Health inspection·March 24, 2022

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 ensure one (Resident 22) of one resident receiving anticoagulation medication (medication to prevent blood clot formation, commonly known as blood thinner) was free from unnecessary medication when staff did not monitor the side effects of Resident 22's use of apixaban (medication used to thin blood). Residents Affected - Few This failure had the potential to result in Resident 22 developing adverse side effects such as bleeding. Findings: A review of Resident 22's admission Record indicated Resident 22 was admitted to the facility on [DATE], with a diagnosis of atrial fibrillation (an irregular heart rhythm) and tachycardia (heart rate over 100 beats per minute; the normal rate is 60-100 beats per minute). A review of Resident 22's, Order Summary Report, Active Orders as of 3/24/22, indicated a physician order, start date 2/28/22, for Resident 22 to receive one apixaban tablet two times a day for treatment of tachycardia and monitor for bruising. During a concurrent record review and interview, on 3/24/22 at 11:03 a.m., with the Director of Nursing (DON), Resident 22's Medication Administration Record, dated March 2022, was reviewed. The DON was unable to provide documentation nursing staff had monitored Resident 22 for signs of bruising from 2/28/22 until 3/22/22, as ordered by the physician. The DON further stated there should be documentation from staff about monitoring for the side effects of anticoagulation therapy because there could be serious side effects which would require physician notification. A review of the facility's policy titled, Anticoagulation, revised November 2018, indicated, The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems . If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555899 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 555899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stratford Villa Post-Acute 752 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 follow proper sanitation and food handling practices when: Residents Affected - Some 1. The walk-in refrigerator had four trays of previously frozen raw meat in the refrigerator for more than three days; the raw meat was not labeled with a use by date. 2. The reach-in refrigerator had undated and unlabeled individually packaged liquids and a bowl of cooked oatmeal. 3. Two dietary personnel did not perform hand hygiene and or glove changes during food handling. 4. The ice machine interior had a pink substance on the ice chute surface, and the exterior surface of the ice bin had a white residue along the bin seams. These failures had the potential to result in food contamination and foodborne illnesses. Findings: 1. During a concurrent kitchen observation and interview with [NAME] 1, on 3/21/22, at 9:43 a.m., the walk-in refrigerator's temperature was 38 degrees Fahrenheit (F). The bottom shelf of the refrigerator had four separate trays of raw meat labeled and dated as follows: pork 3/18/22; beef 3/18/22; chicken 3/19/22; beef 3/19/22. [NAME] 1 stated the label on the trays indicated the type of meat and the date when the package of raw meat was removed from the freezer and put into the refrigerator for defrosting. During a concurrent observation and interview, with Dietary Supervisor (DS), on 3/22/22, at 10:31 a.m., in the kitchen, the walk-in refrigerator's bottom shelf had the same four trays of raw meat: pork 3/18/22; beef 3/18/22; chicken 3/19/22; beef 3/19/22. DS stated each tray of raw meat weighed five pounds and had been pulled out from the freezer and placed in the refrigerator to defrost at the same time, for convenience. DS stated the pork and beef dated 3/18/22 was stew meat, chicken thighs were dated 3/19/22, and the beef dated 3/19/22 was ground beef. During a telephone interview on 3/23/22, at 9:50 a.m., with the Registered Dietitian (RD), RD explained the process of safely thawing raw meat. RD stated raw meat is labeled with a pull-out date when taken out of the freezer and thawed for three days in the bottom shelf of the refrigerator. Defrosted meat should be cooked on the third day. Raw meat if not used on the third day should be cooked and kept in the freezer until ready to serve within 48 hours. Unused thawed raw meat past three days should be discarded. During a review of the facility's P&P titled, Food Preparation, dated 2018, the P&P indicated, .Thawing meat properly can be done in these four ways: 1. In a refrigerator at 41 degrees F or colder. Allow two to three days to defrost, depending on quantity and total weight of meat. Label defrosting meat with pull and use by date . 2. During a concurrent kitchen observation and interview with [NAME] 1, on 3/21/22, at 9:43 a.m., inside the reach-in refrigerator were six glasses with liquids of assorted colors and a cup of cooked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555899 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 555899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stratford Villa Post-Acute 752 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 - Some oatmeal undated and unlabeled. [NAME] 1 stated he poured the drinks into glasses and prepared the oatmeal when he arrived on the morning of 3/21/22. [NAME] 1 stated food items should be labeled to ensure residents received fresh food and drinks and did not get ill from food. During an interview on 03/22/22, at 10:31 a.m., with the DS, DS stated poured drinks should either be individually labeled with the date or placed in a dated tray inside the refrigerator. 3. During an observation on 3/22/22, at 11:30 a.m., in the kitchen, kitchen staff plated food for the residents' lunch service. [NAME] 3 wore gloves and put plated food onto the serving cart. While wearing the same gloves, [NAME] 3 used his hands to place a dinner roll on a plate. [NAME] 3 removed his soiled gloves, and donned new gloves without intervening hand hygiene, and used his hands to place a parsley garnish on a plate. During an observation on 3/22/22, at 11:35 a.m., in the kitchen, during lunch preparation service, DS doffed soiled gloves and without performing hand hygiene, DS donned new gloves and used a scoop to place dried herbs on top of food on a plate. During a review of the facility's P&P titled, Glove Use Policy, dated 2018, the P&P indicated, The appropriate use of gloves is essential in preventing food borne illness. Gloved hands are considered a food contact surface that can get contaminated or soiled. Disposable gloves are a single use item and should be discarded after each use, especially before handling clean food items .Wash hands when changing to a fresh pair. Gloves must never be used in place of handwashing .When Gloves Need to be Changed .before beginning a different task .before handling all food as described in food handling procedures . 4. During a concurrent kitchen observation and interview with [NAME] 1, on 3/21/22, at 9:53 a.m., the ice machine interior had a pink substance on the ice chute surface, and the exterior surface of the ice bin had a white residue along the bin seams. [NAME] 1 stated the Maintenance Director (MD) was responsible for cleaning and maintenance of the ice machine. During a concurrent observation and interview on 3/22/22, at 10:40 a.m., with MD, in the kitchen, MD stated the interior of the ice machine had a pink substance on the catch rail of the ice machine chute. MD also stated the white residue on the exterior seams of the ice machine bin was calcium build-up. MD stated the ice machine was supposed to be cleaned every month. During a concurrent record review of the facility, Ice Machine Cleaning Log, MD stated the Log indicated the ice machine was last cleaned on 1/5/22. A review of the facility's P&P titled, Ice Machine Cleaning Procedures, dated 2020, indicated, The ice machine needs to be cleaned and sanitized monthly or per manufacturer recommendation and the date recorded when cleaned .Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions . A review of the ice machine's manufacturer's manual titled, Maintenance, indicated, Exterior Cleaning Clean the area around the ice machine as often as necessary to maintain cleanliness and efficient operation. A review of the 2017 Federal Food Code, section 4-601.11 titled, Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils, indicated, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (C) Nonfood-contact surfaces of equipment shall be kept free of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555899 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 555899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stratford Villa Post-Acute 752 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 an accumulation of dust, dirt, food residue, and other debris. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555899 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 555899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stratford Villa Post-Acute 752 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 provide a sanitary environment for two of five sampled residents (Resident 14, Resident 16) when staff failed to: 1. perform hand hygiene between glove changes when administering medication to Resident 14, and 2. clean the oxygen mask and tubing for Resident 16. Residents Affected - Few This failure had the potential for infection of Resident 14 and Resident 16. Findings: 1. During a concurrent observation and interview on 3/23/22 at 09:03 a.m., in Resident 14's room, Licensed Vocational Nurse 2 (LVN 2), LVN 2 prepared Resident 14's medication by opening multiple medication bottles and medication packs with gloved hands and placing the medication into separate medicine cups. With the same gloved hands, LVN 2 went to Resident 14's bedside and touched Resident 14's remote control to adjust Resident 14's bed, adjusted Resident 14's blankets, and handed the medicine cups to Resident 14 without changing gloves or performing hand hygiene. A review of the facility's policy titled, Hand Washing/Hand Hygiene, revised August 2019, indicated, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . Before and after direct contact with residents; before preparing or handling medications .after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. 2. A review of Resident 16's admission Record, dated 3/23/22, indicated Resident 16 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD, constricted airways making it difficult to breath) and pulmonary embolism (blocked blood flow to the lung). A review of Resident 16's Physician Order Summary, dated 2/8/22, indicated Resident 16's order summary of Albuterol Sulfate Nebulization Solution (used to treat wheezing and shortness of breath) 2.5 milligram (mg)/3 milliliter (ml) 0.083% one vial inhale orally via nebulizer at bedtime for COPD. During an observation on 3/21/22, at 10:20 a.m., inside Resident 16's room, a nebulizer (a device used to change liquid medicine into a very fine mist that a person can inhale through a face mask or mouthpiece) was on the top of Resident 16's bedside table. On top of the nebulizer was Resident 16's oxygen mask with tubing connected to the mask. The mask had scattered dry white matter adhered to the interior of the mask. The tubing was connected to the mask at one end, and open to air at the end which was used to connect to the nebulizer. During an interview on 3/21/22 at 10:25 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 16's oxygen mask did not look clean. LVN 1 stated the mask and tubing should be kept in a bag when not in use to prevent bacterial growth and contamination. During an interview on 3/23/22, at 10:51 a.m., with the Director of Nursing (DON), the DON stated oxygen tubing, and oxygen masks should be dated when changed and stored in a Ziploc bag when not in use, for infection control purposes. Review of the facility's undated policy and procedure, titled Use of Oxygen, indicated, To promote (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555899 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 555899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stratford Villa Post-Acute 752 Holmes Street Livermore, CA 94550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete patient safety in administering oxygen .The following guidelines will be observed in oxygen administration A. The oxygen cannula or mask does not require scheduled changing when used on one patient. It should be changed when soiled or dirty . Further review of the facility's undated policy and procedure, titled Oxygen Equipment, indicated, .D. Oxygen masks, nasal cannulas, and tubing will be used for one resident only. When used continuously or intermittently, tubing will be regularly monitored to prevent the build-up of respiratory secretions/mucous. E. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms . Event ID: Facility ID: 555899 If continuation sheet Page 7 of 7