Health inspection·December 21, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 was provided supervision when staff were unaware of Resident 1's whereabouts for two eight-hour shifts (16 hours). This failure had the potential to result avoidable accidents while Resident 1 was not in the facility unsupervised. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included, abnormal posture, difficulty walking, anemia (when your blood produces a lower-than-normal amount of healthy red blood cells), depression (persistent feeling of sadness and loss of interest and can interfere with your daily life), anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), end stage kidney disease (kidneys are no longer able to work at a level needed for day-to-day life) and was dependent on hemodialysis (process of purifying the blood of a person whose kidneys are not working normally). During a concurrent interview and review of clinical records with Director of Nursing (DON) on 11/8/23 at 11:20 a.m., the progress notes were reviewed. DON stated Resident 1 went to the dialysis clinic on 10/25/23 for treatment and did not return to the facility. DON stated during the afternoon shift, Licensed Vocational Nurse (LVN) 1 did not document the incident and did not notify the incoming night shift that Resident 1 was not in the building. DON further stated, on the following day, after being unable to locate Resident 1, DON called Resident 1's cellphone and learned Resident 1 had gone home to the Family Member's (FM) home after dialysis treatment. DON stated FM answered DON's call and stated Resident 1 was sent to the hospital after complaining of abdominal cramps. DON stated the hospital discharged Resident 1 back to the facility on [DATE]. During a follow-up interview on 11/8/23 at 12:59 p.m., DON stated a wandering/elopement assessment should have been completed for Resident 1 upon admission to determine appropriate interventions. DON stated there was no wandering/elopement assessment done for Resident 1. During a telephone interview on 12/11/23 at 12:27 p.m., LVN 1 stated not knowing that Resident 1 was not in the building on 10/25/23. LVN 1 also stated he did not receive any calls from the facility management about Resident 1 not being inside the building during LVN 1's shift and no one from the facility called to ask Resident 1's whereabouts. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555399 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 555399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avondale Villa Post-Acute 788 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)