23 experiencing a lower quality of life when they received a less advanced diet which was not to their documented preference.A review of Resident 23's admission record titled, admission Record, dated 9/25/25, indicated Resident 23 was admitted to the facility for senile degeneration of brain and hypertension (high blood pressure).During a record review of Resident 23's minimum data set (MDS, an assessment tool to guide resident care), dated 6/24/25, the MDS indicated Resident 23 had Brief Interview for Mental Status score of 12 (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve indicates a moderate cognitive impairment.) The MDS further indicated Resident 23 required supervision and set up and did not have difficulty swallowingDuring a record review of Resident 23's physicians' orders set titled, [Facility] Order Summary Report, dated 9/25/25, indicated Resident 23 had an order for Fortified diet Chopped Meat texture.start date 1/18/2025.A review of Resident 5's admission record titled, admission Record, dated 9/25/25, indicated Resident 5 was admitted to the facility for unspecified dementia, anemia (low red blood cell count) and cirrhosis of liver (inflammation of liver).During a record review of Resident 5's minimum data set (MDS, an assessment tool to guide resident care), dated 8/19/25, the MDS indicated Resident 5 had BIMS score of 12. The MDS further indicated Resident 5 did not have difficulty swallowing but was dependent on staff for feeding.During a record review of Resident 5's physicians' orders set titled, [Facility] Order Summary Report, dated 9/25/25, indicated Resident 5 had an order for Regular Chopped Meat texture.start date 6/13/2025.During an interview on 9/24/25, at 10:00 a.m., with Dietary Manager (DM), DM stated the facility followed the International Dysphagia Diet Standardization Initiative (IDDSI, a guideline to determine appropriate food texture and drink thickness for residents with difficulty swallowing, the guideline indicates a 4-7 scale for food texture) when determining appropriate food textures for residents.During an observation on 9/24/25, at 12:49 p.m., Resident 5's lunch time meal tray and meal ticket were inspected. The meal tray contained minced meat with gravy. The meal ticket indicated Resident 5 had Diet Order: Reg/Chopped Meats. A photo of the tray was taken.During a concurrent observation and interview on 9/24/25, at 1:17 p.m., with Registered Dietitian (RD), a lunch test tray was inspected. A meat patty chopped into small pieces was on the test tray. RD stated the chopped diet was the meat patty mechanically chopped into bite size pieces and represented the soft and bite sized texture on the IDDSI guideline.During a concurrent observation and record review on 9/24/25, at 1:22 p.m., Resident 23's partially consumed lunch tray and meal ticket were inspected. The meal ticket indicated Resident 23 had Diet Order: Reg/Chopped Meats. The meat on the meal tray was minced with gravy. A photo of the tray was taken.During a concurrent interview and record review on 9/25/25, at 1:50 p.m., with RD, Resident 5's nutrition assessment titled, Nutritional Risk Review (Quarterly), dated 8/19/25, and the picture of Resident 5's lunch tray, dated 9/24/25, were reviewed. RD stated RD had completed the assessment and the assessment indicated Resident 5 was dependent on staff for feeding and had no issues swallowing but had order meat to be chopped. The assessment further indicated a diet plan to honor res's rights and wished and preferred diet to promote quality of life. After reviewing Resident 5's lunch tray picture, RD stated the meat texture corresponded to minced and moist.During a concurrent interview and record review on 9/25/25, at 1:55 p.m., with RD, Resident 23's nutrition assessment titled, Nutritional Risk Review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555710 If continuation sheet Page 3 of 7 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 555710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tice Valley Post Acute 1975 Tice Valley Blvd. Walnut Creek, CA 94595 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (Quarterly), dated 9/11/25, and the picture of Resident 23's lunch tray, dated 9/24/25, were reviewed. RD stated RD had completed the assessment and the assessment indicated Resident 23 was able to feed themselves and had no issues swallowing but prefers meat to be chopped. After reviewing Resident 23's lunch tray picture, RD stated the meat texture corresponded to minced and moist. RD stated all residents should be served the highest diet possible to promote quality of life and respect residents rights to eat food according to their preferences.During a review of Resident 23's care plan titled, Care Plan Report, dated 7/15/25, the care plan indicated Resident 23 had a care plan for risk of nutritional decline evidenced by.altered mechanical texture, (history) of inadequate oral intake, (history) of unintentional weight loss and had interventions which indicated staff honor food preferences.provide diet as ordered: regular diet, SB6 (IDDSI scale 6 indicating soft and bite sized food texture) meats only texture.During a review of Resident 5's care plan titled, Care Plan Report, dated 9/2/25, the care plan indicated Resident 5 had a care plan for risk of malnutrition and had interventions which indicated staff provided diet as ordered .provide regular diet per resident's wishesA review of facility policy and procedure (P&P) titled, Therapeutic Diets, dated 10/17, the P&P indicated therapeutic diets are prescribed by the attending physician to support resident's treatment and plan of care and in accordance with his or her goals and preferences. Event ID: Facility ID: 555710 If continuation sheet Page 4 of 7 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 555710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tice Valley Post Acute 1975 Tice Valley Blvd. Walnut Creek, CA 94595 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staffed and supervised by qualified and competent staff which affected all 120 residents.This failure resulted in all 120 residents receiving social services care from unqualified staff.During an interview on 9/23/25, at 10:35 a.m., with Social Services Director (SSD), SSD stated they were the director of the social services department and were responsible for admission assessments, discharge planning. SSD stated the social services department assisted residents with dental, optometry, podiatry and psychiatric appointments to ensure residents' physical, mental and psychosocial needs were met. SSD stated they had been working since 5/2025.During a concurrent interview and record review on 9/24/25, at 4:23 p.m., with Director of Staff Development (DSD), SSD's two job descriptions, dated 5/15/25 and 8/18/25, were reviewed. DSD stated after review of the job descriptions, SSD did not meet the qualifications of the 5/25/25 description and did not meet the preferred qualifications of the 8/18/25 copy because SSD did not meet the education requirement of Bachelor's Degree in Social Work or in Human Services.During a concurrent interview and record review on 9/24/25, at 4:30 p.m., with DSD, SSD's resume titled, [SSD] Professional Summary, undated, and education registration form titled, SSD Online Certification Course, undated, were reviewed. DSD stated the SSD's resume did not indicate or list any education and the education registration form indicated SSD had completed a high school education.During a concurrent interview and record review on 9/25/25, at 10:14 a.m., with Human Resources (HR), SSD's two job descriptions, dated 5/15/25 and 8/18/25, were reviewed. HR stated they were responsible to ensure staff had current credentials and qualifications before hire. After review of SSD's job descriptions, for the 5/15/25 job description, HR stated SSD was not qualified for the position because SSD did not have a bachelor's degree in social work. HR stated SSD was hired without the required qualifications because everyone was confused by the qualifications section on the job description. HR stated the SSD didn't need to have a bachelor's degree and the facility created another job description which SSD signed on 8/18/25.During a concurrent interview and review of facility policy and procedure (P&P), on 9/25/25, at 4:15 p.m., with Administrator (ADM), the facility's P&P titled, Social Services, dated September 2024, was reviewed. The ADM stated the P&P indicated the director of social services was a qualified social worker. ADM stated the social services department did not have social workers, and there was no plan to hire a qualified social worker. ADM stated SSD was the only supervisor of the social services department. ADM stated they were unaware of any regulations which required the social services department to be supervised by a qualified social worker.During a review of facility's facility assessment titled, [Facility] Facility Assessment, dated 8/27/25, the facility assessment indicated a staffing plan which included Total Number Needed or Average or Range.Social Worker.FULL-TIME on AM and PM shift.During a review of California state regulation titled, Title 22 S72433, the state regulation indicated 'Social Work Service' means those services which assist.a patient and a patient's family to understand and cope with.personal, emotional and related health and environmental problems.During a review of California state regulation titled, Title 22 S72437, the state regulation indicated Social Work Service Unit-Staff.the social work service unit shall be organized, directed and supervised by a social worker, who is responsible for supervision of other social work staff, including social work assistants. Event ID: Facility ID: 555710 If continuation sheet Page 5 of 7 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 555710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tice Valley Post Acute 1975 Tice Valley Blvd. Walnut Creek, CA 94595 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 two (Residents 9 and 69) out of eight sampled residents received appropriate catheter care per facility policy when there were inconsistent cleaning methods used by staff.This failure had the potential to result in increased risk of urinary tract infections for residents 9 and 69. Findings: During a review of the medical record titled, PACS Medication Administration Record, dated 8/26/25, the record indicated Resident 9 was admitted [DATE] with instructions to provide catheter care every shift. During a review of the medical record, dated 9/19/25, titled, Care Plan Report, the record indicated Resident 9 was at risk for complications with urinary system related to urinary tract infections (UTI- an infection of the urinary system often caused by bacteria).During a review of the medical record, dated 9/2/25, titled, SBAR Communication Form, the record indicated resident 9 had a history of benign prostatic hyperplasia (enlarged prostate which can cause blocking of the flow of urine out of the bladder) with lower urinary tract symptoms, retention (holding) of urine, with a change of condition identified as a urinary tract infection (UTI).During a review of the medical record, dated 9/25/25, titled Diagnostic Report, the record indicated Resident 69 had stage 3 kidney disease (moderate damage to the kidneys), a history of malignant neoplasm (cancerous cells which can spread to other tissues and organs) of the prostate, and prostatic hyperplasia with lower urinary tract symptoms, and foley catheter (A thin, flexible tube inserted into the urethra, the tube that carries urine from the bladder to the outside of the body) placed 9/4/25. During a review of the medical record, dated 9/25/25, titled, Care Plan, the record indicated Resident 69 was admitted to facility on 9/6/25 to provide indwelling catheter care to prevent complications with urinary systems. During an interview on 9/24/25, at 10:40 a.m., Resident 69 stated he has an indwelling foley catheter and the staff cleaned it about a week ago. During an interview on 9/24/25, at 10:50 a.m., with Resident 9, Resident 9 stated he has an indwelling urinary catheter and the staff cleaned it about a week ago. During an interview on 9/24/25, at 10:25 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she cleaned Residents 9 and 69's urinary catheter with Remedy Essentials Spray Cleaner, a scented cleansing solution used to condition skin and nails. During an interview on 9/24/25, at 10:50 a.m., with (CNA) 2, CNA 2 stated she cleaned resident's urinary catheter using Chlorhexidine wipes (An antiseptic solution used to clean skin, wounds, often used to prep the skin before surgery). During an interview on 9/24/25, at 10:35 a.m., with Registered Nurse (RN) 1, RN 1 stated she was unaware of different wipes and solutions being used by CNA's for catheter care. RN 1 stated it was important to use warm soapy water and to make sure bacteria was not introduced into the meatus (a passage or opening leading to the interior of the body), to prevent a urinary tract infection. During an interview on 9/24/25, at 11:10 a.m., with Director of Staff Development (DSD), DSD stated CNA's are trained on how to clean the catheter and can use chlorhexidine (a potent antiseptic, antibacterial, for short term use) or warm soapy water, wiping from meatus away from catheter tubing to prevent bacteria from entering meatus (a passage or opening leading to the interior of the body) which can cause an introduction of bacteria.During concurrent interview and record review on 9/25/25, at 9:20 a.m., with Assistant Director of Nursing (ADON), ADON stated that only warm soapy water should be used to clean the foley catheter tubing and chlorhexidine is used only if there is a doctor's order. During review of Resident 9's and 69's physicians order, there was no order to use chlorhexidine for catheter care. ADON stated that solution for skin and nails should not be used for catheter care. During a review of the facility policy and procedure (P&P), dated 2001, titled, Catheter Care, Urinary indicated, the purpose of this procedure is to prevent urinary catheter-associated complications, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555710 If continuation sheet Page 6 of 7 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 555710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tice Valley Post Acute 1975 Tice Valley Blvd. Walnut Creek, CA 94595 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 including urinary tract infections. Instructions for catheter. care include using clean washcloths with warm water and soap . to cleanse and rinse the catheter from insertion site to approximately four inches outward.Antiseptic wipes for daily cleansing are not recommended. During a review of the Director of Staff Development's (DSD) lesson plan for training staff, titled, UTI Prevention ., dated 6/18/25, the lesson plan indicated best practice for catheter care was to ensure daily cleaning to prevent infection. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555710 If continuation sheet Page 7 of 7