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. Page 1 of 4 555399 555399 12/21/2023 Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550

F 0689 Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 12/12/23 at 12:14 p.m. with LVN 2, LVN 2 stated, during shift report with LVN 1, LVN 1 stated everything was okay and left. LVN 2 stated she did not know Resident 1 was not in the building until about 4 a.m. when LVN 2 entered Resident 1's room to find an empty bed. LVN 2 stated she asked Certified Nursing Assistant (CNA) 1 and CNA 2, and both did not know Resident 1 was not in the room the entire time. Residents Affected - Few During a review of Resident 1's Order Recap Report dated 10/25/23 to 11/8/23, that indicated an order dated 8/17/23 to check Resident 1's vital signs after dialysis and to monitor the dialysis access site on Resident 1's left upper arm every shift. During a telephone interview on 12/11/23 at 2 p.m. with CNA 3, CNA 3 stated Resident 1 eft for dialysis around 1 p.m. accompanied by the transport personnel. CNA 3 was working until the afternoon shift and assigned to care for Resident 1. CNA 3 stated Resident 1 did not return to the facility at the usual time but did not notify LVN 1 about it. 555399 Page 2 of 4 555399 12/21/2023 Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to maintain medical records on Resident 1 that were accurately documented and complete when; Residents Affected - Few - Licensed Vocational Nurse (LVN) 1 did not document Resident 1's whereabouts for the entire afternoon/evening shift. - LVN 1 signed off Medication Administration Record (MAR) indicating medications were administered to Resident 1 while Resident 1 was actually not in the facility. These failures resulted in inaccurate medical records and falsification of medication administration. Findings: During a concurrent interview and review of clinical records with Director of Nursing (DON) on 11/8/23 at 11:20 a.m., Resident 1's progress notes were reviewed. DON stated Resident 1 went to dialysis clinic on 10/25/23 for treatment and did not return to the facility. DON stated Licensed Vocational Nurse (LVN) 1, during the afternoon shift, did not document the incident and did not notify the incoming night shift that Resident 1 was not in the building. On the following day after being unable to locate Resident 1, DON called Resident 1's cellphone and found out that Resident 1 went home to a Family Member's (FM) home after dialysis treatment. During a review of Resident 1's Order Recap Report dated 10/25/23-11/8/23, the Order Recap Report indicated Resident 1 was to receive the following during the afternoon shift; -Buspirone (treats anxiety) hydrochloride (HCL) 10 milligram (mg) tablet one tablet by mouth. -Cholestyramine powder (treats bile-acid diarrhea) four grams by mouth. -Cyclosporine (targets the body's immune system) oral capsule 25 mg 1 capsule by mouth. -Depakote (treats manic episodes) oral tablet delayed release 125 mg one tablet by mouth. -Florastor (probiotic, maintains body's digestive balance) oral capsule 250 mg one capsule by mouth. -Melatonin (sleep aid) oral tablet three mg one tablet by mouth. -Mycophenolate Mofetil (suppresses/targets the immune system) oral capsule 250 mg one capsule by mouth. -Assess pain level every shift. -Dialysis: check vital signs after dialysis every evening shift on Monday, Wednesday and Friday. -Dialysis: monitor AV fistula (abnormal connection or passageway between an artery and a vein often 555399 Page 3 of 4 555399 12/21/2023 Avondale Villa Post-Acute 788 Holmes Street Livermore, CA 94550

F 0842 Level of Harm - Minimal harm or potential for actual harm surgically created for hemodialysis) on left upper arm for presence of bruit (abnormal sound generated by turbulent flow of blood in an artery) &thrills (thrill is a vibration felt upon palpation of a blood vessel) every shift. -Monitor dressing on access site for any bleeding and reinforce dressing as needed. Residents Affected - Few During a review of Resident 1's MAR for October 2023, the MAR indicated the following medications/treatments were administered/provided to Resident 1; -Vital signs that included blood pressure, temperature, pulse rate, respiration rate, oxygen saturation were checked at 3 p.m.; the MAR indicated Resident 1's blood pressure=126/77, temperature=97. 3 degrees Fahrenheit, pulse rate=76, respiration rate= 17 and oxygen saturation= 96 percent (%). - Melatonin three mg one tablet was administered at 9 p.m. - Buspirone 10 mg tablet was administered at 5 p.m. - Cholestyramine Powder four grams was administered at 5 p.m. - Cyclosporine 25 mg oral capsule was administered at 9 p.m. - Depakote 125 mg oral tablet was administered at 5 p.m. - Florastor 250 mg oral capsule was administered at 5 p.m. - Mycophenolate Mofetil 250 mg oral capsule was administered at 9 p.m. - Resident 1's pain level was assessed at 3 p.m., Resident 1's pain level was zero out of 10 (pain level 0-10, zero as no pain and 10 as the worst pain). - Resident 1's AV fistula on the left upper arm was checked for presence of bruit and thrills at 3 p.m. - Resident 1's dialysis access site on the left upper arm was monitored for signs and symptoms of infection, bleeding, redness, pain, swelling and discharge. - Novasource Renal four ounces was given to Resident 1, Resident consumed 90 percent (%). - Norco 5-325 mg oral tablet was administered to Resident 1 at 8:20 p.m. for a five out of 10 pain. During a telephone interview on 12/11/23 at 12:27 p.m. with LVN 1, LVN 1 stated not knowing Resident 1 was not in the building on 10/25/23 during LVN 1's shift at the facility or knowing Resident 1 had not returned to the facility (after dialysis). LVN 1 stated during medication administration, LVN 1 signed off on the medications as given to Resident 1 before the actual administration. During a telephone interview on 12/11/23 at 2 p.m. with CNA 3, CNA 3 stated Resident 1 left for dialysis around 1 p.m. accompanied by the transport personnel. CNA 3 was assigned to care for Resident 1 and knew Resident 1 did not return to the facility. CNA 3 did not notify LVN 1 about it. 555399 Page 4 of 4