Health inspection·November 7, 2023

F 0678 death. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 10:29 a.m., with LVN 2, LVN 2 stated, she did not initiate CPR because it was reported to her by the nurse from the previous shift that Resident 1 ' s code status was DNR (Do Not Resuscitate). LVN 2 stated she did not check the POLST form in Resident 1 ' s medical chart. LVN 2 further stated after she found Resident 1 without vital signs, she just informed the DON, the physician, and the resident ' s family that Resident 1 expired. Also, LVN 2 stated she did not know she was supposed to check the POLST for the facility residents ' code status and used the residents ' progress notes for information of their code status. Residents Affected - Few During an interview on [DATE] at 4:00 p.m., with Medical Doctor (MD), MD stated, I am sorry, it was a mistake the facility did not call 9-1-1. The resident ' s code status was a full code, and the nurse on duty should have called 9-1-1. The 9-1-1 (emergency personnel) would be the one to pronounce the resident ' s death. During a review of the facility ' s policy and procedure (P&P) titled, Emergency procedureCardiopulmonary Resuscitation, dated February 2018, indicated, .if an individual (resident, visitor or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual . Emergency ProcedureCardiopulmonary Resuscitation indicated if an individual is found unresponsive, briefly assess for abnormal breathing .begin CPR, instruct a staff member to activate the emergency response system and call 911 .verify or instruct a staff member to verify the DNR or code status of the individual . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555899 If continuation sheet Page 2 of 6 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 11/07/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to perform a proficient neurological assessment (a series of questions and or motor tests in the event of a sudden change in condition to detect neurological changes: level of consciousness, orientation, movement of arms and legs, pupil size and reaction to light) for one (Resident 1). Staff did not maintain monitoring according to professional standards to detect early changes that required emergent medical treatment after Resident 1 sustained an unwitnessed fall. Residents Affected - Few This failure resulted in not identifying a change in Resident 1 ' s neurological status. Resident 1 died in the facility the following day after the unwitnessed fall. Findings: A review of Resident 1 ' s hospital record titled, Physician Hospitalist Discharge and Transfer Instruction (PHDTI) dated [DATE], indicated the diagnosis of a subarachnoid hemorrhage (SAH, bleeding in the space that surrounds the brain) due to a fall at home. The PHDTI indicated, Resident 1 was being discharged to a skilled nursing facility for rehabilitation services and recovery. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's Alert Charting (AC) by Licensed Vocational Nurse (LVN) 1 dated [DATE] at 7:29 a.m., the AC indicated Resident 1 was admitted to the skilled nursing facility on [DATE] and was described by LVN 1 on admission as: alert and oriented x 2-3 (referring to Resident 1 ' s orientation to 1-person, 2-place, and 3-time. Resident 1 was not fully aware of the time). A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool for sharing information between facility team members) written by LVN 1, dated [DATE] at 2:21 a.m., indicated, Resident 1 had an unwitnessed fall and was found lying on the floor next to his bed on [DATE] at 12:00 a.m. The SBAR indicated, Resident was alert and oriented x 1-2 with confusion and was not able to explain the reasoning behind his fall. Resident 1 knew who he was but was not fully aware of where he was or knew the time). The SBAR indicated a decline in Resident 1 ' s orientation from LVN 1 ' s AC notes on [DATE]. Resident 1 was aao (awake, alert, and oriented) x 2-3 on [DATE]. Further record review showed LVN 1 was aware of Resident 1 ' s primary diagnosis of SAH due to mechanical fall resulting in head trauma (head injury). Resident 1 was not transferred to the hospital after the fall on [DATE]. A review of Resident 1's Daily Nurses Notes (DNN), dated [DATE] at 7:15 a.m., (the day after the unwitnessed fall) by LVN 2, the DNN indicated, Resident 1 was found without Vital signs (Vs, includes temperature, pulse, respirations, and blood pressure) at 5:20 a.m. The DNN also indicated LVN 2 had informed the Medical Doctor (MD), Director of Nursing (DON), and the resident ' s family that Resident 1 expired (died). During a concurrent interview and record review, on [DATE], at 12:03 p.m., with DON, and Resident 1 ' s Nursing Progress Notes (NPP), dated [DATE] and [DATE] were reviewed. The NPP indicated the nurses only monitored Resident 1 ' s Vs but did not perform the complete neurological checks every 4 hours because these were not documented by the licensed nurses. DON stated, the licensed nurses were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555899 If continuation sheet Page 3 of 6 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 11/07/2023 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 0684 Level of Harm - Actual harm Residents Affected - Few supposed to monitor Resident 1 ' s pupil size, range of motion, changes in behavior, pain, mentation, and responsiveness to environment, aside from his Vs, to ensure Resident 1 had no head injury after the unwitnessed fall and to determine if the resident needed further medical interventions. DON also stated, LVN 1 should have asked for an order from the MD to transfer Resident 1 to the hospital for further medical evaluation after the unwitnessed fall. During a phone interview with LVN 2 on [DATE] at 10:29 a.m., LVN 2 stated her definition of performing neuro checks was only checking the safety of Resident 1. LVN 2 stated she performed neuro checks by checking the resident ' s vital signs, alertness and stated she could not recall what other neuro assessments she needed to check. During a phone interview with LVN 1, on [DATE] at 9:48 a.m., LVN 1 stated she informed the MD regarding Resident 1 ' s unwitnessed fall by texting MD and MD did not tell LVN 1 to transfer the resident to the hospital. During a phone interview with the Deputy Coroner (DC), on [DATE] at 9:15 a.m., DC stated, with Resident 1 ' s diagnosis of SAH due to a mechanical fall at home, the facility should have done more interventions for Resident 1 by doing the complete neurologic assessments and sending Resident 1 to the hospital for further evaluation to determine if Resident 1 sustained a head trauma after the unwitnessed fall in the facility. During a review of the facility ' s policy and procedure (P&P) titled, Neurological Assessment, dated [DATE] indicated, Neurological Assessments are indicated: upon physician order; following an unwitnessed fall . any change vital signs or /neurological status in a previously stable the resident should be reported to the physician immediately. The P&P also indicated, Steps in the procedure include: .Perform neurological checks with the frequency as ordered; Determine resident ' s orientation to time, place and person; Observe resident ' s speech and speech clarity; Check pupil reaction; Determine motor ability; Determine sensation in extremities; Check eye opening, verbal, and motor responses . Also, The following information should be recorded in the resident ' s medical record: the date and time the procedure was performed, the name and title of the individual(s) who performed the procedure, all assessment data obtained during the procedure, how the resident tolerated the procedure . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555899 If continuation sheet Page 4 of 6 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 11/07/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility's Quality Assessment Performance Improvement (QAPI) committee failed to identify an adverse event (untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses) and the root cause resulting in the death of one (Resident 1) of three sampled residents. Resident 1 was a full code (all emergency interventions in the event breathing and or heart stops). Staff failed to provide emergency medical treatment when Resident 1 was found unresponsive because nursing staff mistakenly thought Resident 1 had a Do Not Resuscitate (DNR) order. This failure resulted in the QAPI committee not taking steps to review the circumstances of Resident 1's death and monitor their system for code status verification to correct the issue. Findings: A review of resident 1 ' s Physician Orders for Life Sustaining Treatment form (POLST-directs individual end-of-life preferences during a medical emergency), dated [DATE], was signed by Resident 1 ' s legally recognized decision-maker and his physician. The POLST form included . Cardiopulmonary Resuscitation (CPR, chest compressions and rescue breathing) .If patient has no pulse and is not breathing .Attempt Resuscitation/CPR . Review of Resident 1's nurse's progress notes, dated [DATE] at 7:15 a.m., by Licensed Vocational Nurse 2 (LVN 2), indicated Resident 1 was found unresponsive in bed, with no vital signs (Vs, temperature, pulse, respirations, blood pressure) at 5:20 a.m. The progress notes had no documentation that LVN 2 provided CPR on Resident 1 and no 9-1-1 emergency personnel were summoned for emergency care. During an interview on [DATE] at 3:50 p.m., with the Administrator (ADM), who also serves as the facility's head of QAPI, ADM stated the committee meets quarterly and during daily stand-up meetings to determine if there are concerns from family or others that could be (an activity) for the QAPI committee. ADM further stated for every death, we (QAPI committee) ask if there was a cause of death, and review when the Director of Nurses (DON) was notified and whether it was a DNR or full code. ADM further stated the facility's goals and benchmarks for concerns has a tracker and conducts monthly or quarterly audits from the start date. The QAPI committee evaluates and revaluates their performance and decides when it may be discontinued. Record review of the QAPI Committee Meeting Records with ADM, dated [DATE] through [DATE], reflected there were no identified concerns about CPR, POLST forms or adverse events concerning resident deaths. ADM acknowledged there were no other documents that Resident 1's death was identified as a concern for the QAA committee to address. The facility's policy and procedure (revised February 2020) titled, QAPI Program indicated the QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance. b. establishing goals and thresholds for performance measurement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555899 If continuation sheet Page 5 of 6 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 11/07/2023 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 0867 c. identifying and prioritizing quality deficiencies; Level of Harm - Minimal harm or potential for actual harm d. systematically analyzing underlying causes of systemic quality deficiencies; e. developing and implementing corrective action or performance improvement activities; and Residents Affected - Many f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. The facility's policy and procedure (revised [DATE]) titled, QAPI Program Analysis and Action indicated the methodology for analysis and action is guided by a written QAPI plan that includes: a. definition of the problem, based on information obtained through data, self-assessment and feedback systems. b. an analysis of the root cause of the problem from a systems perspective. c. establishing measurable goals or benchmarks for improvement. d. specific interventions aimed at correcting the problem and achieving the stated goals or benchmarks. e. methods and frequency of monitoring performance improvement objectives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555899 If continuation sheet Page 6 of 6