Inspection·May 21, 2024

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 care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when: Residents Affected - Few 1. medications were not administered as ordered by the physician; and, 2. Resident 1's physician was not informed regarding missed doses of medication. These failures had the potential to compromise Resident 1's health and well-being. Findings: 1. Review of Resident 1's clinical record indicated she was admitted on [DATE] and had diagnoses including fractured shaft of right fibula (a break of the larger lower leg bone below the knee joint), atrial fibrillation (irregular heart rate), congestive heart failure (heart cannot pump enough blood to meet the body's needs), hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure pressure), presence of cardiac pacemaker (implantable device that regulates heart muscle and contractions) Review of Resident 1's physician's order, dated 3/24/24, indicated she was to receive sotolol (medication used to treat heart rhythm problems) 80 milligram (mg, dose measurement) tablet, one half tablet two times a day. Review of Resident 1's medication administration record (MAR) indicated she did not receive her scheduled doses of sotolol on 4/9/24 at 9:00 a.m. and 5:00 p.m., 4/10/24 at 9:00 a.m. and 5:00 p.m., and 4/11/24 at 5:00 p.m. During an interview and concurrent record review with the director of nursing (DON) on 5/21/24 at 12:00 p.m., she reviewed Resident 1's MAR and confirmed Resident 1 did not receive sotolol on the above dates and times. The DON confirmed the MAR indicated the sotolol was not available. The DON stated the licensed nurses should follow up with the pharmacy when a medication is not available. 2. Resident 1's physician's order, dated 3/24/24, indicated she was to receive sotolol 80 mg tablet, one half tablet, two times a day. Review of Resident 1's medication administration record (MAR) indicated she did not receive her scheduled doses of sotolol on 4/9/24 at 9:00 a.m. and 5:00 p.m., 4/10/24 at 9:00 a.m. and 5:00 p.m., and 4/11/24 at 5:00 p.m. (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 2 Event ID: 055210 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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)