Health inspection·February 11, 2026

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for two out of four residents (Resident 1 and 2), that their rights were protected, when facility did not verify the informed consents were obtained from the responsible party, and informed consent were not in Resident 1 and 2's medical records. These failures resulted in violating the residents' right to be informed with their medical treatment.Cross reference to F 684Findings:A review of Resident 1's admission Record (AR) indicated Resident 1 was admitted on [DATE] with diagnoses that included Parkinson's Disease without dyskinesia, without mention of fluctuations. Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 11/08/2025 indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 05 (BIMS score of 00 - 07: severe impairment; 08 - 12: moderately impaired; and 13 - 15: cognitively intact). During a review of facility's admission Record (AR), it indicated Resident 2 was admitted on [DATE], with diagnoses that included Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Aphasia. Resident 2's MDS dated [DATE], the MDS indicated a BIMS score of 02.During an interview on 02/11/2026 at 10:45 a.m., with Administrator (ADM), ADM stated the Brain Mapping/Neurofeedback treatment (a biofeedback, which teaches self-control of brain functions to subjects by measuring brain waves and providing a feedback signal. Neurofeedback usually provides audio and/or video feedback) was performed by a third party provider in the facility. ADM further added the brain mapping/neurofeedback treatment provider obtains the informed consent from Resident 1 and 2' Responsible Party (RP). Furthermore, the facility verifies the informed consent that was obtained by the provider by reviewing a copy of the informed consent and filing this copy in the resident's medical chart.During a concurrent interview and record review on 02/11/2026 at 12: 27 p.m. with ADM, ADM stated the consent for brain mapping/neurofeedback was emailed by the provider when Resident 2's Responsible Party requested informed consent. ADM stated a copy of the informed consent was not among his medical records.During an interview on 02/11/2026 at 01:28 p.m., with ADM, ADM stated she requested Resident 1's informed consent for the brain mapping/neurofeedback from the provider today to email the informed consent. During an interview on 03/04/2026 at 10:18 a.m. with Responsible Party (RP), RP stated she was not aware that Resident 2 was referred for brain mapping/neurofeedback treatment. RP stated she was first made aware of Resident 2's brain mapping/neurofeedback treatment when she requested a physician order summary to review Resident 2's medications. RP stated she did not give a consent to treat Resident 2 with brain mapping/neurofeedback and the treatment was not explained to her.During a review of the facility's policy and procedures titled Informed Consent, it indicated a policy statement The facility shall ensure the resident's rights are maintained and a copy of these rights and pertinent policies are made available to Page 1 of 5 555899 555899 02/11/2026 Stratford Villa Post-Acute 752 Holmes Street Livermore, CA 94550

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident and to any representative of the resident. Among these rights under this section are the right to: a. Receive in advance all information that is material to a decision to accept or refuse treatment, b. Consent to or to refuse treatment or procedure or participation in experimental research, and c. Participate in care planning. 1. Informed Consent: The voluntary agreement of a patient or a representative of an incapacitated patient to accept a treatment or procedure after receiving information. Guidelines 1. The disclosure of material information and obtaining informed consent is the responsibility of the licensed health care practitioner who, in acting within the scope of his/her professional licensure. 2. The facility staff shall verify the resident or his/her surrogate has given informed consent to the propose treatment or procedure. 555899 Page 2 of 5 555899 02/11/2026 Stratford Villa Post-Acute 752 Holmes Street Livermore, CA 94550

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure for two out of four residents (Residents 1 and 2), Residents 1 and 2 receive treatments according to their needs. Residents 1 and 2 were treated with brain mapping/neurofeedback treatment (a biofeedback, which teaches self-control of brain functions to subjects by measuring brain waves and providing a feedback signal. Neurofeedback usually provides audio and/or video feedback), without after treatment plan and care provided. These failures had potential to affect Residents 1 and 2's health and safety due to lack of care coordination.Cross reference to F 578Findings:1. During a review of Resident 1's admission Record (AR), indicated Resident 1 was admitted on [DATE], with diagnoses that included Parkinson's Disease without dyskinesia, without mention of fluctuations. Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 11/08/2025, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 05, (BIMS score of 00 - 07: severe impairment; 08 - 12: moderately impaired; and 13 - 15: cognitively intact). During a review of facility's admission Record (AR), indicated Resident 2 was admitted on [DATE], with diagnoses that included Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Aphasia. Resident 2's MDS dated [DATE], the MDS indicated a BIMS score of 02.During an interview on 02/11/2026 at 01: 10 p.m., with Medical Doctor (MD), MD stated that he made the referrals for Brain Mapping/Neurofeedback treatment for Residents 1 and 2. MD stated the referrals was for Parkinson's disease and dementia. MD stated the brain mapping/neurofeedback treatment was not a standard treatment for Parkinson's disease or dementia, but it may be beneficial to Residents 1 and 2. MD stated he discontinued the treatment after three to four weeks because he did not see an improvement.During an interview on 02/11/2026 at 10:45 a.m., with Administrator, (ADM) stated the Brain Mapping/Neurofeedback treatment was performed by third party provider in the facility.During a review of Resident 1's physician order dated 03/17/2023, indicated Brain Mapping/NeuroFeed Back (NFB) due to: Altered Mental Status. QEEG [Quantitative electroencephalography] Brain Mapping now, and after every 5th NFB therapy session. NFB therapy 2 -3 times a week for 20 - 40 sessions, with re-evaluation for continuance thereafter based on therapeutic appropriateness/patient response.During a review of Resident 1's Brain Mapping/Neurofeedback treatment record, indicated treatment started on 03/17/2023 through 10/24/2023.During a review of Resident 2's physician order dated 03/13/2024, indicated Brain Mapping/NeuroFeed Back (NFB) due to: Altered Mental Status. QEEG Brain Mapping now, and after every 5th NFB therapy session. NFB therapy 2 -3 times a week for 20 - 40 sessions, with re-evaluation for continuance thereafter based on therapeutic appropriateness/patient response.During a review of Resident 2's Brain Mapping/Neurofeedback treatment record, indicated treatment started on 03/13/2024 through 05/01/2024.During an interview on 02/11/2026 at 11:20 a.m., with ADM, ADM stated Responsible Party (RP) requested to discontinue the brain mapping/neurofeedback treatment because there were no improvements after months of treatment. ADM further added that Resident 2's RP requested to stop treatment and Resident 2's RP claimed they did not give consent for the brain mapping/neurofeedback treatment. 2. During a concurrent interview and record review on 02/11/2026 at 11:40 a.m., ADM, ADM reviewed Resident 2's nursing care plan, and ADM stated that there was no nursing care plan for Resident 2's Brain Mapping/Neurofeedback treatment.During a concurrent interview and record review on 02/11/2026 at 12:00 p.m., with ADM, ADM reviewed Resident 1's nursing care plan, and ADM stated there was no nursing care plan for Resident 1's Brain Mapping/Neurofeedback treatment.During a concurrent interview and record review Residents Affected - Few 555899 Page 3 of 5 555899 02/11/2026 Stratford Villa Post-Acute 752 Holmes Street Livermore, CA 94550

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 02/11/2026 at 01:04 p.m., with ADM, ADM stated she contacted the brain mapping/neurofeedback treatment provider to obtain Resident 1's first visit notes.During an interview on 02/11/2026 at 01:33 p.m., with Director of Staff Development/Licensed Vocational Nurse (DSD/LVN), DSD/LVN stated the Brain mapping/neurofeedback provided did not give after treatment care instructions for Resident 1 and 2's brain mapping/neurofeedback treatment. DSD/LVN stated the visit notes were not given immediately after the visit, and he was unaware when the visit notes were provided to the facility.During a review of Resident 1 and 2's Brain Mapping/Neurofeedback Nursing Home Visit notes indicated Plan of care coordinated with primary care team, nursing staff. Counseling provided to staff regarding adequate patient hydration and nutrition in conjunction with Neurofeedback. 555899 Page 4 of 5 555899 02/11/2026 Stratford Villa Post-Acute 752 Holmes Street Livermore, CA 94550

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 for one out of four residents (Resident 1), that Resident 1 was in a room with Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities), EBP was not followed during nursing care. This failure had the potential to spread infection when prevention was not consistently practiced.Findings:During a review of the facility's admission Record (AR), it indicated that Resident 2 was admitted on [DATE], with multiple diagnoses that included Encounter for attention to gastrostomy(a surgical opening into the stomach for a feeding tube to deliver nutrition, hydration, or medication directly). Resident 2's Minimum Data Set (MDS resident assessment tool) dated 12/25/2025 indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 02 (BIMS score of 00 - 07: severe impairment; 08 - 12: moderately impaired; and 13 - 15: cognitively intact).A review of Resident 2's Order Summary Report indicated Enteral Feed Order every 3 hours Enteral: Flush with a minimum of 130 ml water via PEG tube, . Enhanced Barrier Precaution during high contact time secondary to: G-tube indwelling device every shift.During a review of Resident 2's Care Plan Report it indicated Enhanced Barrier Precautions Required: [Resident 2] requires enhanced barrier precaution during high contact care activities due to: G-Tube indwelling device.During a concurrent observation and interview on 02/11/2026 at 11:24 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she would flush Resident 2's g-tube with water. LVN 1 entered Resident 2's room and prepared and administered the water flush via g-tube. Resident 2's family was at bedside visiting. LVN 1 and Resident 2's family member repositioned Resident 2 in bed. LVN 1 did not wear a gown before administering Resident 2's g-tube water flush, and to reposition Resident 2 in bed.During a concurrent observation and interview 02/11/26 at 12:54 p.m., with, LVN 1, LVN 1 stated that Resident 2 was on enhanced barrier precautions for the presence of a g-tube. There was a sign posted outside Resident 2's room that read : Enhanced Barrier Precaution. LVN 1 stated she did not put on a gown when she flushed water into Resident 2's g-tube.During a review of facility's policy and procedures titled Enhanced Barrier Precautions it stated Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 1. Enhanced barrier precautions (EBPs) are used as infection prevention and control interventions to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing a high contact resident care activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities required the use of gown and gloves for EBPs include. g. device care or use (central line, urinary catheter, feeding tube.). Residents Affected - Few 555899 Page 5 of 5