Health inspection·August 18, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 received care and services with reasonable accommodation when the bathroom did not have a grab bar on the left side to assist Resident 1's toileting needs. Residents Affected - Few This failure had the potential to result in decreased independence to perform activities of daily living (ADLs). Findings: During a review of Resident 1's admission Record dated 8/8/23, the admission Record indicated Resident 1 was admitted to the facility in June 2022 with diagnoses that included aphasia (loss of ability to understand or express speech, due to brain damage), hemiplegia (paralysis of one side of the body), muscle weakness, osteoarthritis (type of arthritis when cartilage/ flexible tissue at the end of the bones wear down) and the need for assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/27/23, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 13 out of 15 indicating Resident 1 is cognitively intact. The MDS also indicated, under Section G, Resident 1 was able to transfer from bed to chair and use the toilet with staff assistance. During an interview on 8/8/23 at 1:15 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 refused to go to the bathroom despite a lot of encouragement from the staff. CNA 1 also stated Resident 1 was able to hold onto the grab bar to stand up. During a concurrent observation and joint interviews on 8/18/23 at 1 p.m. with Resident 1 and CNA 2, CNA 2 stated she did not know why Resident 1 did not want to use the bathroom. CNA 2 stated a bedside commode is provided at the bedside for Resident 1 to use for bowel movements and a urinal was at the bedside. Resident 1 stated the bathroom did not have a grab bar to hold onto during transfers from the chair to the toilet. An observation of Resident 1's bathroom was done. There was a grab bar on the right side of the toilet, while none was on the left side. Resident 1 stated not being able to use the right grab bar because of right side paralysis and only the left hand was good. Resident 1 stated not feeling safe if there was not a left side grab bar. During an interview on 8/8/23 at 1:09 p.m. with Director of Nursing (DON), DON stated Resident 1 was not able to move right side of the body because of right side paralysis but was able to hop on the left leg and use the left arm to hold onto the grab bar in the bathroom. DON stated Resident 1 needed some staff assistance on the right side. Page 1 of 5 555399 555399 08/18/2023 Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550

F 0558 During a review of Resident 1's ADL care plan dated 9/29/22, the ADL care plan indicated for the staff to encourage Resident 1 to participate to the fullest extent possible with all ADLs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555399 Page 2 of 5 555399 08/18/2023 Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550

F 0641 Ensure each resident receives an accurate assessment. 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, for one of two sampled residents (Resident 1), the facility failed to ensure assessment accurately reflects Resident 1's status when the Minimum Data Set (MDS, an assessment tool used to direct resident care) coded a diagnosis of diabetes mellitus without supporting documentation. Residents Affected - Few This failure had the potential to result in uncoordinated care. Findings: During a review of Resident 1's admission Record, dated 8/8/23, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included aphasia (loss of ability to understand or express speech, due to brain damage), hemiplegia (paralysis of one side of the body), muscle weakness, osteoarthritis, and diabetes mellitus (inappropriately elevated blood sugar levels). During a telephone interview with Family Member (FM) 1 on 8/7/23 at 7:09 p.m., FM 1 stated facility staff had been saying Resident 1 was diabetic and was filling out forms for Resident 1 incorrectly despite Resident 1 not having of diabetes. During a concurrent interview and record review on 8/8/23 at 12:38 p.m. with Director of Nursing (DON), Resident 1's admission Record, dated 8/8/23 and MDS dated [DATE], were reviewed. DON stated, when Resident 1 was admitted to the facility in June 2022, a company that helped the facility enter ICD (International Classification of Diseases, a medical coding system to catalog health conditions by categories) codes in the clinical record added diabetes as one of Resident 1's diagnoses. DON stated Resident 1's clinical record from the discharging facility did not have documentation that Resident 1 had diabetes. DON stated because Resident 1 did not receive any treatment for diabetes, Resident 1's MDS should not reflect the diagnosis. Review of Resident 1's MDS dated [DATE] indicated, under Section IActive Diagnoses, instructions included to check the diagnoses that were active the last 7 days of assessment period. The MDS indicated Resident 1 was checked off for diabetes mellitus. DON stated the MDS was coded incorrectly. During a review of Resident 1's Order Summary Report, dated 8/8/23, the Order Summary Report indicated Resident 1 did not receive any treatment for diabetes. During a review of Resident 1's care plan initiated in July 2022, the care plan indicated Resident 1 did not have any actual or potential problems related to diabetes and did not receive any interventions to address it. 555399 Page 3 of 5 555399 08/18/2023 Avondale Villa Post-Acute 788 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 Based on observation, interview, and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 received treatment in accordance with professional standards and Resident 1's choices when: Residents Affected - Few 1. A long-standing skin rash was not treated in a timely manner. 2. Neurovascular Specialist's (one who has expertise in treating a variety of conditions and vascular malformations of the brain, spine, and peripheral nerves) recommendation for a 30-day heart function monitor was not followed up. This failure resulted in delayed management of care. Findings: 1. During a review of Resident 1's admission Record, dated 8/8/23, the admission Record indicated Resident 1 was admitted to the facility in June 2022 with diagnoses that included aphasia (loss of ability to understand or express speech, due to brain damage), hemiplegia (paralysis of one side of the body), muscle weakness, osteoarthritis (type of arthritis when cartilage/ flexible tissue at the end of the bones wear down) and the need for assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care). dated 7/27/23, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 13 out of 15 indicating Resident 1 is cognitively intact. During a concurrent observation and joint interviews on 8/8/23 at 11 a.m. with Director of Nursing (DON) and Resident 1, Resident 1's left upper arm had thick raised patches of scaly and pinkish brown area. Resident 1 stated the rash started since admission. A smaller area of raised pink, scaly patch was noted on Resident 1's left elbow. DON stated it was Resident 1's scar tissue but Resident 1 quickly stated it was not a scar tissue but a rash like the one in the upper arm. Resident 1 stated the rashes were itchy and kept Resident 1 up at night. Resident 1 also stated the staff had been applying cream but that had stopped four days ago. During a concurrent interview and review on 8/8/23 at 11:05 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Order Summary Report dated 8/8/23 was reviewed. LVN 1 stated Resident 1's rash had been treated with ketoconazole cream (antifungal, treats fungal infection of the skin) which was kept at Resident 1's bedside for the Certified Nursing Assistants (CNAs) to apply. LVN 1 stated there was no physician's order in the clinical record to apply ketoconazole cream, and no care plan that addressed it. During an interview and concurrent review on 8/8/23 at 11:15 a.m. with DON, Resident 1's clinical record was reviewed. DON stated there was no Interdisciplinary Team meeting to address Resident 1's rash. DON also stated Resident 1 has had the rashes since admission in June 2022 but there was no documentation that Resident 1's attending physician was notified about it. During a review of the facility's policy and procedure (P&P) titled Administering Medications last revised April 2019, the P&P indicated the following; 555399 Page 4 of 5 555399 08/18/2023 Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550

F 0684 - Medications may only be administered by persons licensed or as permitted by this state. Level of Harm - Minimal harm or potential for actual harm - Medications are administered in accordance with prescriber's orders, including any required time frame. Residents Affected - Few - Topical medications used in treatments are recorded on the resident's Treatment Administration Record (TAR). 2. During a telephone interview on 8/7/23 at 7:09 p.m. with Family Member (FM) 1, FM 1 stated Resident 1 was taken to an appointment with a specialist and came back with an order for heart monitor, but the facility refused to put it on because Resident 1 was not Skilled. During a review of Neurovascular Clinic Follow-up Visit dated 9/9/22, the Neurovascular Clinic Follow-up Visit indicated a recommendation for a 30-day cardiac event monitor to check for paroxysmal atrial fibrillation (abnormal heartbeat) which was a possible cause of Resident 1's stroke. The recommendation indicated, if Resident 1 was found to have atrial fibrillation, Resident 1 would be switched from aspirin 81 milligrams (mg) to a direct oral anticoagulant to prevent any future secondary stroke. The recommendation indicated for Resident 1 to continue taking aspirin until results of the 30-day cardiac monitor is available. During a review of Resident 1's Order Summary Report dated 8/8/23, the Order Summary Report indicated Resident 1 received aspirin 81 mg one tablet daily. During a telephone interview on 8/22/23 at 12:33 p.m. with DON, DON stated Resident 1 went to the hospital Emergency Department (ED) on 10/28/22 after experiencing chest pain. DON stated the hospital performed several tests and Resident 1 returned to the facility the same day without any new order. DON confirmed there was no documentation in the clinical record that indicated the cardiac monitor was not needed. 555399 Page 5 of 5