Inspection visit

Health inspectionMay 23, 2025

Q: What happened during the May 23, 2025 survey of MOUNTAIN VIEW HEALTHCARE CENTER?

This was a inspection survey of MOUNTAIN VIEW HEALTHCARE CENTER on May 23, 2025. The surveyor cited 26 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Q: Were any deficiencies cited at MOUNTAIN VIEW HEALTHCARE CENTER on May 23, 2025?

Yes, 26 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

Q: What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

MOUNTAIN VIEW HEALTHCARE CENTERCMS #05531626 citations on this visit

26 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 26 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation inside Resident 25's room on 5/19/25 at 9:06 a.m., Resident 25 was observed lying in bed. Her Foley catheter drainage bag was left uncovered hanging on the right side of the bed towards the door. yellow colored urine was visible from the drainage bag. During a concurrent observation and interview on 5/19/25 at 9:12 a.m., with Certified Nursing Assistant Q (CNA Q), She confirmed that Resident 25's Foley Catheter drainage bag was left uncovered with the privacy bag. CNA Q further stated usually it should have cover with privacy bag . During a review of Resident 25's clinical record indicated Resident 25 was admitted to the facility with diagnosis including neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should). During a review of Resident 25's physician's order indicated an order for Indwelling Catheter to straight drainage. Size: 16 FR (French, size is comparable to the circumference of the catheter in millimeters) . dated 4/11/25. During an interview on 5/22/25 at 2:34 p.m., with the Director of Nursing (DON), the DON stated the Foley catheter drainage bag should have privacy bag covered all the time and the catheter drainage bag should be placed away from the door. During a review of the facility's policy and procedures titled, Catheter Care, dated 3/1/23, indicated, It is the policy of this facility to ensure that residents with the indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use . 4. Review of Resident 325's clinical record, indicated, Resident 325 was admitted on [DATE] with diagnoses including hereditary and idiopathic neuropathy (nerve damage caused by an unknown genetic defect), malignant neoplasm of prostate (growth of abnormal cells in the prostate, a male reproductive organ), obstructive and reflux uropathy (urine blocked from flowing out of the body and flows backward into the wrong place, such as back into the kidneys). Review of Resident 325's clinical record indicated he had a physician's order, dated 5/6/25, for suprapubic catheter (a tube placed directly into the bladder to drain urine). During a concurrent observation and interview on 5/19/25 at 8:41 a.m., with Certified Nursing Page 1 of 67 055316 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assistant (CNA) J, CNA J emptied the urine drainage bag. CNA J stated that the drainage bag does not need to have a privacy cover. During a concurrent observation and interview on 5/19/25 at 10:33 a.m., with the Director of Nursing (DON), the DON confirmed that the drainage bag did not have a privacy cover. The DON stated that urinary bag should have a privacy cover. Review of the facility's policy and procedure (P&P), titled Catheter Care, dated 3/1/23, indicated Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Based on observation, interview, and record review, the facility failed to maintain respect, and dignity to five of five residents (Residents 71, 108, 284, 325, and 25) when: 1. Certified nursing assistant K (CNA K) addressed Resident 71 as mama several times which could be heard at the facility's hallway; 2. Resident 108's privacy curtain was not fully drawn when occupational therapist M (OT M) was doing exercises with Resident 108; 3. Resident 284's urine drainage bag (a pouch that attaches to a urinary catheter [example is foley catheter, a thin, hollow tube inserted into the bladder to drain urine] and collects urine) was not covered with a privacy bag; 4. Resident 325's urine drainage bag was not covered with a privacy bag; and 5. Resident 25's urine drainage bag was not covered with a privacy bag. These failures had the potential to negatively affect resident's emotional and psychosocial well-being. Findings: 1. Review of Resident 71's clinical record titled, admission Record, dated 5/22/2025, indicated Resident 71 was admitted to the facility with diagnoses including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a condition characterized by memory loss) and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) with hallucinations (a false perception of objects or events involving the senses: sight, sound, smell, touch and taste). During an observation on 5/19/2025 at 9:58 a.m., CNA K together with certified nursing assistant L (CNA L) went inside Resident 71's room. CNA K stated in a loud voice, mama we will pull you up. CNA K addressed Resident 71 as mama, three more times and it could be heard at the facility's hallway. During a follow-up interview with CNA K on 5/19/2025 at 10:00 a.m., CNA K confirmed above observation and stated she had to address Resident 71 mama because she had a hard time pronouncing Resident 71's name. CNA K further stated she should have addressed Resident 71 with her first or last name. During a concurrent interview with director of nursing (DON) and record review on 5/21/2025 at 9:55 a.m., DON reviewed Resident 71's list of care plans. DON stated staff could call or address 055316 Page 2 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents mama, if it was the resident's preference. DON confirmed there was no preference care plan to address Resident 71 mama, and stated staff should address residents by their name. 2. Review of Resident 108's clinical record titled, admission Record, date 5/22/2025, indicated Resident 108 was admitted to the facility with diagnoses including gout (a type of inflammatory arthritis caused by a buildup of uric acid in the body), and muscle weakness (generalized). During an observation on 5/21/2025 at 12:48 p.m., at the facility's hallway, in front of Resident 108's room, Resident 108 was observed seated at the left side of the bed in front of OT M who was standing, and the privacy curtain was not fully drawn. OT M was giving some exercise instructions to Resident 108 who wore the facility's gown, tied at the back of her neck, her back down to her disposable brief was exposed and every time Resident 108 lifted her arms up, the side of her right breast could be seen at the hallway by any passersby. During an interview with OT M on 5/21/2025 at 12:57 p.m., OT M confirmed the above observations and stated she should have pulled the privacy curtain to provide Resident 108 dignity. During an interview with DON on 5/23/2025 at 11:20 a.m., DON stated the privacy curtain should always be drawn whenever staff were assisting residents with exercises or activities of daily living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) to provide some privacy. During a review of the facility's policy and procedure titled, Promoting/Maintaining Resident Dignity, dated 3/1/2022, indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, including privacy .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .When interacting with a resident, pay attention to the resident as an individual 3. Review of Resident 284's clinical record titled, Order Summary Report, dated 5/23/2025, it indicated an order of foley catheter attached to a bedside drainage bag for diagnosis of urinary retention (a condition when the patient is unable to completely empty their bladder). During a concurrent observation and interview with Resident 284 on 5/19/2025 at 10:21 a.m., inside Resident 284's room, Resident 284 was in bed, and a urine drainage bag was observed hanged at the lower part of the bed without a privacy bag. The urine drainage bag had yellow urine at 400 milliliter (ml, volume of measurement) which could easily be seen by any visitor inside the room. Resident 284 stated that she was not sure if the urine drainage bag had to be covered. Resident 284 further stated she did not mind if it was not covered as long as there was no urine in the urine drainage bag. During a concurrent observation and interview with CNA L on 5/19/2025 at 12:46 p.m., inside Resident 284's room, Resident 284 was eating lunch in bed, the urine drainage bag did not have a privacy bag. CNA L confirmed the above observation and stated the urine drainage bag should have been covered for privacy reasons. 055316 Page 3 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 implement their policy and procedure on self-administration of medication (resident takes medication without staff assistance) when there was no assessment performed for self-administration of medication, and medications were left at bedside for one of eight sampled residents (Resident 325). Residents Affected - Few This failure had the potential for unsafe and improper administration of medications. Findings: Review of Resident 325's clinical record, indicated, Resident 325 was admitted to the facility on [DATE] with diagnoses including hereditary and idiopathic neuropathy (nerve damage caused by an unknown genetic defect), malignant neoplasm of prostate (growth of abnormal cells in the prostate, a male reproductive organ), obstructive and reflux uropathy (urine blocked from flowing out of the body and flows backward into the wrong place, such as back into the kidneys). During a concurrent observation and interview with Resident 325 in his room on 5/19/25 at 10:27 a.m., Resident 325 was in bed. There was one bottle of Lutein (dietary supplement) placed on top of the bedside table. Resident 325 stated the medication was left on top of the bedside table. Review of Resident 325's clinical record indicated he has a physician's order for Lutein 20 milligram (mg, unit of measurement) one time a day for supplement. During a concurrent observation and interview on 5/19/25 at 10:27 a.m., with the Director of Nursing (DON), the DON confirmed the medication was on top of the bedside table in Resident 325's room with no label. The DON stated there should have an assessment that the patient can take it on his own. The DON stated there was no assessment done for self-administration. The DON further stated that the medication should be kept in the medication cart and labeled. During an interview with Resident 325's Significant Other (SO), on 5/20/25 at 12:53 p.m., the SO stated she informed the nurse that she brought the medication, and the nurse stated okay. The SO stated the nurse did not take the medication. The SO gave the medication to Resident 325 and informed the nurse, and the nurse said okay. The SO stated she was not told to not give the medication to Resident 325. During a concurrent observation and interview on 5/21/25 at 1:31 p.m., with Registered Nurse (RN) N, the RN N confirmed the medication had no label. RN N stated the medication should be labeled. RN N used a pen with permanent ink to write Resident 325's name on the cap of the medication bottle. During a review of the facility's policy and procedure (P&P), titled Self-Administration of Medications, undated, indicated As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. During a review of the facility's P&P, titled Labeling of Medications and Biologicals, dated 2/1/24, indicated All medications and biologicals used in the facility will be labeled in accordance with 055316 Page 4 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few current state and federal regulations to facilitate consideration of precautions and safe administration of medications. During a review of the facility's P&P, titled Medication Monitoring, dated 6/1/24, indicated Medications shall be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. 055316 Page 5 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 needs was accommodated for two of 26 sampled residents (Residents 279 and 278) when call light button (a red or white button used to call for assistance) was not within Resident 279 and 278's reach for use. Residents Affected - Few This failure had the potential for a delayed response and not meeting Resident 279 and 278's needs. Findings: 1. Review of Resident 279's clinical record titled, admission Record, dated 5/22/2025, indicated Resident 279 was admitted to the facility with diagnoses including injury of facial nerve (a nerve that runs from the brainstem, through openings in the skill, to the face and tongue) and displaced bicondylar fracture of right tibia (a severe injury that occurs when both upper and lower parts of the shinbone (tibia) are fractured and displaced from their normal position). Review of Resident 279's admission minimum data set (MDS, a federally mandated resident assessment tool) dated 5/8/2025, indicated a brief interview for mental status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a concurrent observation and interview with Resident 279 on 5/19/2025 at 8:52 a.m., inside Resident 279's room, Resident 279 was seated on a wheelchair located at the left, end side of the bed. The call light button was hanging at the right upper bed rail. Resident 279 stated she had been seated for 30 minutes to finish her breakfast, and she couldn't reach the call light button. Resident 279 further stated she would just yell if she needed help. During a concurrent observation and interview with certified nursing assistant L (CNA L) on 5/19/2025 at 8:59 a.m., inside Resident 279's room, CNA L confirmed above observation and stated Resident 279's call light button was not within Resident 279's reach for use. 2. Review of Resident 278's clinical record titled, admission Record, dated 5/22/2025, indicated Resident 278 was admitted to the facility with diagnoses including primary generalized osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), other low back pain, left hip pain and dementia (a progressive state of decline in mental abilities). Review of Resident 278's 5-day MDS assessment dated [DATE], indicated a BIMS score of 13. During a concurrent observation and interview with Resident 278 on 5/19/2025 at 9:01 a.m., inside Resident 278's room, Resident 278 was eating breakfast in bed, complained of back pain and stated she couldn't find her call light button. Further observation, the call light button was not located. Resident 278 stated she was not feeling well and started to sneeze continuously with some food (pancakes) in her mouth. During a concurrent observation and interview with CNA L on 5/19/2025 at 9:05 a.m., inside Resident 278's room, CNA L confirmed above observation and found Resident 278's call light button on the floor at the left side of the bed. CNA L stated the call light button should always be within 055316 Page 6 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0558 resident's reach for use. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Call Lights: Accessibility Policy, dated 3/1/2023, indicated, Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Residents Affected - Few 055316 Page 7 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

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 interviews, and record review, the facility failed to ensure one of three residents (Resident 36) had been informed about having an advance directive (AD, legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about advance directive and the Physician Orders for Life -Sustaining Treatment (POLST, a legal document stating the kinds of medical treatment patients want toward the end of their lives) was not completed and readily available in the event of a medical emergency. This failure had the potential to result in inability to make medical decisions and could lead to the delivery of unnecessary or inappropriate medical services. Findings: Review of Resident 36's clinical record titled, admission Record, dated 5/21/2025, indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS, a nervous system disease that affects nerve cells in the brain and spinal cord which cause loss of muscle control), asthma (inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath), needs assistance with personal care and dysphagia (difficulty in swallowing). During Resident 36's chart and electronic record review on 5/21/2025 at 1:03 p.m., Resident 36 did not have an AD and a POLST on file. During a concurrent interview with nurse case manager R (NCM R) and record review on 5/21/2025 at 1:05 p.m., NCM R reviewed Resident 36's chart and electronic record and confirmed Resident 36 was admitted on [DATE]. NCM R further confirmed there was no AD or POLST found in Resident 36's records. NCM R stated if the POLST was not in the chart, it might be in the doctor's lounge pending for doctor's signature. During a concurrent interview with medical records director (MRD) and record review on 5/21/2025 at 2:35 p.m., MRD reviewed Resident 36's electronic records and confirmed she just uploaded Resident 36's POLST. MRD further confirmed the POLST was completed and signed by both physician and Resident 36 on 5/21/2025. During a concurrent interview with administrator in training (AIT) and Resident 36's POLST review on 5/21/2025 at 2:39 p.m., AIT made a copy of the POLST and confirmed it was just completed on 5/21/2025. AIT stated admission nurses were responsible for completing the POLST upon admission or when the family visited, if resident is not the responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action). During an interview with director of nursing (DON) on 5/23/2025 at 12:10 p.m., DON stated nurses should initiate the completion of resident's POLST upon admission and should be followed up by her, assistant director of nursing (ADON) and the other supervisors. DON further stated the POLST should be completed within 24-48 hours upon admission for them to know what they needed to do when something would happen to the resident. During a review of the facility's policy and procedure titled, POLST Policy, dated 6/1/2023, 055316 Page 8 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0578 Level of Harm - Minimal harm or potential for actual harm indicated, A Do Not Resuscitate (DNR) order form must be completed and signed by the Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in front of the resident's medical record or other accessible area. a. Physician Orders for Scope of Treatment (POST). Should the resident be transferred to the hospital, the form must be provided to the personnel transporting the resident to the hospital. Residents Affected - Few 055316 Page 9 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on interview and record review, the facility failed to ensure one of five residents (Resident 37) reviewed for unnecessary medications received a gradual dose reduction (GDR, a stepwise tapering of a dose to determine if symptoms can be managed by a lower dose or if the medication can be discontinued) for Seroquel (a medication used to treat various psychiatric conditions) and a risk-benefit assessment for Seroquel and metoclopramide (generic for Reglan, a medication used for acid reflux) despite having a documented diagnosed abnormal movement disorder and drug-induced akathisia (a condition caused by medications resulting in an inability to stay still and an involuntary urge to move), conditions that could be caused or worsened by Seroquel and/or metoclopramide use. This failure had the potential for Resident 37 to have worsening abnormal movements and receive unnecessary medications. Findings: A review of Resident 37's clinical record indicated she was admitted to the facility with diagnoses including abnormal movement disorder and drug-induced akathisia. A review of Resident 37's clinical record, indicated Resident 37 had an active order for Seroquel 100 mg, 1 tablet by mouth every 12 hours for bipolar disorder (a condition characterized by extreme changes in mood) with psychotic features manifested by constant pacing and exposing herself, dated 8/2/24. Resident 37's clinical record indicated that she had been on this dose of Seroquel since April 2023 (2 years ago). Resident 37's clinical record also indicated an active order for metoclopramide 5 mg (milligram, a unit of measure) per 5 mL (milliliter, a unit of measure) - give 5 mL by mouth every eight hours as needed for GERD (gastroesophageal reflux disease, a condition in which stomach acid goes up the esophagus, causing symptoms such as heartburn), dated 8/2/24. A review of Resident 37's clinical record indicated there had been no GDR attempts since April 2023; and there was no risk-benefit assessment conducted for the use of Seroquel and/or metoclopramide. A review of the Prescribing Information (PI, a detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Seroquel, dated 2009, indicated it has the ability to cause abnormal movement disorders and akathisia (https://www.accessdata.fda.gov/drugsatfda_docs; accessed 5/29/25). Likewise, a review of the PI for metoclopramide, dated 8/2017, indicated drug-induced akathisia and other extrapyramidal symptoms (group of motor side effects) have been known in patients taking metoclopramide (https://www.accessdata.fda.gov/drugsatfda_docs; accessed 5/29/25). During an interview on 5/22/25 at 11:45 a.m. with the Director of Nursing (DON), Assistant Director of Nursing (ADON) A and ADON B, ADON A stated she, the DON, and ADON B were unable to find a GDR for Seroquel in Resident 37's chart. She continued, We reached out to the pharmacist to review [Resident 37's] chart. It was left off the review. ADON A stated she was unable to find a risk-benefit analysis of metoclopramide and Seroquel. ADON A also stated she did an AIMS (abnormal involuntary movement scale) assessment yesterday, on 5/21/25, and the AIMS score was 6 (scored from 0-28), which indicated Resident 37 had positive signs and symptoms of abnormal involuntary movements. ADON A stated Resident 37's abnormal movements are related to facial movements and rocking when walking. 055316 Page 10 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure (P&P) titled, Gradual Dose Reduction of Psychotropic Drugs, implemented 3/1/23, indicated, 1. Reducing the need for and maximizing the effectiveness of medications shall be considered for all residents who use psychotropic [medication that affects brain activities associated with mental processes and behavior] drugs. Therefore, dose reductions .are part of medication management .2. Within the first year .a resident is .on a psychotropic medication .the facility will attempt a GDR in two separate quarters .unless clinically contraindicated. 3. After the first year, a GDR will be attempted annually, unless clinically contraindicated . A review of the facility's P&P titled, Psychotropic Medication Use, dated 2001, indicated, Residents on psychotropic medication receive gradual dose reductions .unless clinically contraindicated, to determine whether the continued use of the medication is benefitting the resident, to find an optimal dose, or in an effort to discontinue the medication . 055316 Page 11 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

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 observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment for Resident 29 who was on oxygen (O2, a colorless, odorless gas) therapy and missed to complete the MDS significant change in status assessment (SCSA - a comprehensive assessment completed in nursing homes when a resident experiences a significant decline or improvement in their condition, according to federal regulations) for Resident 51 who had declined in the four areas of functional mobilities (the ability to move around and perform activities of daily living [ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves] effectively and safely in one's environment). Residents Affected - Few These failures resulted in inaccurate MDS assessments and had the potential to affect the residents' care. Findings: 1. Review of Resident 29's clinical record titled, admission Record, dated 5/21/2025, indicated Resident 29 was re- admitted to the facility on [DATE] with diagnoses including acute (severe, or intense, often referring to something with a sudden onset and relatively short duration) and chronic (lasting for a long time or recurring frequently) respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low), type 2 diabetes mellitus (DM, occurs when the body is unable to regulate glucose [sugar] in the blood), end stage renal disease (ESRD, irreversible kidney failure) and shortness of breath. During an observation on 5/19/2025 at 11:10 a.m., inside Resident 29's room, Resident 29 was seated at the edge of his bed, played his ukulele (a musical instrument) and with O2 therapy at 2 liters per minute (LPM - a unit of measurement that indicates the volume of a fluid or gas, typically measured in liters, that flows in one minute) via (thru) nasal cannula (NC, a tubing used to deliver oxygen from the machine through the nostrils). Review of Resident 29's Order Summary Report, dated 5/21/2025, it revealed an order on 11/22/2024 for use of O2 at 2 LPM via NC continuously. Review of Resident 29's April 2025 medication administration record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), it revealed Resident 29 used O2 daily from April 1 to 30. Review of Resident 29's MDS Quarterly review assessment dated [DATE], indicated Resident 29's oxygen therapy while a resident at the facility was not coded or it did not reflect Resident 29's used of oxygen. During a concurrent interview with minimum data set nurse S (MDSN S) and record review on 5/22/2025 at 11:07 a.m., MDSN S reviewed Resident 29's order summary report, April 2025 MAR, and MDS Quarterly review assessment dated [DATE]. MDSN S confirmed Resident 29 had a continuous O2 therapy order and it did not reflect in Resident 29's MDS Quarterly review assessment. MDSN S stated the look back period to code the oxygen in MDS was 7 days and Resident 29 had used the O2 from April 1-3. MDSN S further stated Resident 29's O2 used should have been coded or reflected in the MDS Quarterly review 055316 Page 12 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0641 assessment. Level of Harm - Minimal harm or potential for actual harm Review of the Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI - a guide for facility staff to existing coding and transmission) 3.0 User's Manual Version 1.19.1, dated 10/2024, indicated, SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS: Coding Instructions for Column b. While a Resident. Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. If no treatments, procedures or programs were received by, performed on, or participated in by the resident within the 14 days or since admission/entry or reentry, check Z, None of the above .O0110C1, Oxygen therapy Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia this item .This item may be coded if resident places or removes their own oxygen mask, cannula. Residents Affected - Few 2. Review of Resident 51's clinical record titled, admission Record, dated 5/22/2025, indicated Resident 51 was admitted to the facility with diagnoses including gout (a type of inflammatory arthritis caused by a buildup of uric acid in the body), type 2 diabetes mellitus and need assistance with personal care. Review of Resident 51's MDS 5-day scheduled assessment and admission assessment dated [DATE], indicated Resident 51 had: a. an impairment on both upper extremities (shoulder, elbow, wrist, hand); b. an impairment on one side in the lower extremity (hip, knee, ankle, foot); c. required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating and oral hygiene; d. required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self; e. required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) with upper body dressing; and the rest of his functional mobilities were dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident 51's MDS Quarterly review assessment dated [DATE], indicated Resident 51 had 055316 Page 13 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0641 some changes: Level of Harm - Minimal harm or potential for actual harm a. no impairment on both upper extremities; Residents Affected - Few b. no impairment on both lower extremities; c. required partial/moderate assistance with eating; d. became dependent with oral hygiene, shower/bathe self, and upper body dressing; and remained dependent with other functional mobilities. Review of Resident 51's MDS Quarterly review assessment dated [DATE] and the recent MDS Annual assessment dated [DATE], indicated same coding with the MDS Quarterly review assessment dated [DATE]. During a concurrent interview with MDSN S and review of Resident 51's MDS from 3/29/2024 to 3/26/2025, MDSN S confirmed there were some changes in Resident 51's functional mobilities from the admission assessment dated [DATE] and Quarterly review assessment dated [DATE]. MDSN S stated a significant change in status assessment should be completed when there were 2 and more changes in resident's functional mobilities, behavior, cognition or other areas in MDS. MDSN S confirmed Resident 51's MDS Quarterly assessment completed on 6/28/2024 should have been coded as a significant change in status assessment (SCSA) and he stated they missed it. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1, dated 10/2024, indicated, The SCSA is a comprehensive assessment for a resident that must be completed when the IDT [ interdisciplinary team, a group of health care professionals from diverse fields who work toward a common goal for residents] has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of made that the resident had a significant change. A significant change is a major decline or improvement in resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. 055316 Page 14 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. A review of Resident 67's physician's order, dated 11/13/24, indicated monitoring episodes of anxiety (a common reaction to stress that involves occasional worry about circumstantial events) manifested by restlessness and agitation. A review of Resident 67's physician's order, dated 12/12/24, indicated monitoring episodes of depression manifested by lack of interest. A review of Resident 67's Interdisciplinary Team (a group of individuals with different expertise and backgrounds who work together to achieve a common goal) on Psychotherapeutic Review, dated 5/13/2025, indicated Resident 67's behaviors exhibited two episodes of restlessness and agitation and one episode of lack of interest. During a concurrent interview and record review with minimum data set nurse (MDSN) S on 5/23/25 at 08:29 a.m., MDSN S reviewed Resident 67's care plan and confirmed no care plan addressing Resident 67's restlessness, agitation, and lack of interest behavior. MDSN S further indicated that the behavior manifested by the resident should be reflected in the care plan to effectively address these concerns. During a concurrent interview and record review with the director of nursing (DON), on 05/23/25 at 10:17 a.m., the DON reviewed Resident 67's care plan and confirmed that there was no care plan addressing Resident 67's behavior. The DON further stated that specific resident behaviors should be included in the focus section of the care plan to ensure patient-centered care. A review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 3/1/2023, the P&P indicated, .The care planning process will include an assessment of the resident's strengths and needs . 8. A review of Resident 82's admission record, indicated Resident 82 was admitted to facility on 4/30/25 with diagnoses including unspecified protein-calorie malnutrition (a condition caused by inadequate intake or absorption of protein and energy); chronic kidney disease, stage 3 unspecified (a disease characterized by progressive damage and loss of function in the kidneys) A review of Resident 82's physician order, dated 5/1/25, indicated monitoring of weight weekly x 4 then monthly for new admit. A review of Resident 82's treatment administration record (TAR) and medication administration record (MAR) revealed no weight indicated since admission. A review of Resident 82's care plan, date initiated 5/1/25, indicated resident is at risk for altered nutrition related to refused admission weight. During an interview with the registered dietitian (RD), on 05/22/25 at 4:52 p.m., the RD indicated that Resident 82 declined to undergo weighing upon admission. The RD further stated that she utilized the most recent recorded weight of 70.4 kilogram (155 pounds), obtained from the hospital on 4/27/25, as the baseline measurement. 055316 Page 15 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review with minimum data set nurse (MDSN) S on 5/23/25 at 08:32 a.m., MDSN S reviewed Resident 82's care plan and confirmed that there was no care plan in place addressing Resident 82's noncompliance with the weight order. During concurrent interview and record review with the director of nursing (DON), on 05/22/25 at 9:11 a.m., the DON reviewed Resident 82's care plan and confirmed that there was no care plan addressing Resident 82's weight refusal. The DON stated it's important to weigh Resident 82 according to his diagnosis and the refusal should be included in the care plan. A review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 3/1/2023, the P&P indicated, .The comprehensive care plan will include measurable objectives and time frames to meet the resident's need as identified on the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress During a tour of facility on 05/19/2025 at 10:40 a.m., Resident 7 was approached by surveyor. Resident 7 said I am hard of hearing while pointing to her right ear for surveyor to come closer and talk in her right ear. When asked if she uses a hearing aid, she shook her head in the negative. Surveyor did not see hearing aid anywhere in the resident's room. During an interview on 05/23/2025 at 08:47 a.m., with Assistant Director of Nursing B (ADON B) in Resident 7's room ADON B confirmed Resident 7 was hard of hearing but she doesn't really know much about the details of her care plan. She acknowledged Resident 7's frustration alongside resident's complaint of being left bed bound for about a month, not being put to sit on her wheelchair for one hour a day by the CNAs like they used to do. During an interview on 5/23/25 at 9:22 a.m., with Certified Nursing Assistant U (CNA U), she stated Resident 7 has hearing problem on right side of the ear. CNA U stated Resident 7 use headset to communicate, speak closer, and use writing to communicate. During a review of Resident 7's Minimum Data Set (MDS, an assessment tool) section B (Hearing, Speech, and Vision Changes), dated April 23, 2025, indicated Resident 7 has impaired hearing. During a review of Resident 7's comprehensive care plan indicated there was no care plan developed for hearing impaired. During a concurrent interview and record review on 5/23/25 at 9:47 a.m., with Minimum Data Set Nurse S (MDSN S), MDSN S reviewed Resident 7's MDS section B (Hearing, Speech and Vision Changes) dated April 23,2025. MDSN S confirmed Resident 7 coded in MDS section B as hearing impaired. MDSN S then reviewed Resident 7's comprehensive care plan. MDSN S stated there were no care plan develop for hearing impaired. MDSN S further stated there should have care plan develop Resident 7. During a review of the facility's policy and procedure titled, Comprehensive Care Plans, dated 3/1/2023, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 4. A review of Resident 37's clinical record indicated that she often refuses her morning and afternoon medications. For the month of March 2025, Resident 37 refused her 9 a.m. medications that were 055316 Page 16 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0656 Level of Harm - Minimal harm or potential for actual harm active the entire month 26 times or more. Resident 37 refused her 1 p.m. medications that were active for the entire month 27 times or more. For the month of April 2025, Resident 37 refused her 9 a.m. medications 25 times or more and refused her 1 p.m. medications 27 times. From May 1-May 21, 2025, Resident 37 refused her 9 a.m. medications 19 times or more and refused her 1 p.m. medications 19 times. Residents Affected - Some Resident 37's 9 a.m. medications included, but not limited to the following: - amiodarone (a medication for various heart conditions, include an irregularly rapid heart rate) - cholecalciferol (vitamin D, used to supplement low vitamin D levels) - ferrous sulfate (iron, used to supplement low iron levels) - senna (a laxative) - divalproex sodium (a medication used to treat various neurological and psychiatric conditions) - oyster shell (calcium, used to supplement low calcium) - Seroquel (a medication used to treat various psychiatric conditions) - midodrine (a medication used to treat a drop in blood pressure due to a change in body positioning) - gabapentin (a medication used to treat various neurological conditions) Resident 37's 1 p.m. medications included, but not limited to the following: - divalproex sodium - midodrine During an interview with Resident 37 on 5/20/25 at 4:15 p.m., Resident 37 stated she does not take senna (a laxative) or Seroquel (a medication used to treat various psychiatric conditions). Resident 37 stated, I'm not comfortable with Seroquel because she thought it was for anxiety, but later learned it was for aggressive behavior. Resident 37 stated, I get angry, but I don't lash out. During an interview with Registered Nurse (RN) I on 5/21/25 at 2:27 p.m., RN I stated Resident 37 refuses her morning and afternoon medications most of the time. RN I stated, we offer [the medications] three times within the time [period]. After that, we inform the doctor of medication refusals. RN I stated Resident 37 will refuse medications either because she does not want to take it or will tell nursing staff it is not time to take it and she'll take it later in the afternoon instead. During an interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON) A and ADON B on 5/21/25 at 2:48 p.m., the DON stated, The doctor is aware of the refusal. When asked if there was an interdisciplinary team (IDT, team composed of members of multiple healthcare fields to assess how to provide care for residents and meet their individual needs) meeting about Resident 37's repeated medication refusals, DON stated, IDT, I can't find any. When asked if there was a care plan 055316 Page 17 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0656 Level of Harm - Minimal harm or potential for actual harm (a document that details a resident's individual needs, treatments and goals) for the medication refusals, ADON A stated, Not that I can see at this point. During an interview with the DON, ADON A and ADON B on 5/22/25 at 11:47 a.m., ADON A stated, We weren't able to locate [medication refusals] on the care plan. Residents Affected - Some A review of the facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, revised February 2021, indicated, .5. If a resident .refuses .treatment, an appropriate member of the interdisciplinary team (IDT) will meet with the resident .to: a. determine why .she is .refusing .treatment; b. try to address .her concerns and discuss alternative options; and c. discuss the potential outcomes or consequences .of the decision .6 .b. The IDT will assess the resident's needs and offer the resident .alternative treatments, if available and pertinent, while continuing to provide other services outlined in the care plan. 5. A review of Resident 10's clinical record indicated that she had a diagnosis of OCD. Resident 10 had two active orders for OCD: - Fluvoxamine ER (extended release) 150 milligram (mg, unit of measurement) capsule: give one capsule by mouth at bedtime for obsessive compulsive disorder manifested by excessive health concerns related to care, dated 3/7/24. - Fluvoxamine 100 mg tablet: give one tablet by mouth at bedtime for obsessive compulsive disorder, dated 1/20/25. A review of Resident 10's clinical record indicated she did not have a care plan for OCD. During an interview with the DON, ADON A and ADON B on 5/22/25 at 12:14 p.m., ADON A stated fluvoxamine was being used to treat Resident 10's OCD. ADON A stated she could not find a care plan for OCD in Resident 10's clinical record. ADON A acknowledged there should be one. A review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, implemented, 3/1/23, indicated, .1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal .preferences in developing goals of care .2 .Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care .3. The comprehensive care plan will describe .f. Resident specific interventions that reflect the resident's needs and preferences .7 .The facility will attempt alternative methods for refusal of treatment .and document such attempts in the clinical record . Based on observation, interview, and record review, the facility failed to develop a person-centered care plan (identifies residents' concerns and outlines the care and services needed to meet their needs) for 8 of 26 sampled residents (Residents 21, 1, 29, 10, 37, 7, 67 and 82) when: 1. No care plan for the use of side rails for Resident 21; 2. No care plan developed for Resident 1's diagnosis of post traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and care plans for use of aripiprazole (brand name: Abilify , an atypical antipsychotic medication used to treat a variety of mental health conditions) and bupropion (brand name: Wellbutrin, an 055316 Page 18 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some antidepressant medication used to treat depression) were not person-centered without mentioned about the behavior monitoring and the non-pharmacological interventions; 3. Resident 29's care plans for use of mirtazapine (brand name: Remeron, an antidepressant medication used to treat depression) and doxepin (an antidepressant medication, used to treat depression, help manage anxiety, and treat insomnia [a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early]) were not person-centered without mentioned about specific behavior monitoring and the non-pharmacological interventions. 4. The facility failed to develop and implement a comprehensive care plan for Resident 37 who repeatedly refused her medications; 5. Facility did not develop a comprehensive care plan for Resident 10's obsessive compulsive disorder (OCD, a condition characterized by persistent, unwanted thoughts and repetitive behaviors associated with those thoughts) 6. No care plan for hearing impairment for Resident 7; 7. Resident 67's care plan did not reflect the restlessness, agitation, and lack of interest behavior; and 8. Resident 82's care plan did not reflect the resident's noncompliance regarding weight orders and monitoring. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their health, safety and well-being. Findings: 1. Review of Resident 21's clinical record, indicated, Resident 21 was admitted on [DATE] with diagnoses including metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body ) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body ) following cerebral infarction (stroke ) affecting left non-dominant side, pneumonia (infection in the lungs) . Review of Resident 21's clinical record indicated he had a physician's order, dated 4/19/25, for bilateral 1/4 upper side rail for functional mobility and to aid in ADL (Activities of Daily Living, basic self-care tasks) care/repositioning. There was no care plan developed to address the application of side rail. During an observation on 5/19/25 at 8:16 a.m., Resident 21 was in bed with two upper side rails raised. During a concurrent interview and record review on 5/23/25 at 10:12 a.m., with the Director of Nursing (DON), the DON acknowledged there was no care plan developed for side rail. During a review of the facility's policy and procedure (P&P), titled Proper Use of Bed Rails, undated, indicated The facility will continue to provide necessary treatment and care to the resident who 055316 Page 19 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan . 2a. Review of Resident 1's clinical record titled, admission Record, dated 5/23/2025, indicated Resident 1 was admitted to the facility with diagnoses including primary osteoarthritis (OA, a degenerative joint disease, in which the tissues in the joint break down over time) of right knee, anxiety disorder (a mental illness that causes constant fear), PTSD, schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an observation on 5/19/2025 at 10:39 a.m., inside Resident 1's room, Resident 1 was asleep, and intermittently talking while asleep. During another observation on 5/23/2025 at 8:43 a.m., inside Resident 1's room, Resident 1 was eating breakfast in bed and stated she enjoyed playing BINGO. Review of Resident 1's Quarterly review minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1 had PTSD. During a concurrent interview with social services director (SSD) and review of Resident 1's list of care plans on 5/23/2025 at 10:37 a.m., SSD confirmed she couldn't find any care plan related to Resident 1's diagnosis of PTSD. SSD stated a care plan related to Resident 1's PTSD should have been developed for staff to avoid any triggers and to implement a plan of care. During a review of the facility's policy and procedure titled, Comprehensive Care Plans, dated 3/1/2023, indicated, The comprehensive care plans will describe, at a minimum, the following: .Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. 2b. Review of Resident 1's order summary report dated 5/23/2025, indicated the following orders: to monitor episodes of schizophrenia manifested by (m/b) hearing voices that are not real for use of aripiprazole; to monitor episodes of depression m/b episode of crying and anxiety m/b restlessness for use of bupropion; and to attempt non-pharmacological interventions prior to psychotherapeutic agent like provide quiet and dark environment, assess for pain, keep resident comfortable, provide back rub as needed, offer warm beverages, engage resident in preferred activities, and minimize environmental stressors. During a concurrent interview with DON and review of Resident 1's care plans related to use of aripiprazole and bupropion on 5/23/2025 at 12:20 p.m., DON confirmed the mentioned care plans were not person-centered without Resident 1's targeted behavior to be monitored and the non-pharmacological interventions to be implemented. 3. Review of Resident 29's clinical record titled, admission Record, dated 5/21/2025, indicated Resident 29 was re- admitted to the facility on [DATE] with diagnoses including acute (severe, or intense, often referring to something with a sudden onset and relatively short duration) and chronic (lasting for a long time or recurring frequently) respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body 055316 Page 20 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some organs are low), type 2 diabetes mellitus (DM, occurs when the body is unable to regulate glucose [sugar] in the blood), end stage renal disease (ESRD, irreversible kidney failure), depression and shortness of breath. Review of Resident 29's order summary report dated 5/21/2025, indicated orders: to monitor episodes of depression m/b insomnia for use of doxepin; to monitor hours of sleep every evening and night shifts; to monitor episodes of poor oral intake for use of mirtazapine; and the use of non-pharmacological approach for use of psychotherapeutic agent like provide quiet and dark environment, assess the presence of pain, keep resident comfortable, provide back rub as needed, and offer warm beverages. During an observation on 5/19/2025 at 11:10 a.m., inside Resident 29's room, Resident 29 was seated at the edge of his bed, played his ukulele (a musical instrument) with O2 therapy at 2 liters per minute (LPM a unit of measurement that indicates the volume of a fluid or gas, typically measured in liters, that flows in one minute) via (thru) nasal cannula (NC, a tubing used to deliver oxygen from the machine through the nostrils). During a concurrent interview with DON and review of Resident 29's care plans for use of mirtazapine and doxepin on 5/23/2025 at 11:55 a.m., DON confirmed above care plans were not person-centered for not having the specific behavior monitoring and use of non-pharmacological interventions. During a review of the facility's policy and procedure titled, Comprehensive Care Plans, dated 3/1/2023, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 055316 Page 21 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 89's clinical record, indicated, Resident 89 was admitted to the facility on [DATE] with diagnoses including encephalopathy (condition affecting how the brain works), acute and chronic respiratory failure with hypoxia (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), anemia (a condition where the body does not have enough red blood cells to carry enough oxygen to the body), thrombocytopenia (having a low number of platelets [tiny blood cells to stop the bleeding] in the blood). Review of the physician's order dated 5/2/24 and 9/5/24, indicated Resident 89 was on enteral feeding (liquid nutrients given through a tube inserted in the stomach) and enteral bolus feeding (liquid nutrients given over a short period multiple times a day), and was discontinued on 10/4/24. A care plan for tube feeding was initiated on 5/2/24 and was not revised (to change) and resolved (completed) after the order was discontinued. Review of the physician's order dated 1/30/25 and 2/19/25, indicated Resident 89 was on Fluconazole (used to treat fungal infection) tablet 150 milligram (mg, unit of measurement) for possible infection for one day, and Macrobid (used to treat urinary tract infection, UTI) capsule 100 mg two times a day for UTI for 7 days. A care plan for antifungal therapy (Fluconazole) was initiated on 1/30/25, and a care plan for antibiotic therapy was initiated on 2/19/25. The care plan was not resolved after completion of the antibiotics. During a concurrent interview and record review on 5/23/25 at 8:28 a.m., with the Minimum Data Set Nurse (MDSN) S, the MDSN S confirmed the care plan for the antibiotics was not resolved and should have been resolved as soon as the medication were completed or discontinued. The MDSN S also confirmed that Resident 21 was no longer on tube feeding and the care plan was still active. MDSN S further stated that the care plan should have been resolved because the tube feeding was discontinued in 2/2025. During a concurrent interview and record review on 5/23/25 at 9:49 a.m., with the Director of Nursing (DON), the DON confirmed the tube feeding was discontinued on 2/5/25 and the care plan was still active. The DON stated the care plan should have been resolved when it was discontinued. The DON also confirmed the care plan for the antibiotics was still active and should have been resolved when the medication was completed. 4. Review of Resident 21's clinical record, indicated, Resident 21 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), pneumonia (infection of the lungs), bronchiectasis (condition where the airways are damaged, widened, and thickened making it harder to clear mucus), pseudomonas (a type of bacteria that can cause infections) as the cause of diseases. Review of the physician's order indicated Resident 21 was on Azithromycin (used to treat bacterial infections) tablet from 6/5/23 to 10/13/24, 10/28/24 to 11/6/24, 11/14/24 to 12/12/24, and 12/13/24 to 4/19/25; Meropenem (used to treat bacterial infections) intravenous (administering medications into a vein) solution from 11/8/24 to 11/14/24; and Vancomycin (used to treat infections caused by bacteria) intravenous solution from 10/13/24 to 10/26/24, and 11/8/24 to 11/14/24. The care plan for the use of antibiotics was initiated but not revised and resolved. 055316 Page 22 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 5/21/25 at 2:11 p.m., with the DON, the DON verified that the care plan for the antibiotic was not updated, revised or resolved. The DON stated care plans must be reviewed quarterly and revised. During a concurrent interview and record review on 5/23/25 at 8:28 a.m., with the MDSN S, the MDSN S confirmed the care plan were not resolved and should have been resolved as soon as the medications were completed or discontinued. During an interview on 5/23/25 at 10:38 a.m., with Registered Nurse (RN) I, RN I stated care plans should be reviewed and resolved when the medications have been discontinued or completed. Based on observation, interview, and record review, the facility failed to ensure care plans were reviewed and updated by the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward the common goal for the resident) for 4 of 26 sampled residents (Residents 1, 54, 89, and 21) when: 1. Resident 1's care plans for use of aripiprazole (brand name: Abilify , an atypical antipsychotic medication used to treat a variety of mental health conditions) and bupropion (brand name: Wellbutrin, an antidepressant medication used to treat depression) were not updated or revised with specific manifestations of Resident 1's behavior; 2. Resident 54's care plan for behavior problem was not updated or revised when Resident 54's use of olanzapine (brand name: Zyprexa, an antipsychotic medication that can treat several mental health conditions like schizophrenia [a mental illness that can affect thoughts, mood, and behavior] and bipolar disorder [mood swings that range from the lows of depression to elevated periods of emotional highs] ) was discontinued, and there was a refusal to be seen by a psychiatrist; 3. Resident 89's care plan for enteral tube( a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) feeding, bolus tube feeding (a method when liquid nutrition [formula] is delivered through a feeding tube using a syringe, typically in a few larger doses throughout the day) and antibiotic (medications used to treat infections caused by bacteria and other microorganisms) use were not resolved; and 4.Resident 21's care plan for antibiotic use were not revised or resolved. This deficient practice had the potential to compromise resident's health, safety and psychosocial well-being. Findings: 1. Review of Resident 1's clinical record titled, admission Record, dated 5/23/2025, indicated Resident 1 was admitted to the facility with diagnoses including primary osteoarthritis (OA, a degenerative joint disease, in which the tissues in the joint break down over time) of right knee, anxiety disorder (a mental illness that causes constant fear), PTSD, schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 1's Quarterly review minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated a brief interview for mental status (BIMS-an 055316 Page 23 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During an observation on 5/19/2025 at 10:39 a.m., inside Resident 1's room, Resident 1 was asleep, and intermittently talking while asleep. During another observation on 5/23/2025 at 8:43 a.m., inside Resident 1's room, Resident 1 was eating breakfast in bed and stated she enjoyed playing BINGO. Review of Resident 1's order summary report dated 5/23/2025, indicated the following orders: to monitor episodes of schizophrenia manifested by (m/b) hearing voices that are not real for use of aripiprazole, order dated 4/2/2025; to monitor episodes of depression m/b episode of crying, order dated 4/2/2025 and anxiety m/b restlessness for use of bupropion, order dated 2/20/2025; and to attempt non-pharmacological interventions prior to psychotherapeutic agent like provide quiet and dark environment, assess for pain, keep resident comfortable, provide back rub as needed, offer warm beverages, engage resident in preferred activities, and minimize environmental stressors, order dated 2/20/2025. Review of Resident 1's care plan related to use of Abilify date initiated 1/31/2025, indicated it was not updated when the order on 4/2/2025 to monitor episodes of schizophrenia m/b hearing voices and the order on 2/20/2025 to attempt non-pharmacological interventions were not added to the care plan. Review of Resident 1's care plan related to use of bupropion date initiated 4/20/2023, indicated it was not updated when the specific behavior monitoring of episode of crying for depression was ordered on 4/2/2025 and restlessness for anxiety ordered on 2/20/2025. Further review indicated in one of the interventions, Monitor Dosage - Use of two or more antidepressants simultaneously may increase risk of side effects. Date initiated: 04/20/2023 and Resident 1 was only taking one antidepressant which was bupropion. During a concurrent interview with director of nursing (DON) and review of Resident 1's care plans related to use of aripiprazole and bupropion on 5/23/2025 at 12;20 p.m., DON confirmed the mentioned care plans were not updated or revised. DON stated care plans should be updated or revised whenever there was a change in plan of care. DON confirmed Resident 1 was only taking one antidepressant and the intervention about the use of two or more antidepressants should have been discontinued. 2. Review of Resident 54's clinical record titled, admission Record, dated 5/22/2025, indicated Resident 54 was admitted to the facility with diagnoses including other psychotic disorder (a severe mental disorder that cause abnormal thinking and perceptions) bipolar disorder, depression, and Alzheimer's disease (a progressive disease that destroys memory and mental functions). Review of Resident 54's quarterly MDS assessment dated [DATE], indicated a BIMS score of 4 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further indicated Resident 54 had disorganized thinking (also known as thought disorder, refers to a disturbance in the way an individual processes and organizes their thoughts, leading to difficulties in expressing ideas coherently and logically). During a concurrent observation and interview with Resident 54 on 5/19/2025 at 10:55 a.m., inside 055316 Page 24 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 54's room, Resident 54 was in bed, lying on her left side, and showed her left upper arm with purplish, yellow discoloration. Resident 54 stated someone punched her and she did not tell anybody about it. Resident 54 was not able to state who punched her. During a follow up interview with Resident 54 on 5/20/2025 at 9:32 a.m., Resident 54 stated she stayed awake at night when certain people are in the property. Resident 54 stated she was okay now, and managers are taking care of it. Review of Resident 54's order summary report dated 5/22/2025, it indicated an order dated 1/16/2023, May have psychology consult and treatment PRN [as needed] Further review indicated Resident 54 had no order for any psychotropic medications. Review of Resident 54's care plan on behavior problem related to diagnoses of bipolar and psychotic disorder, date initiated 12/29/2023, indicated, Resident is verbally aggressive and at time refuses ADL [activities of daily living - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves)] care. Further review indicated the interventions were dated 12/29/2023 and 3/5/2024. One of the interventions dated 3/5/2024, indicated, Administer medications as ordered. Monitor/document for side effects and effectiveness. During a concurrent interview with services director (SSD) and review of Resident 54's list of care plans on 5/23/2025 at 8:56 a.m., SSD confirmed Resident's care plan related to behavior problem should have been reviewed and revised for any changes in plan of care. SSD stated she was not sure about Resident 54's psychiatry consultation and she would get back to the nurse surveyor. During a concurrent interview with DON and review of Resident 54's care plan related to behavior problem, DON confirmed the care plan was not updated when the use of an antipsychotic was discontinued. During a concurrent interview with SSD and review of Resident 54's physician progress on 5/23/2025 at 4:05 p.m., SSD confirmed the progress note was dated 5/23/2025, the use of olanzapine had been discontinued in the past and Resident 54 had been refusing psychiatry visits. During a review of the facility's policy and procedure dated 3/1/2023, indicated, The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 055316 Page 25 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 provide care and services for dining/eating with meals when the facility did not provide meal assistance to one of three residents (Resident 36). This failure had the potential to affect the psychosocial well-being of the resident and a decline in the activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). Residents Affected - Few Findings: Review of Resident 36's clinical record titled, admission Record, dated 5/21/2025, indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS, a nervous system disease that affects nerve cells in the brain and spinal cord which cause loss of muscle control), asthma (inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath), needs assistance with personal care and dysphagia (difficulty in swallowing). During a dining observation on 5/19/2025 at 9:05 a.m., inside Resident 36's room, Resident 36 was seated at the edge of her bed eating breakfast, and there were some food spilled on Resident 36's chin down to the protective clothing. No one was present to provide meal assistance. During lunch observation on 5/19/2025 at 1:11 p.m., inside Resident 36's room, Resident 36 was eating lunch by herself with food spilled on her chin down to her clothing. During another lunch observation on 5/20/2025 at 1:25 p.m., inside Resident 36's room, Resident 36 was eating by herself with food spilled on her clothes. Review of Resident 36's order summary report dated 5/21/2025, indicated, REQUIRE ASSISTANCE AT ALL MEALS with meals, order dated 5/14/2025. Review of Resident 36's admission/5-day minimum data set (MDS, a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 36's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 10 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further review indicated, Resident 36 required supervision or touching assistance (helper provides verbal cues and/ or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating. During breakfast observation on 5/21/2025 at 8:50 a.m., inside Resident 36's room, Resident 36 was eating by herself with food spilled to her chin down to her clothes. Resident 36 still had no assistance with meals. During a concurrent interview with registered nurse D (RN D) and review of Resident 36's order summary report on 5/21/2025 at 8:54 a.m., RN D confirmed Resident 36 had an order that she required to have assistance with meals. RN D stated she was not aware that Resident 36 had been eating without assistance on 5/19, breakfast and lunch; 5/20, lunch; and 5/21, breakfast. 055316 Page 26 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with director of nursing (DON) on 5/21/2025 at 10:05 a.m., DON confirmed Resident 36 should have assistance with meals. During a review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), dated 11/1/2022, indicated, Care and services will be provided for the following activities of daily living: .Eating to include meals and snacks .A resident who is unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming . 055316 Page 27 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

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** 2. Review of Resident 47's clinical record titled, admission Record, indicated, Resident 47 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (a condition which affects the way the body processes blood sugar), spondylosis (wear and tear on the joints and disks of the spine), viral hepatitis (infectious disease that causes liver inflammation and damage), difficulty walking and muscle weakness. Residents Affected - Few Review of Resident 47's minimum data set (MDS, federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 47's Brief Interview for Mental Status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 12 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further review revealed, Resident 47 experienced chronic pain in back and BLE (bilateral lower extremitites) for five years. During an interview on 5/19/25 at 9:24 a.m. in the room of Resident 47. Resident 47 stated, I didn't get my pain medicine this morning. Resident 47 also stated, My legs hurt. Review of Resident 47's clinical record titled, Order Summary Report, indicated an order dated 4/29/25 for gabapentin (medication used to treat nerve pain) 300 milligrams (mg, unit of measurement) give 3 capsules by mouth every 12 hours for neuropathy (weakness, numbness and pain from nerve damage) (900 mg dose). Review of Resident 47's Medication Administration Record (MAR, a record of medications given) for May indicated an order for gabapentin 300 mg, give 3 capsules by mouth every 12 hours for neuropathy (900 mg dose) start date 4/29/25. Further review indicated the 9:00 a.m. dose on 5/19/25 was not given by nursing staff. Review of the Progress Notes for Resident 47 dated 5/19/25, signed by Registered Nurse H (RN H) indicated gabapentin capsule 300 mg (900 mg dose) was not given and awaiting delivery from pharmacy. Review of Resident 47's care plan dated 4/11/25 indicated resident 47 was at risk for alteration in comfort and pain and to administer pain medication as ordered. During a concurrent interview and record review on 5/20/25 at 3:30 p.m. with the Assistant Director of Nursing A (ADON A), ADON A confirmed on 5/19/25 Resident 47 did not receive the 9:00 a.m. dose of gabapentin and stated it should have been given. During a review of the facility's P&P titled, Pain Management, dated 6/15/2023, indicated, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. During a review of the facility's P&P, titled Medication Administration, dated 3/1/23, indicated Medications are administered by licensed nurse, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Based on observation, interview and record review, the facility failed to provide care in accordance with standards of practice for two of five sampled residents (Resident 84 and Resident 47) when: 055316 Page 28 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0684 1. Resident 84 was administered oxygen without a physician's order. Level of Harm - Minimal harm or potential for actual harm 2. Resident 47 did not receive pain medication as ordered by the physician. These failures had the potential to negatively affect the resident's health, well-being and safety. Residents Affected - Few Findings: 1. During a review of Resident 84's clinical record, indicated, Resident 84 was admitted to the facility on [DATE] with diagnoses including traumatic subarachnoid hemorrhage (a brain bleed caused by head trauma where blood leaks into the space around the brain) without loss of consciousness (temporarily unaware of themselves and their surroundings), asthma (a chronic respiratory condition that causes breathing difficulties), essential hypertension (high blood pressure that does not have a known cause), low back pain. During an observation on 5/19/25 at 8:03 a.m., Resident 84 was lying in bed, awake, with a nasal cannula (flexible tubing inserted into the nostrils and attached to an oxygen source) delivering oxygen (a colorless, odorless gas) attached from a running oxygen concentrator (a medical device that delivers oxygen). There was no No Smoking Oxygen In Use signage posted on Resident 84's door. During a concurrent observation and interview on 5/19/25 at 8:12 a.m., with the Director of Nursing (DON), the DON confirmed that Resident 84 was receiving oxygen via nasal cannula and no No Smoking Oxygen in Use signage posted on the door. The DON stated there should be a signage on the door. During a review of the facility's policy and procedure (P&P), titled Oxygen Safety, dated 3/1/23, indicated No Smoking signs will be utilized to clearly identify oxygen is in use before connecting the oxygen supply, and will remain in place until oxygen administration has been discontinued. During a review of the facility's P&P, titled Medication Orders, dated 7/1/23, indicated Medications should be administered only upon the order of a person lawfully authorized to prescribe. During a review of the facility's P&P, titled Medication Administration, dated 3/1/23, indicated Medications are administered by licensed nurse, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 055316 Page 29 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 10's clinical record titled, admission Record, indicated Resident 10 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, condition that limits airflow to the lungs), obstructive sleep apnea (disorder that affects breathing while sleeping), diabetes mellitus (a condition which affects the way the body processes blood sugar) and chronic kidney disease. Residents Affected - Some During an observation on 5/19/25 at 8:54 a.m. in the room of Resident 10, Resident 10 was observed in bed receiving oxygen therapy at 2 L/min via nasal cannula. The O2 concentrator's filter located at the back of the equipment had grayish substance build up. During a concurrent observation and interview on 5/19/25 at 12:30 p.m. with the Director of Staff Development (DSD) in the room of Resident 10, the DSD confirmed the filter should not have grayish substance build up. During an interview on 5/20/25 at 11:00 a.m., with the Director of Nursing (DON), the DON stated the oxygen air filter should not have substance build up on it and should be cleaned or replaced regularly by the nursing staff. During a review of the facility's policy and procedure titled, Oxygen Administration, dated 5/1/2023, indicated, Cleaning and care of equipment shall be in accordance with facility policies for such equipment. Based on observation, interview and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for three of four residents (residents on oxygen therapy) (Residents 29, 88, and 10) when: 1. Residents 29's O2 concentrator's (a device which concentrates the oxygen from ambient air) filter had some grayish substance build up and there was no O2 saturation (O2 sat, to measure how much oxygen the blood is carrying. A healthy level is between 95% and 100%)) monitoring for Resident 29's continuous use of O2; 2. Resident 88's O2 concentrator' filter had some grayish substance build up; and 3. Resident 10's O2 concentrator's filter had some grayish substance build up. These deficient practices had the potential for Resident's 29, 88, and 10 to have complications related to improper treatment while receiving O2 therapy. Findings: 1a. Review of Resident 29's clinical record titled, admission Record, dated 5/21/2025, indicated Resident 29 was re- admitted to the facility on [DATE] with diagnoses including acute (severe, or intense, often referring to something with a sudden onset and relatively short duration) and chronic (lasting for a long time or recurring frequently) respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low), type 2 diabetes mellitus (DM, occurs when the body is unable to regulate glucose [sugar] in the blood), end stage renal disease (ESRD, irreversible kidney failure) and shortness of 055316 Page 30 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0695 breath. Level of Harm - Minimal harm or potential for actual harm During an observation on 5/19/2025 at 11:10 a.m., inside Resident 29's room, Resident 29 was seated at the edge of his bed, played his ukulele (a musical instrument) and with O2 therapy at 2 liters per minute (LPM - a unit of measurement that indicates the volume of a fluid or gas, typically measured in liters, that flows in one minute) via (thru) nasal cannula (NC, a tubing used to deliver oxygen from the machine through the nostrils). It was observed the filter located at the back of the O2 concentrator had grayish substance build up. Residents Affected - Some During a concurrent observation and interview with certified nursing assistant W (CNA W) on 5/19/2025 at 11:13 a.m., inside Resident 29's room, Resident 29's O2 concentrator's filter had grayish substance build up. Resident 29 confirmed the observation and stated the filter had a dust build up. During a concurrent observation and interview with licensed vocational nurse F (LVN F) on 5/19/2025 at 11:17 a.m., LVN F confirmed the above observation and stated the oxygen concentrator's filter had a dust build up. LVN F further stated it was the central supply (CS) person's responsibility to check the oxygen concentrator. 1b. Review of Resident 29's Order Summary Report, dated 5/21/2025, it revealed an order on 11/22/2024 for use of O2 at 2 LPM via NC continuously. Further review revealed the following orders: a. May administer O2 at 2L/min via nasal cannula for dx [diagnosis] SOB [shortness of breath], chest pain, oxygen saturation less than 90% and notify MD (medical doctor). as needed. May titrate as needed to maintain O2 sat above 90%. Order dated 10/16/2024. b. May administer O2 at 2L/min via nasal cannula for Oxygen saturation of <90% and notify MD. May titrate as needed to maintain O2 sat above 90%. As needed. Order dated 1/21/2023. c. May titrate up to 4:/min for O2 saturation less than 86% Order dated 11/22/2024. d. There was no order to monitor Resident 29's O2 sat. Review of Resident 29's nurse's progress notes and May 2025 medication administration record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), it indicated nurses had no documentation of Resident 29's O2 saturation monitoring every shift. During a concurrent interview with minimum data set nurse S (MDSN S) and record review on 5/22/2025 at 11:07 a.m., MDSN S reviewed Resident 29's progress notes and the May 2025 MAR and confirmed there were no documentation that nurse's had checked and monitored Resident 29's O2 sat. MDSN S stated nurses should have monitored Resident 29's O2 sat to determine if Resident 29 was getting enough O2. During a concurrent interview with DON and record review on 5/23/2025 at 12:08 p.m., DON reviewed Resident 29's progress notes and the May 2025 MAR and DON confirmed there was no O2 sat monitoring done for Resident 29. During a review of the facility's policy and procedure titled, Oxygen Administration, dated 5/1/2023, indicated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and 055316 Page 31 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some preferences. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy .Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. Monitoring for complications associated with the use of oxygen. 2. Review of Resident 88's clinical record titled, admission Record, dated 5/21/2025, indicated Resident 88 was admitted to the facility with diagnoses including malignant neoplasm (also known as cancer) of endometrium (the inner lining of the uterus, also known as the womb), encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), and respiratory disorders (are conditions that affect the lungs and other parts of the respiratory system, impacting the body's ability to breathe) in diseases classified elsewhere. During a concurrent observation and interview with certified nursing assistant L (CNA L) on 5/19/2025 at 9:51 a.m., inside Resident 88's room, Resident 88 was in bed with oxygen therapy at 1.5 LPM via nasal cannula. The O2 concentrator's filter located at the back of the equipment had some grayish substance build up. CNA L confirmed the observation and stated nurses should be the one to change the O2 filter. During an interview with director of nursing (DON) on 5/21/2025 at 9:56 a.m., DON stated the CS person was responsible for the oxygen concentrator's filter. DON further stated nurses should also check the O2 concentrator's filter in a weekly basis. 055316 Page 32 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 one of three residents (Resident 85 ) who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with professional standards of practice when staff did not follow Resident 85's fluid restriction (limiting liquids). Residents Affected - Few This deficient practice had the potential to result in Resident 85's fluid overload (a condition where there is an excessive amount of fluid in the body). Finding: During an observation in Resident 85's room on 5/21/25 at 8:57 a.m., Resident was observed lying in her bed with gray water pitcher and a glass of water about ¾ full at bedside table. Resident 85 stated inside the pitcher is ice water. Review of Resident 85's clinical record indicated Resident 85 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD - irreversible kidney failure) and dependence on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). During a review of Resident 85's physician's order indicated an order, dated 3/20/25 Fluid Restrictions: 1200 ML/Day (milliliter per day). Dietary: 720ML/Day. -Breakfast: 240 mL -Lunch:240 mL -Dinner: 240 mL Nursing: 480ML/Day -Day Shift: 180ML/Day -Eve (evening) Shift: 180 ML/Day -Noc (night) Shift: 120 ML/Day. During an observation in Resident 85's room on 5/22/25 at 1:16 p.m., Resident was observed sitting in her bed, the gray water pitcher with white straw at her bedside table. Resident 85 stated sometimes they get water from the pitcher and put in the glass. During a concurrent observation and interview on 5/22/25 at 1:22 p.m., with Registered Nurse P (RN P). RN P confirmed Resident 85 has a water pitcher ¾ full at bedside table. RN P stated Resident 85 should not have a water pitcher at bedside table because Resident 85 is on fluid restriction. During a concurrent interview and record review on 5/22/25 at 2:37 p.m., with the Director of Nursing (DON), the DON reviewed Resident 85's physician's order and she confirmed resident on fluid restriction of 1200 per day. The DON further stated resident on dialysis they should not have water pitcher at bedside. During a review of the facility's policy and procedure titled, Hemodialysis, dated 7/1/2023, indicated, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. 055316 Page 33 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an assessment for the use of side rails was performed for one of 26 sampled residents (Resident 97). This failure had the potential to put Resident 97 at risk of entrapment and serious injury. Findings: Review of Resident 97's clinical record, indicated, Resident 97 was admitted on [DATE] with diagnoses including sepsis (body's extreme and potentially dangerous response to infection), urinary tract infection (infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra), primary osteoarthritis (joint pain and stiffness) left shoulder, anxiety disorder (mental health conditions characterized by excessive and persistent worry, fear, and nervousness). During an observation on 5/19/25 at 8:16 a.m., Resident 97 was lying in bed with two upper side rails raised. Review of Resident 97's clinical record indicated he had a physician's order, dated 4/17/25, for bilateral 1/4 upper side rail for functional mobility and to aid in ADL (Activities of Daily Living, basic self-care tasks) care/repositioning. There was no assessment performed for the use of side rails that include use of alternatives, risk and benefits, and risk of entrapment. During a concurrent interview and record review on 5/23/25 at 10:12 a.m., with the Director of Nursing (DON), the DON confirmed there was no assessment for the use of side rails on Resident 97. The DON stated an assessment should be done before applying the side rails. During a review of the facility's policy and procedure (P&P), titled Proper Use of Bed Rails, undated, indicated 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails. 4. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. 055316 Page 34 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 provide appropriate social services (SS) support for one of three residents (Resident 54) when there was no documentation of SS support for Resident 54, and no person-centered care plan developed to meet Resident 54's mental and psychosocial well-being. Residents Affected - Few This failure resulted in a lack of timely social services interventions for Resident 54. Findings: Review of Resident 54's clinical record titled, admission Record, dated 5/22/2025, indicated Resident 54 was admitted to the facility with diagnoses including other psychotic disorder (a severe mental disorder that cause abnormal thinking and perceptions) bipolar disorder, depression, and Alzheimer's disease (a progressive disease that destroys memory and mental functions). Review of Resident 54's quarterly MDS assessment dated [DATE], indicated a BIMS score of 4 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Furtherore, it indicated Resident 54 had disorganized thinking (also known as thought disorder, refers to a disturbance in the way an individual processes and organizes their thoughts, leading to difficulties in expressing ideas coherently and logically). During a concurrent observation and interview with Resident 54 on 5/19/2025 at 10:55 a.m., inside Resident 54's room, Resident 54 was in bed, lying on her left side, and showed her left upper arm with purplish, yellow discoloration. Resident 54 stated someone punched her and she did not tell anybody about it. Resident 54 was not able to state who punched her. During a follow up interview with Resident 54 on 5/20/2025 at 9:32 a.m., Resident 54 stated she stayed awake at night when certain people are in the property. Resident 54 stated she was okay now, and managers are taking care of it. Review of Resident 54's order summary report dated 5/22/2025, it indicated an order dated 1/16/2023, May have psychology consult and treatment PRN [as needed] Review of Resident 54's social services (SS) progress notes before 5/19/2025, revealed the following: a. On 6/18/2024, SS documented a voicemail was left for a friend to participate in care conference; b. On 6/22/2024, SS documented a voicemail was left regarding Resident 54's quarterly care conference; c. On 1/31/2025, SS documented Resident 54 was seen by the podiatrist; and d. On 4/17/2025, SS documented resident was seen by podiatrist. There was no documentation of SS regular visits with Resident 54, no referral to psychiatrist or no 055316 Page 35 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0745 refusal with psychiatry visits and no interventions implemented to manage any behavioral problems. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview with services director (SSD) and record review on 5/23/2025 at 8:56 a.m., SSD reviewed Resident 54's list of care plans and SS progress notes before 5/19/2025. SSD confirmed there was no SS regular visits documented in Resident 54's progress notes, no person-centered care plan developed and implemented to meet Resident 54's psychosocial needs . SSD stated she was not sure about Resident 54's psychiatry consultation and she would get back to the nurse surveyor. SSD further stated she had one SS that oversees their long-term care (LTC) residents, and she was also involved in their care as needed. Residents Affected - Few During an interview with director of nursing (DON) on 5/23/2025 at 11:27 a.m., DON stated SS should have a regular visit on residents with behavior problem, especially with Resident 54. DON further confirmed SS should have developed a person-centered long term plan of care to help manage Resident 54's behavior. During a concurrent interview with SSD and review of Resident 54's physician progress notes on 5/23/2025 at 4:05 p.m., SSD confirmed the progress note was just dated 5/23/2025, the use of olanzapine had been discontinued in the past, Resident 54 had been refusing psychiatry visits and there was no other documentation of Resident 54's refusal of psychiatry visits. Review of the facility's unsigned and undated job description titled, Social Worker, indicated, Ensure that each resident receives necessary behavioral health care and services to obtain and maintain the highest practical physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Keep abreast of current federal and state regulations as well as professional standards and make recommendations on changes in facility policies and procedures to the Director of Social Services .Participate in the development of a resident-centered care plan for each resident. Involve the resident/family in planning individualized objectives and goals for the resident. Communicate the social, psychological and emotional needs of the resident/family to other members of the IDT [interdisciplinary team - a group of health care professionals from diverse fields who work toward a common goal for residents). Collaborate with the IDT prioritizing non-pharmacological interventions for resident behaviors in accordance with facility policies and best practices. 055316 Page 36 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with a high abuse potential) when: Residents Affected - Some 1. Registered Nurse (RN) D did not sign out the Controlled Drug Record (CDR, a count sheet nurses sign when administering controlled medications to record the usage and inventory of such medications) sheet after medication administration for six medications in one of three medication carts inspected. 2. Random controlled medication use audit for three out of five sampled residents (Residents 7, 102 and 426) did not reconcile. The residents' medications were signed out of the CDR, but not documented on the Medication Administration Record (MAR) to indicate they were administered to the residents. These failures resulted in inaccurate accountability and had the potential for abuse and diversion (unlawful distribution or use) of controlled medications. Findings: 1. During an inspection of Station 1A Medication Cart with the Assistant Director of Nursing (ADON) B on 5/19/25 at 10:58 a.m., six medication bubble packs (blister packs, a card with pills in individual bubbles or blisters) did not match the corresponding CDRs. The medications and inventory documentation were as follows: - Oxycodone (a potent narcotic for moderate to severe pain) 5 milligram (mg, a unit of measure) for Resident 278. Number of pills in the bubble pack: 11 Number of pills documented in the CDR: 12 - Hydrocodone/acetaminophen 10-325 mg (a controlled medication used to treat moderate to severe pain) tablet for Resident 36 Number of pills in the bubble pack: 29 Number of pills documented in the CDR: 30 - Modafinil 200 mg (a narcotic to treat excessive daytime sleepiness) tablet for Resident 86 Number of pills in the bubble pack: 4 Number of pills documented in the CDR: 5 - Hydrocodone/acetaminophen 5-325 mg tablet for Resident 1 Number of pills in the bubble pack: 14 055316 Page 37 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0755 Number of pills documented in the CDR: 15 Level of Harm - Minimal harm or potential for actual harm - Pregabalin (medication to treat nerve pain or depression) 100 mg capsule for Resident 425 Number of pills in the bubble pack: 7 Residents Affected - Some Number of pills documented in the CDR: 8 - Tramadol 50 mg (medication for pain) tablet for Resident 425 Number of pills in the bubble pack: 7 Number of pills documented in the CDR: 8 ADON B acknowledged that for each of these six medications, there was one fewer pill in the bubble pack than what was recorded on the CDR. During an interview with RN D and ADON B on 5/19/25 at 11:21 a.m., RN D stated she administered the six medications to the respective residents and documented the administrations on the MAR. RN D stated she was too busy and did not document the controlled drug administrations on the CDR. RN D acknowledged the six CDR sheets were not signed out and that she should have signed the CDRs immediately. ADON B confirmed the CDR sheets should be signed immediately when administering controlled medications. During an interview with ADON B on 5/19/25 at 3:40 p.m., ADON B stated the exact time RN D administered the six medications as documented on the MAR. - RN D administered oxycodone 5 mg for Resident 278 at 9:26 a.m. - RN D administered hydrocodone/acetaminophen 10-325 mg tablet for Resident 36 at 9:32 a.m. - RN D administered modafinil 200 mg tablet for Resident 86 at 8:06 a.m. - RN D administered hydrocodone/acetaminophen 5-325 mg tablet for Resident 1 at 8:27 a.m. - RN D administered pregabalin 100 mg capsule for Resident 425 at 8:16 a.m. - RN D administered tramadol 50 mg tablet for Resident 425 at 8:16 a.m. During an interview with the Director of Nursing (DON) and ADON A on 5/19/25 at 2:24 p.m., ADON A stated nurses are expected to document on the MAR and sign the CDR right away when administering controlled medications. 2. The CDRs for five random residents receiving PRN (as needed) controlled medications were requested for review. a) A review of Resident 7's clinical record indicated she had an order for hydrocodone/acetaminophen 10-325 mg tablet - take one tablet by mouth every 6 hours as needed for pain, dated 2/7/25. 055316 Page 38 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0755 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the DON, ADON A and ADON B on 5/20/25 at 1:03 p.m., a review of Resident 7's CDR for hydrocodone/acetaminophen 10-325 mg and May 2025 MAR indicated the nursing staff signed out of the CDR but did not document the medication administration on two occasions: 5/1/25 at 1:10 p.m. and 5/11/25 at 2 p.m. ADON A and ADON B confirmed this finding and stated they could not find MAR documentation on 5/1 or 5/11 for hydrocodone/acetaminophen. Residents Affected - Some b) A review of Resident 426's clinical record indicated he had an order for oxycodone 5 mg tablet - take 1 tablet by mouth every 8 hours as needed for severe pain, dated 5/15/25. During a concurrent interview and record review with the DON, ADON A and ADON B on 5/20/25 at 1:10 p.m., a review of Resident 426's CDR for oxycodone 5 mg and the May 2025 MAR indicated the nursing staff signed out of the CDR but did not document the medication administration on 3 occasions: 5/16/25 at 9:20 p.m., 5/17/25 at 9 p.m., and 5/19/25 at 12:18 a.m. ADON A and ADON B confirmed this deficiency and stated they could not find any documentation on the MAR for oxycodone on 5/16, 5/17 or 5/19. c) A review of Resident 102's clinical record indicated he had orders for hydrocodone/acetaminophen, including hydrocodone/acetaminophen 5-325 mg tablet - give one tablet by mouth every 4 hours as needed for moderate pain, dated 4/24/25. During a concurrent interview and record review with the DON, ADON A and ADON B on 5/20/25 at 1:11 p.m., a review of Resident 102's CDR for hydrocodone/acetaminophen 5-325 mg and the April 2025 and May 2025 MARs indicated nursing staff signed the CDR but did not document on the medication administration on 2 occasions: 4/28 at 3 p.m. and on 5/8/25 at 9:28 p.m. ADON A and ADON B stated they could not find any documentation on the MAR on 4/28 at 3 p.m. or on 5/8/25 at 9:28 p.m. for hydrocodone/acetaminophen. During an interview with the DON, ADON A and ADON B on 5/20/25 at 1:10 p.m., ADON A stated controlled medication administration should be documented on the CDR and MAR. The DON stated it is important for both the CDR and MAR to be signed and match for accuracy and validation. To validate the pain medication is effective. The DON stated it is not acceptable for the CDR and MAR to not match, no, definitely it's a no. A review of the facility's policy and procedure (P&P) titled, Controlled Substance Administration and Documentation, implemented 6/1/24, indicated, .8. The nurse must document on the controlled substance accountability sheet and MAR after administration . 055316 Page 39 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the Consultant Pharmacist (CP) failed to identify and report to the facility medication-related irregularities during the monthly medication regimen review (MRR) for three of 26 sampled residents (Residents 81, 37, and 10), as follows: 1. Resident 81 received lidocaine 4% patch (topical medication applied to the skin for pain) longer than manufacturer's specification. 2. Resident 37 received Seroquel (an antipsychotic medication) for over 2 years without a gradual dose reduction (GDR, a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); and had no risk-benefit assessment for the use of Seroquel and metoclopramide (medication used to treat various digestive conditions), medications that could cause or worsen movement disorders. 3. Resident 10 received levothyroxine (medication to treat underactive thyroid) without periodic monitoring for TSH (thyroid stimulating hormone, this can be measured to determine thyroid function and activity). These failures resulted in excessive durations, unnecessary medications, and inadequate monitoring. Findings: 1. A review of Resident 81's clinical record indicated he had an active order for lidocaine external patch 4% - apply to knee joint pain topically at bedtime (9 p.m.) for pain management and remove per schedule. Remove at 8:59 p.m. (1 minute from application of a new patch), dated 1/7/25. During a concurrent interview and record review with Registered Nurse (RN) H on 5/19/25 at 2:03 p.m., RN H stated Resident 81's lidocaine patch is removed at 8:59 p.m. RN H stated the timing between the old and new patches is one minute apart. A review of the product labeling on the lidocaine patch 4% carton box which would be used for Resident 81 indicated, use 1 patch for up to 12 hours. During an interview with the Director of Nursing (DON) and Assistant DON (ADON) A on 5/19/25 at 2:20 p.m., both the DON and ADON A acknowledged the lidocaine patch should be used for up to 12 hours, based on the manufacturer's specifications. During a telephone interview with the CP on 5/22/25 at 1:54 p.m., the CP stated a lidocaine patch should only be applied for 12 hours. The CP stated, If more than 12 hours, it will cause side effects that are not pleasant to the resident like dizziness, irritation, redness. The CP acknowledged Resident 81 having a lidocaine patch on for 24 hours was an irregularity. When asked if she made a recommendation to have the lidocaine patch removed after 12 hours of use, the CP stated, I don't see it. I checked. It's one of the recommendations consultants make. I don't know how I missed it . A review of the National Library of Medicine's Medline Plus drug reference site, revised 6/15/21, indicated, wearing lidocaine patches for too long may increase the risk of having too much lidocaine .absorbed into your blood. In that case, you may experience symptoms of an overdose (https://medlineplus.gov/druginfo/meds/a603026.html, accessed 5/29/25). Some overdose symptoms listed include lightheadedness, dizziness, drowsiness, confusion, ringing in the ears, blurred or double vision, 055316 Page 40 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0756 vomiting, twitching, numbness, slow heartbeat or seizures. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident 37's clinical record indicated she was admitted to the facility with diagnoses including abnormal movement disorder and drug-induced akathisia (a condition caused by medications resulting in an inability to stay still and an involuntary urge to move). Residents Affected - Some A review of Resident 37's clinical record indicated Resident 37 had an active order for Seroquel 100 mg, 1 tablet by mouth every 12 hours for bipolar disorder (a condition characterized by extreme changes in mood) with psychotic features manifested by constant pacing and exposing herself, dated 8/2/24. Resident 37's clinical record indicated that she had been on this dose of Seroquel for two years, since April 2023. Resident 37's clinical record also indicated an active order for metoclopramide 5 mg (milligram, a unit of measure) per 5 mL (milliliter, a unit of measure) - give 5 mL by mouth every eight hours as needed for GERD (gastroesophageal reflux disease, a condition in which stomach acid goes up the esophagus, causing symptoms such as heartburn), dated 8/2/24. A review of Resident 37's clinical record indicated there had been no GDR attempts since April 2023; and there was no risk-benefit assessment conducted for the use of Seroquel and/or metoclopramide. A review of the Prescribing Information (PI, a detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Seroquel, dated 2009, indicated it has the ability to cause abnormal movement disorders and akathisia (https://www.accessdata.fda.gov/drugsatfda_docs; accessed 5/29/25). Likewise, a review of the PI for metoclopramide, dated 8/2017, indicated drug-induced akathisia and other extrapyramidal symptoms (group of motor side effects) have been known in patients taking metoclopramide (https://www.accessdata.fda.gov/drugsatfda_docs; accessed 5/29/25). During an interview on 5/22/25 at 11:45 a.m. with the DON, ADON A and ADON B, ADON A stated she, the DON, and ADON B were unable to find a GDR for Seroquel in Resident 37's chart. We reached out to the pharmacist to review [Resident 37's] chart. It was left off the review. ADON A stated she was unable to find a risk-benefit analysis of metoclopramide and Seroquel. ADON A stated she did an AIMS (abnormal involuntary movement scale) assessment yesterday, on 5/21/25, and the AIMS score was 6 (scored from 0-28), which indicated Resident 37 had positive signs and symptoms of abnormal involuntary movements. ADON A stated Resident 37's abnormal movements are related to facial movements and rocking when walking. During a telephone interview with the CP on 5/22/25 at 1:54 p.m., the CP stated, Somehow Seroquel wasn't included in a [GDR] request six months ago for all psychotropics (medications affecting brain activities associated with mental processes and behavior). The CP also stated that a Seroquel risk-benefit analysis was requested and the physician was given the option to provide risk-benefit analysis documentation four times, as recently as April 2024 and September 2024. During a record review on 5/22/25 at 3:29 p.m. of a years-worth of MRR binders, a risk-benefit analysis was not found. 3. A review of Resident 10's clinical record indicated she had an active order for levothyroxine 125 microgram (mcg, a unit of measure) tablet - give one tablet by mouth in the morning for hypothyroidism (underactive thyroid) 30 minutes before breakfast, dated 7/31/23. Resident 10's most recent TSH level was done on 1/23/24 (more than a year ago). 055316 Page 41 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the DON, ADON A and ADON B on 5/22/25 at 11:47 a.m., ADON A stated the last TSH level she could find for Resident 10 was one from January 23, 2024. During a telephone interview with the CP on 5/22/25 at 2:21 p.m., the CP stated she could not see any recent TSH levels for Resident 10. The CP stated TSH levels are to be done every six months. The CP stated, I should have asked for one, but apparently I didn't ask for one. A drug review of the medication levothyroxine on Daily Med, a drug resource site, updated 11/6/24, indicated, [i]n patients on a stable and appropriate .dosage, evaluate clinical and biochemical response [biological and chemical reactions in the body] every 6 to 12 months and whenever there is a change in the patient's clinical status [health]. A review of the facility's policy and procedure titled, Medication Regimen Reviews, revised May 2019, indicated, 1. The Consultant Pharmacist performs a medication regimen review .for every resident in the facility receiving medications .upon admission .and at least monthly thereafter .5. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example g. incorrect .administration times .h. other medication errors, including those related to documentation .14. The Consultant Pharmacist provides the Director of Nursing Services and Medical Director with a written, signed and dated copy of all medication regimen reports . 055316 Page 42 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 seven out of 26 residents (Residents 82, 278, 81, 115, 10, 21, and 25) were free from unnecessary medications when: Residents Affected - Some 1. Residents 82 and 278 received anticoagulants (blood thinners) with incorrect/inappropriate indications for use. This failure had the potential for the facility not having the right plan of care/treatment and monitoring related to anticoagulants for the residents. 2. Lidocaine patch was administered longer than manufacturer's specification for three residents (Residents 81, 115, 278). This failure had the potential for Residents 81, 115 and 278 to experience side effects from excessive duration of lidocaine patch use. 3. Resident 10 received levothyroxine (medication to treat underactive thyroid) without the periodic monitoring for TSH (thyroid stimulating hormone). This failure had the potential for Resident 10 to have thyroid levels outside the acceptable range and experience negative consequences. 4. Resident 21 received Azithromycin (used to treat bacterial infections) tablets without a proper indication for use and a definite end date. 5. Resident 25 received Clopidogrel (medication used to prevent blood clots) without monitoring for sign and symptoms of bleeding. Findings: 1a. A review of Resident 82's clinical record indicated he had a physician's order for apixaban (generic name of Eliquis, a blood thinner) 5 milligram (mg, unit of measurement) tablet, give one tablet by mouth two times a day for A Fib (atrial fibrillation, a type of irregular heart rhythm), dated 5/1/25. Resident 82's clinical record indicated he was previously hospitalized , and his past medical history includes deep vein thrombosis (DVT) [a blood clot in a deep vein] managed with apixaban. During an interview with Resident 82 on 5/21/25 at 10:46 a.m., Resident 82 stated he has been on apixaban for at least 3 years because he had a blood clot in the lungs. During an interview with the Assistant Director of Nursing (ADON) A on 5/21/25 at 10:56 a.m., ADON A stated Resident 82's apixaban was for A Fib. ADON A reviewed Resident 82's hospital record and acknowledged it indicated apixaban was used for DVT. ADON A also reviewed the resident's plan of care for apixaban and acknowledged it was for atrial fibrillation which was incorrect. During an interview with ADON A on 5/21/25 at 4:44 p.m., ADON A stated she clarified the apixaban order with the physician and it is for DVT .I have not figured out where A Fib came from. 1b. A review of Resident 278's clinical record indicated she had an active order for dabigatran (generic for Pradaxa, a blood thinner) 110 mg capsule, give one capsule by mouth two times a day for congestive heart failure (CHF, a condition in which the heart cannot pump blood well enough to meet the body's needs), dated 5/2/25. A drug review of the medication dabigatran on Daily Med, a drug resource site, updated 2/11/25, 055316 Page 43 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0757 listed the indications for dabigatran use. They were as follows: Level of Harm - Minimal harm or potential for actual harm - Reduction of stroke risk and systemic embolism (a blood clot that dislodges and ends up in the arterial circulation) in non-valvular atrial fibrillation (A Fib not caused by a heart valve problem) in adult patients Residents Affected - Some - Treatment and risk reduction of DVT and pulmonary embolism (PE, a blood clot in the lungs) in adult patients - Prevention of DVT and PE in adult patients after hip replacement surgery - Treatment and prevention of venous thromboembolic events (blood clots in the deep veins or lungs, includes DVT and PE) in pediatric patients CHF was not listed as an indication of dabigatran. During an interview with the Director of Nursing (DON), ADON A and ADON B on 5/22/25 at 11:45 a.m., ADON A stated Resident 278's clinical record indicated dabigatran was for CHF. The DON stated the diagnosis and indication came from the interfacility transfer order when Resident 278 was admitted to the facility from a hospital and we follow that .if the doctor doesn't change it. During a telephone interview with the Consultant Pharmacist (CP) on 5/22/25 at 1:54 p.m., the CP stated, dabigatran is usually for DVT. CHF? No. During an interview with the DON, ADON A and ADON B on 5/22/25 at 4:14 p.m., ADON A stated she clarified Resident 278's dabigatran order with the physician and the indication was for atrial fibrillation. A review of the facility's policy and procedure (P&P) titled, Unnecessary Drugs, undated, indicated, .4. Documentation will be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed . 2a. A review of Resident 81's clinical record indicated he had an active order for lidocaine (used to treat pain) external patch 4% - apply to knee joint pain topically at bedtime (9 p.m.) for pain management and remove per schedule. Remove at 8:59 p.m. (1 minute from application of a new patch), dated 1/7/25. During a concurrent interview and record review with Registered Nurse (RN) H on 5/19/25 at 2:03 p.m., RN H stated Resident 81's lidocaine patch is removed at 8:59 p.m. RN H stated the timing between the old and new patches is one minute apart. A review of the product labeling on the lidocaine patch 4% carton box which would be used for Resident 81 indicated, use 1 patch for up to 12 hours. 2b. A review of Resident 115's clinical record indicated she had two active orders for lidocaine 4% patch. Her newer order, dated 5/7/25, was for lidocaine external patch 4% - apply to right knee topically one time a day (at 9 a.m.) for knee pain and remove per schedule. Remove at 8:59 a.m. During an interview with the DON, ADON A and ADON B on 5/22/25 at 11:47 a.m., ADON B stated Resident 115's lidocaine patch for her right knee is applied at 9 a.m. ADON A stated it is removed at 8:59 a.m. (1 minute apart from the application). 055316 Page 44 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2c. A review of Resident 278's clinical record indicated she had two active orders for lidocaine 4% patch, both dated 5/7/25. The first order was to apply the patch to the lower back topically one time a day (at 9 a.m.) for back pain. The second order was to apply the patch to the mid back topically one time a day (at 9 a.m.) for back pain. Neither order had a scheduled removal time. During a concurrent interview and record review with RN I in the presence of ADON A on 5/22/25 at 11:32 a.m., RN I stated Resident 278 had an order for lidocaine to be applied to the lower back at 9 a.m. When asked when it is scheduled to be removed, ADON A assisted RN I to find that information in Resident 278's clinical record. RN I stated, I don't see it here. When asked when a lidocaine patch is typically removed, RN I stated, it's not good after 12 hours. During an interview with the DON and ADON A on 5/19/25 at 2:20 p.m., both the DON and ADON A acknowledged the lidocaine patch should be used for up to 12 hours. During an interview with the DON, ADON A and ADON B on 5/22/25 at 11:47 a.m., ADON A stated Resident 278's lidocaine patch is to be applied at 9 a.m. and should be removed after 12 hours. During a telephone interview with the CP on 5/22/25 at 1:54 p.m., the CP stated a lidocaine patch should only be applied for 12 hours. The CP stated, if more than 12 hours, it will cause side effects that are not pleasant to the resident like dizziness, irritation, redness. A review of the National Library of Medicine's Medline Plus drug reference site, revised 6/15/21, indicated, wearing lidocaine patches for too long may increase the risk of too much lidocaine may be absorbed into your blood. In that case, you may experience symptoms of an overdose (https://medlineplus.gov/druginfo/meds/a603026.html, accessed 5/29/25). Some overdose symptoms listed include lightheadedness, dizziness, drowsiness, confusion, ringing in the ears, blurred or double vision, vomiting, twitching, numbness, slow heartbeat or seizures. 3. A review of Resident 10's clinical record indicated she had an active order for levothyroxine 125 microgram (mcg, a unit of measure) tablet - give one tablet by mouth in the morning for hypothyroidism (underactive thyroid) 30 minutes before breakfast, dated 7/31/23. Resident 10's most recent TSH level was done on 1/23/24 (more than a year ago). During a concurrent interview and record review with the DON, ADON A and ADON B on 5/22/25 at 11:47 a.m., ADON A stated the last TSH level she could see for Resident 10 was one from January 23, 2024. During a telephone interview with the CP on 5/22/25 at 2:21 p.m., the CP stated she could not see any recent TSH levels. The CP stated TSH levels are to be done every six months for residents receiving levothyroxine. A drug review of the medication levothyroxine on Daily Med, a drug resource site, updated 11/6/24, indicated, [i]n patients on a stable and appropriate .dosage, evaluate clinical and biochemical response [biological and chemical reactions in the body] every 6 to 12 months and whenever there is a change in the patient's clinical status [health]. A review of the facility's P&P titled, Medication Utilization and Prescribing - Clinical Protocol, revised April 2018, indicated, .Monitoring 1. The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications . 055316 Page 45 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5.During a review of Resident 25's clinical records indicated Resident 25 was admitted to the facility with diagnosis including type diabetes mellitus (DM, a condition which affects the way the body processes blood sugar). During a review of Resident 25 physician's order indicated an order for Clopidogrel oral tablet 75 mg (milligram, unit of measure) Give 1 tablet by mouth one time a day for cva (cerebrovascular accident, which is another term for a stroke) ppx (prophylaxis, an attempt to prevent disease), dated 11/28/24. During a review of Resident 25's Medication Administration Record (MAR) indicated the nursing staff did not monitor the sign and symptoms of bleeding for Clopidogrel. During a concurrent interview and record review on 5/22/25 at 2:39 p.m., with the Director of Nursing (DON), the DON reviewed Resident 25's physician's order and she confirmed there were no monitoring for sign and symptoms of bleeding for Clopidogrel. The DON further stated Resident 25 should have monitoring every shift for bleeding. During a review of the facility's policy and procedures titled, Medication Monitoring, revision date 2025, indicated, This facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences. 4. Review of Resident 21's clinical record, indicated, Resident 21 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), pneumonia (infection of the lungs), bronchiectasis (condition where the airways are damaged, widened, and thickened making it harder to clear mucus), pseudomonas (a type of bacteria that can cause infections) as the cause of diseases. Review of the physician's order indicated Resident 21 was on Azithromycin tablet from 6/5/23 to 10/13/24 for prophylaxis chronic bronchitis, 10/28/24 to 11/6/24 for prophylaxis, 11/14/24 to 12/12/24 for prophylaxis, and 12/13/24 to 4/19/25 for pneumonia prophylaxis. Review of the physician's order, dated 4/19/25, indicated Resident 21 was on Azithromycin tablet 250 milligrams (mg, unit of measurement) one time a day every Monday, Wednesday, Friday for Chronic Bronchitis. The physician order does not have an end date. During a concurrent interview and record review on 5/22/25 at 3:57 p.m., with the Infection Preventionist (IP), the IP confirmed that the Azithromycin order did not specify the indication for use and that the order was not complete. The IP stated there should be an indication for use and not just write For Prophylaxis. During a concurrent interview and record review on 5/23/25 at 1:03 p.m., with the Consultant Pharmacist (CP), the CP stated the physician's order for Azithromycin, dated 4/19/25, did not have an end date. The CP stated she should have asked the physician for the end date. During a review of the facility's policy and procedure (P&P), titled Medication Monitoring, dated 6/1/24, indicated Medications shall be prescribed with clear indications for use. During a review of the facility's P&P, titled Medication Orders, dated 3/1/25, indicated Elements of the Medication Order .f. Duration or stop date, (e.g., antibiotics) .j. Diagnosis or indication 055316 Page 46 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0757 for use . Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P, titled Medication Utilization and Prescribing - Clinical Protocol, undated, indicated When a medication is prescribed for any reason, the physician and staff will identify the indications (condition or problem which it is being given, or what the medication is supposed to do or prevent) . Residents Affected - Some 055316 Page 47 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a medication error rate of 6.45% when two medication errors occurred out of 31 opportunities during the medication administration for one out of six residents (Resident 81). This failure resulted in Resident 81 not receiving medications as ordered and had the potential for Resident 81 to experience unnecessary pain. Residents Affected - Few Findings: 1. During the medication administration observation on 5/19/25 at 7:50 a.m., Registered Nurse (RN) H was observed preparing and administering seven medications for Resident 81. RN H stated she did not have Resident 81's eighth medication, diclofenac gel (a medication used to treat pain), in stock. RN H stated she will order it from the pharmacy to have it delivered that afternoon. A review of Resident 81's clinical record indicated Resident 81 had an active order since 1/8/25 for diclofenac sodium external gel 1%, with instructions to apply to both knees topically two times a day for joint pain . During an interview on 5/19/25 at 2:03 p.m. with RN H, RN H stated Resident 81's diclofenac had not arrived yet, but will come in at 3 p.m. RN H acknowledged that she documented the diclofenac as given and stated she will fix the documentation. A review of Resident 81's May 2025 Medication Administration Record indicated Resident 81 missed two doses of diclofenac gel on 5/19/25 at 9 a.m. and 5 p.m. During an interview with Resident 81 on 5/20/25 at 9:15 a.m., Resident 81 rated pain in his right knee at 6-7 out of 10 (10 being the most extreme pain imaginable). Resident 81 stated the pain kicks in while he is sleeping, during cold weather or under a heavy blanket. Resident 81 stated he was not informed that diclofenac was out of stock. A review of the facility's policy and procedure (P&P) titled, Pharmacy Services Overview revised April 2019, indicated, 4. Residents have a sufficient supply of their prescribed medications and receive medications .in a timely manner 2. During the medication administration observation on 5/19/25 at 7:50 a.m., RN H was observed preparing and administering seven medications for Resident 81. One of the medications RN H prepared and administered to Resident 81 was a multivitamin pill. A review of Resident 81's clinical record indicated Resident 81 had an active order since 1/8/25 for Therems-M oral tablet (multivitamins with minerals), with instructions to give one tablet by mouth daily. During a concurrent observation and interview on 5/19/25 at 2:03 p.m., with RN H at the Station 3 Medication Cart, RN H was asked to show the multivitamin bottle she used for Resident 81. The label on the bottle read, THERA a high potency multi-vitamin dietary supplement. RN H stated she did not have a bottle of multivitamins with minerals in her medication cart to give to Resident 81. During a telephone interview on 5/22/25 at 1:54 p.m., with the Consultant Pharmacist (CP), she stated that multivitamins were not the same as multivitamins with minerals. The CP stated they are not 055316 Page 48 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0759 interchangeable because they have different ingredients. Level of Harm - Minimal harm or potential for actual harm A review of the facility's P&P titled, Medication Administration implemented 3/1/23, indicated, 14. Administer medication as ordered . Residents Affected - Few 055316 Page 49 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure medications were labeled in accordance with standards of practice and facility policy and procedures (P&P) when: 1. An opened bottle of dabigatran (generic for Pradaxa, a blood thinner) for Resident 278 was found without an open date in one of three medication carts. This had the potential for the medication to be used beyond its effective date; and 2. The direction for use on the pharmacy label was altered with handwritten markings for one of six residents (Resident 86) observed during medication administration. This had the potential for medication errors for the resident. Findings: 1. During an inspection of the 1A Medication Cart on 5/19/25 at 10:58 a.m., with the Assistant Director of Nursing (ADON) B, a bottle of dabigatran 110 milligram (mg, unit of measure) capsules for Resident 278 was found opened in the cart. No open date was observed. The product labeling indicated, Once opened, the product must be used within 4 months. ADON B verified this finding and acknowledged it should have an open date. A review of the facility's P&P titled, Labeling of Medications and Biologicals, implemented 2/1/24, indicated, 1. All medications .will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices. 2. During a medication administration observation on 5/19/25 at 4:25 p.m., with Licensed Vocational Nurse (LVN) C in Station 1A, LVN C was observed preparing and administering medications to Resident 86. One of the medications observed was two carvedilol (medication for high blood pressure) 6.25 mg tablets. The number 2 was handwritten with a black Sharpie pen over what was originally typed on the carvedilol label for the number of pills to be given per dose. During an interview with LVN C on 5/19/25 at 4:39 p.m., she verified Resident 86's carvedilol label had handwritten markings over the direction for use. She stated she did not know who did that. During an interview on 5/20/25 at 12:34 p.m., with the Director of Nursing (DON), ADON A and ADON B, the DON stated a handwritten change of directions on the label is not appropriate. The DON stated a handwritten change of directions makes it hard to know the prescriber's original order. The DON stated change of directions needs to be verified by pharmacy. During a telephone interview on 5/22/25 at 1:54 p.m., with the Consultant Pharmacist (CP), the CP stated a handwritten direction change is not appropriate; the change of directions has to be typed or attach a sticker for change of directions. A review of the facility's P&P titled, Labeling of Medications and Biologicals, implemented 2/1/24, indicated, 3. Any medication label that is .illegible .or makeshift must be returned and replaced by the issuing pharmacy .11. Only the issuing pharmacy may place a drug label on a medication container. 12. The pharmacy must be informed of any order changes or changes in directions for the use of 055316 Page 50 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0761 the medication. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055316 Page 51 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility document review, the facility failed to provide and served food that was palatable. These failures placed the 124 residents eating at the facility at risk of poor food intake further compromising their nutritional status. Residents Affected - Some Findings: Note: The nursing home is disputing this citation. During an interview with Resident 102 on 5/19/25 at 8:35 a.m., Resident 102 stated. Food are burnt and cold, dry overcooked. During an interview with Resident 59 on 5/19/25 at 9:01 a.m., Resident 59 stated, the food are terrible and cold. During an interview with Resident 375 on 5/19/25 at 9:59 a.m., Resident 375 stated the food is terrible and sometimes cold. During an interview with Resident 376 on 5/19/25 at 11:09 a.m., Resident 376 stated, the food are terrible and cold. A review of the facility menu for 5/21/2025 lunch indicated, Oven BBQ (barbeque) Beef Roast, Mashed Sweet Potatoes, Fresh Zucchini with Carrots, Cheddar Biscuit, Ice Cream. As a result of the resident complaints about the food, a test tray of regular and puree diet was conducted on 5/21/2025. During the test tray of the lunch meal on 5/21/2025 at 1:30 p.m., in the presence of the Dietary Supervisor (DS), the regular zucchini and carrots appeared bland, and no spices were visible. the regular carrots and zucchini tasted bland, the beef tasted fine, and the sweet potatoes was sweet. The pureed zucchini and carrots also taste bland, there were no taste of spices. The three Surveyors confirmed this tasting observation. The DS stated I could taste the zucchini. A review of the facility's recipe titled, FRESH ZUCCHINI AND CARROTS, indicated, 4. Simmer in boiling water or steam until tender . Drain. Add margarine, dill, salt, and seasonings. May add more dill as desired. A review of the facility's undated policy and procedure titled, Food Preparation Guidelines, dated 6/1/24 indicated, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status.2. Food shall be prepared by methods that conserve nutritive value, flavor and appearance . 3.Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: a. Providing meals that are varied in color and texture. b.Using spices or herbs to season food in accordance with recipes. 055316 Page 52 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure a resident consistently received a pureed texture (a type of food that has been processed to a smooth, uniform texture, like pudding or apple sauce) diet as prescribed by a physician when one of five residents (Resident 36) on pureed texture diet did not receive the pureed food. This failure had the potential to result in Resident 36 not meeting the nutritional needs and aspiration (food, liquid, or other materials accidently enter the airway and lungs instead of going down to the esophagus to the stomach) with not properly pureed food. Findings: Review of Resident 36's clinical record titled, admission Record, dated 5/21/2025, indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS, a nervous system disease that affects nerve cells in the brain and spinal cord which cause loss of muscle control), asthma (inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath), needs assistance with personal care and dysphagia (difficulty in swallowing). Review of Resident 36's order summary report date ordered 5/12/2025, indicated, Diet .PUREE texture, Nectar (Mildly Thick) consistency. During a concurrent observation and interview with Resident 36 on 5/19/2025 at 9:05 a.m., inside Resident 36's room, Resident 36 was seated at the edge of her bed eating breakfast, and there were some foods spilled on Resident 36's chin down to the protective clothing. Resident 36 was unable to talk but communicated with the use of a communication board. Resident 36 used her finger to write in the communication board. Resident 36 wrote, food not blended well, and she showed the pictures of her food that she took in her phone. During another concurrent observation and interview with Resident 36 on 5/19/2025 at 1:11 p.m., inside Resident 36's room, Resident 36 was eating lunch by herself with food spilled on her chin down to her clothing and she pointed to her food. There were two different types of food on her plate that did not look pureed texture, it was like ground meat with gravy. Resident 36 wrote on her communication board that she was having a hard time swallowing the food that looked ground meat. During a concurrent observation and interviews with both Resident 36 and speech therapist (ST) on 5/19/2025 at 1:23 p.m., inside Resident 36's room, ST observed the food Resident 36 was eating and stated the ground looking food was a pureed bread and there was no way they could blend it more. ST stated they were aware about Resident 36's complains about the food texture. Resident 36 wrote in the communication board which indicated the food she was eating was not blended well enough and she showed her writing to the ST. During a test tray observation and interview with dietary supervisor (DS) on 5/21/2025 at 1:40 p.m., DS brought a pureed texture of oven beef roast with barbeque sauce, mashed sweet potatoes, steamed zucchini and carrots and cheddar biscuits. All the food in the lunch tray were tasted and confirmed the pureed texture food should be well blended and easy to swallow. During a concurrent interview with DS and review of the photo of Resident 36's lunch meal taken on 055316 Page 53 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0808 5/19/2025 at 1:12 p.m., DS confirmed Resident 36 food was not pureed. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Therapeutic Diets, date revised 10/2017, indicated, Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Residents Affected - Few Note: The nursing home is disputing this citation. During a review of the facility's recipe titled, PUREED MEATS, indicated, The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. 055316 Page 54 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: Residents Affected - Some 1. There were a gallon 340 grams of whole bay leaves stored in the shelved more than one year from the opening date; 2. There were undated and unlabeled food items and staff-stored metal water bottle in the two-unit refrigerator for residents. 3. Metal tray and muffin pans used for food preparation and food service had black, gray, and yellow buildup; 4. A metal pipe in the kitchen faucet one was covered with gray and brown build up or stain; and 5. A sanitizing agent in red bucket were above the acceptable range. These failures had the potential to cause food contamination and food-borne illness to 124 of 124 residents who received their food from the kitchen. Findings: 1. During an initial kitchen tour on 5/19/25 at 8:04 a.m., with the Registered Dietician (RD) and the Dietary Supervisor (DS), observation in the seasoning shelves found a gallon of 350 grams of whole bay leaves with an open date 1/26/24 and UBD (used by date )1/26/25 and it had expired. The RD stated the whole bay leaves is good for 1 year after opening. The RD further stated it should be thrown away. During a review of the facility's P&P titled Date Marking for Food Safety, dated 2023, indicated, 2.The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded .5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.) . 2. During a concurrent observation and interview in resident refrigerator unit at station 2 on 5/21/25 at 10:10 a.m., with the Infection Prevention Nurse (IP), Found inside the freezer was one unlabeled Mcflurry, box was slightly open with a wooden spoon. The IP stated it should be labeled with name and date. During an observation and interview in resident refrigerator unit at station 3 on 5/21/25 at 10;12 a.m., with the IP, found a metal water bottle with the name [staff], the IP stated he knows the name and it's a facility staff. The IP further stated the staff should not use the resident refrigerator and should use the staff refrigerator in the breakroom. During a review of facility's policy and procedure titled Use and Storage of Food Brought in by Family or Visitors, dated 7/1/23, indicated, It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure 055316 Page 55 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the safety of the resident. 2. All food items that are already prepared by the family or visitor brought in must be labeled and dated.a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator . 3. During an observation in the kitchen on 5/21/25 at 10:49 a.m., observed one big metal tray with black, gray, and brown buildup and four metal muffins pans with black, gray and brown buildup. During a concurrent observation and interview on 5/21/25 at 11:04 a.m., with [NAME] V (CK V), she checks the metal tray and four muffins pan. CK V confirmed the metal tray and four muffin pans has black, gray, and brown buildup. CK V stated the muffin pan is use for baking and the big metal tray is used to place the food after cooking. CK V stated they should be clean. During an interview on 5/22/25 at 10:46 a.m., with the Registered Dietitian (RD), the RD stated the big metal tray, and four muffin pans should be clean or replace. 4. During a kitchen observation on 5/21/25 at 11:17 a.m., observed the metal pipe of faucet 1 in 3-compartment sinks (a type of manual ware washing sink used in commercial kitchens to wash, rinse, and sanitize dishes.) was covered with gray and brown buildup or stain. During a concurrent observation and interview on 5/22/25 at 10:13 a.m., with the Dietary supervisor (DS) check the faucet 1 in 3-compartment sink. The DS confirmed faucet 1 had brown and gray buildup or stain. She further stated maintenance is responsible for cleaning. During a concurrent observation and interview on 5/22/25 at 10:24 a.m., with Facility Service Manager (FSM), the FSM confirmed faucet 1 metal pipe was covered with gray and brown buildup or stain. The FSM further stated it should be clean. 5. During a kitchen observation on 5/22/25 at 10:09 a.m., with the Dietary Supervisor (DS), the DS asked to check the sanitizing steps in red bucket. The DS got the Sink & Surface Cleaner Sanitizer Test Strips, pour a new sanitizer solution into the red bucket and dip the strip, after few seconds the strip turned yellow green indicated the strip result was above the recommended active range of DDBSA (used for sanitization of agricultural equipment, food products, food processing equipment and the food preparation environment) is 272 to 700 ppm. The DS stated the approved range is 700 ppm. During an interview and review of the test strip on 5/23/25 at 1:53 p.m., with the Registered Dietitian (RD), the RD confirmed DDBSA test strips is above the recommended range. The RD further stated the normal range is 272 to 700 ppm. During a review of the facility's policies and procedures (P&P) titled, Sanitation, dated 2023, the P&P indicate, The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. 11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas . 055316 Page 56 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Note: The nursing home is disputing this citation. Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 97's clinical record, indicated, Resident 97 was admitted on [DATE] with diagnoses including sepsis (body's extreme and potentially dangerous response to infection), urinary tract infection (infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra), primary osteoarthritis (joint pain and stiffness) left shoulder, anxiety disorder (mental health conditions characterized by excessive and persistent worry, fear, and nervousness). Review of Resident 97's Inventory of Personal Effects, dated 4/17/25, indicated the form was blank. During a concurrent interview and record review on 5/23/25 at 10:04 a.m., with the Director of Nursing (DON), the DON stated the Inventory of Personal Effects must be filled out upon admission. The DON stated there should be a note in the form indicating if the resident does not have any belongings. The DON further stated that the same form will be used for any changes in the resident's belongings. Review of Resident 97's Inventory of Personal Effects, indicated there was a correction made on the date of the form. During a concurrent interview and record review on 5/23/25 at 2:01 p.m., with the NS, the NS stated she used a new Inventory of Personal Effects form when she did not see any form in Resident 97's medical record. The NS stated she made a mistake in writing the date on the form. The NS stated, I thought it was the 21st but was actually 22. The NS stated documentation should be clean and no erasures and no changes. The NS further stated that she should have drawn a line across and initial when she made an error and not write over it. Review of the facility's policy and procedure (P&P), titled Guidelines for Charting and Documentation, undated, indicated If an error was made while recording data in the medical record, line through the error with a single line and then record the correct data. Review of the facility's P&P, titled Documentation in Medical Record, dated 6/1/23, indicated Each resident's medical record shall contain complete and accurate documentation. Based on interview, and record review, the facility failed to maintain an accurate and systematically organized documentation in accordance with accepted professional standards and practices for four of six residents reviewed (Residents 102, 283, 280, and 97) when: 1. Resident 102's Inventory of Personal Effects (also called resident's belonging's list, a document that details a resident's personal belongings when they move into a facility) form was blank three days after readmission and there was no Inventory of Personal Effects found in the old chart; 2. Resident 283's Inventory of Personal Effects was blank three days after admission; 3. Social services and case manager's progress notes related to Resident 280's discharge was documented 51 days after discharge; and 4. Resident 97's Inventory of Personal Effects was not completed. 055316 Page 57 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Note: The nursing home is disputing this citation. These deficient practices resulted in an inaccurate and inappropriate documentation of Resident 102, 283, 97's belonging's list and Resident 280's progress notes. Findings: 1. Review of Resident 102's clinical record titled, admission Record, dated 5/19/2025, indicated Resident 102's original admission date was 2/19/2025 and was re-admitted back to the facility on 5/18/2025. During a concurrent interview with medical records director (MRD) and record review on 5/20/2025 at 2:32 p.m., MRD reviewed Resident 102's old chart for the Inventory of Personal Effects, and confirmed that the old chart did not have the form. Review of Resident 102's current Inventory of Personal Effects form found at the back of Resident 102's chart revealed, it was blank, or nothing was written on it. 2. Review of Resident 283's clinical record titled, admission Record, dated 5/19/2025, indicated Resident 283 was admitted to the facility on [DATE]. Review of Resident 283's Inventory of Personal Effects form found at the back of Resident 283's chart revealed, it was blank, or nothing was written on it. During a concurrent interview with the assistant director of nursing A (ADON A) and record review on 5/21/2025 at 9:17 a.m., ADON A reviewed Resident 102 and Resident 238's current Inventory of Personal Effects, and confirmed both forms were blank. ADON A stated the admitting certified nursing assistant (CNA) should checked the resident's belongings upon admission and document in the resident's Inventory of Personal Effects form. ADON A further stated the director of staff development (DSD) assistant should follow up the following day. During an interview with director of nursing (DON) on 5/23/2025 at 12:13 p.m., DON stated both licensed nurses and CNAs were responsible in completing the Inventory of Personal Effects form upon resident's admission and it should be completed within 24 hours. During a review of the facility's policy and procedure titled, Admitting the Resident: Role of the Nursing Assistant, date revised 9/2013, indicated, To inventory the resident's personal effects, you should: 1. Ask family member(s) to remain in the room to witness the inventory. 2. Tell the resident that you are going to inventory his or her personal effects. 3. Complete the resident identification portion of the inventory record. 4. Inventory all clothing, equipment, valuables, etc .5. When all personal items have been inventoried and recorded in the Inventory of Personal Effects Record, sign your name and title and instruct the family member that witnessed the inventory to also sign the form. 3. Review of Resident 280's clinical record titled, admission Record, indicated Resident 280 was admitted to the facility on [DATE] with diagnoses including spondylosis in cervical region (age-related wear and tear affecting the spinal disks of the neck), and pneumonia (infection of one or both lungs). Further review indicated, Resident 280 was discharged to home on 3/31/2025. Review of Resident 280's SNF [skilled nursing facility] Beneficiary Protection Notification Review form completed by social serviced director (SSD), it indicated Resident 280's Last covered day [LCD] 055316 Page 58 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0842 of Part A Service [Medicare Part A insurance terminated/denied, or resident was discharged ] was 3/30/2025. Further review indicated, it was Resident 280's self-initiated discharge. Level of Harm - Minimal harm or potential for actual harm Review of Resident 280's nurse, case manager and SS progress notes revealed the following: Residents Affected - Some a. Note: The nursing home is disputing this citation. It was not indicated in any of nurse's notes that Resident 280 had requested to go home; b. The nurse case manager X's (NCM X) progress notes for 3/28/2025 was CREATED on 5/19/2025 at 4:41 p.m. (5/19-5/23/2025 - recertification survey), it indicated the NCM X spoke to Resident 280 about the discharge plan and Resident 280 requested to be discharged ; and c. The social service assistant Y's (SSA Y) progress notes for 3/28/2025 was CREATED on 5/20/2025 at 11:25 a.m., it indicated Resident 280 requested to be discharge to a car, SSA Y explained the discharge process and the physician agreed for Resident 280 to discharged on 3/31/2025. Further review indicated Resident 280 declined home health services. During a concurrent interview with SSD and review of Resident 280's progress notes on 5/23/2025 at 8:44 a.m., SSD confirmed the nurse case manager X's note was just created on 5/19/2025 and SSA Y's progress notes was created on 5/20/2025 while the recertification survey was being held at the facility. SSD stated staff should document as soon as they met with the resident and implemented some plan of care. SSD further stated SS should document any discharge planning or any teachings provided to residents in a timely manner. 055316 Page 59 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

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 infection control practices were implemented in seven of 26 sampled residents (Residents 81, 96, 115, 375, 109, 45, and 51) when: Residents Affected - Some 1. Registered Nurse (RN) H used one tissue to wipe eye drops from both of Resident 81's eyes, and RN H used a dry tissue to wipe Resident 81's eye drop cap that fell on the floor before capping it back on the bottle, 2. Licensed Vocational Nurse (LVN) E did not wear a gown and did not perform hand hygiene after touching potentially contaminated surfaces during medication administration through a feeding tube (a surgically placed tube used to administer food and medications in individuals who have trouble swallowing) for Resident 96. 3. LVN F did not perform hand hygiene after touching potentially contaminated surfaces during the blood sugar check for Resident 115. 4. Medical records assistant (MRA) did not perform hand hygiene after removal of gloves inside Resident 109's room; 5. Resident 45 was in an Enhanced Barrier Precaution (EBP,an infection control intervention designed to reduce the transmission of multidrug-resistant organisms [MDRO, these are microorganisms (primarily bacteria) that have become resistant to one or more classes of antimicrobial agents, like antibiotics.]in healthcare settings, particularly nursing homes.) room and certified nursing assistant K (CNA K) did not wear a gown during Resident 45's repositioning; and 6. There were no EBP signage posted outside Resident 51, Resident 115 and Resident 375's room These failures had the potential to put residents, staff and visitors at risk for infections due to cross-contamination. Findings: 1. During a medication administration observation on 5/19/25 at 7:50 a.m., RN H was observed preparing and administering medications to Resident 81, including dorzolamide/timolol eye drops (generic for Cosopt, a medication for glaucoma) into each eye. After instilling a drop into each of Resident 81's eyes, RN H was observed using a single tissue to wipe both of Resident 81's eyes. The eye drop cap fell on the floor. RN H was observed using a tissue to wipe it and capping it back on the eye drop bottle. During an interview with RN H on 5/19/25 at 8:15 a.m., RN H acknowledged she used a single tissue to wipe both eyes. RN H stated she should have used one tissue per eye. RN H also acknowledged she wiped the dropped eye drop cap with a tissue. RN H stated she did not use an alcohol swab to clean the eye drop cap, but said she should have. During an interview with the Infection Preventionist (IP) on 5/20/25 at 9:55 a.m., the IP stated nursing staff should use two separate tissues for eye drop administration to prevent the spread of infection. The IP stated it is not appropriate to wipe a dropped eye drop cap with a dry tissue because 055316 Page 60 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some you never know what is on the floor. The IP stated the eye drop cap can be cleaned with soap and water and dried with a towel. A review of the facility's policy and procedure (P&P) titled, Administration of Eye Drops or Ointments, implemented 4/1/25, indicated, .h. Wipe off excess solution .with a clean tissue. Use a fresh tissue for each eye to prevent cross-contamination . 2. During a medication administration observation on 5/19/25 at 8:21 a.m., LVN E was observed preparing medications for Resident 96, which were to be given through a feeding tube. A sign was observed outside Resident 96's door, which read, Enhanced Barrier Precautions [EBP] .staff must .wear gloves and a gown for the following high-contact resident care activities .device care or use .feeding tube . LVN E was observed wearing gloves, but no gown as she moved a bedside table and adjusted Resident 96's bed prior to medication administration. LVN E was observed proceeding to administer Resident 96's medications through his feeding tube while wearing the same gloves. During an interview with LVN E on 5/19/25 at 9:46 a.m., LVN E acknowledged she moved a bedside table and used the bed remote while wearing gloves that she later used to administer Resident 96's medications. LVN E stated she should have changed her gloves after touching the furniture in Resident 96's room. LVN E acknowledged she did not wear a gown while administering Resident 96's medications. LVN E stated, I'm supposed to wear a gown for infection control. During an interview with the IP on 5/20/25 at 9:55 a.m., the IP stated nurses need to gown up because of the prolonged contact when administering medications to a resident with a feeding tube. The IP stated, For EBP [enhanced barrier precautions] there has to be gown and gloves to protect against multidrug-resistant organisms (MDROs, germs that are resistant to many antibiotics). The IP stated before providing care to residents, nurses should remove gloves, perform hand hygiene (hand washing, antiseptic handwash or alcohol-based hand rub) and wear new gloves. A review of the facility's P&P titled, Enhanced Barrier Precautions, revised April 2025, indicated, .2. Enhanced barrier precautions apply when .b. a resident .has .[an] indwelling medical device .5. Indwelling medical devices include .feeding tubes .7a. gloves and gown are applied prior to performing high contact resident care activity .8. Examples .include .i. device care or use .feeding tube . 3. During an observation on 5/19/25 at 12:09 p.m., LVN F was observed wearing gloves and moving a bedside table, a folding chair and IV pole, then proceeding to check Resident 115's blood sugar while wearing the same gloves. LVN F was observed washing her hands after checking Resident 115's blood sugar, but the test strip (part of the equipment to test blood sugar; it has a well to put blood in) was still in the glucometer (machine used to measure blood sugar). During an interview on 5/19/25 at 12:18 p.m., LVN F acknowledged she should have changed her gloves after moving the furniture and equipment. LVN F stated, I should have removed [the gloves] and put on new gloves. When asked how she removed the test strip from the glucometer, LVN F stated she removed the test strip with a paper napkin and stated that was her normal process. During an interview with the IP on 5/20/25 at 9:55 a.m., the IP stated if nurses touch surfaces after putting on gloves, then they should remove gloves, perform hand hygiene and wear new gloves. The IP stated it is not okay to remove a used test strip with a paper napkin and no gloves. The IP stated a paper napkin is not a barrier to protect yourself. The IP stated nurses have to put gloves on and remove test strips. 055316 Page 61 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's P&P titled, Medication Administration Infection Control, implemented 6/1/24, indicated, 4. Change gloves and perform hand hygiene as indicated to prevent contamination of any handled item .6. DON gloves as indicated. Perform hand hygiene between glove changes as indicated .8. Perform hand hygiene before and after medication pass for each resident and as indicated. 6a. During an observation in Resident 115's room on 5/19/25 at 8:48 a.m., Resident was observed lying in bed. Foley catheter drainage bag was hanging on the side of the bed covered with privacy bag. There were no EBP signage posted in Resident 115' entrance door. During a concurrent observation and interview outside Resident 115's room on 5/19/25 at 10:27 a.m., with the Infection Prevention Nurse (IP), the IP confirmed that there were no EBP signage posted earlier. The IP further stated the resident with Foley catheter should have EBP signage posted outside the door. During a review of Resident 115's clinical record indicated Resident 115 was admitted to the facility with diagnosis including muscle weakness. During a review of resident 115's physician's order dated 5/13/25 (EBP) Enhanced Barrier Precautions during high contact activities secondary to Foley's catheter use. During a review of Resident 115' clinical record indicated a care plan, dated 5/13/25 Focus: The resident is on (EBP) Enhanced Barrier Precautions to reduce MDRO transmission/due to increased risk of MDRO transmission indwelling medical device. Interventions:Follow Enhance Barrier Precautions (glovers/gown) during high-contact care activities. Place a sign for (EBP) near entrance of the room . 6b. During an observation in Resident 375' room on 5/19/25 at 10:00 a.m., Resident was observed lying in bed Foley catheter drainage bag hanging on the side of the bed covered with privacy bag. There were no EBP signage posted in Resident 375' entrance door. During a concurrent observation and interview outside Resident 375's room on 5/19/25 at 10:29 a.m., with the Infection Prevention Nurse (IP), the IP confirmed Resident 375 has Foley Catheter, and he also confirmed that there were no EBP signage posted outside Resident 375's entrance door. The IP further stated Resident 375 should have EBP signage posted outside the room. During a review of Resident 375's clinical record indicated Resident 375 was admitted to the facility with diagnosis including malignant neoplasm (cancerous tumor that can spread to other parts of the body) of prostate (gland in the male reproductive system). During a review of Resident 375's physician's order, dated 5/19/25 (EBP) Enhanced Barrier Precautions during high contact activities secondary to h/o indwelling FC (Foley Catheter). 6c. Review of Resident 51's medical record indicated Resident 51 was admitted on [DATE] with diagnoses including diabetes mellitus (a condition which affects the way the body processes blood sugar), chronic kidney disease (gradual loss of kidney function), and neuromuscular dysfunction of the bladder (condition where the nerves and muscles that control emptying of urine from the bladder don't work properly). During an observation on 5/19/25 at 9:12 a.m. in Resident 51's room, Resident 51 was observed awake and lying in bed with a foley catheter drainage bag with privacy cover hanging on the side of the 055316 Page 62 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0880 bed. There was no EBP signage posted on the door or wall outside the entrance to Resident 51's room. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 51's Order Summary Report dated 11/19/24 indicated an order for, (EBP) Enhanced Barrier Precautions during high contact activities secondary to Foley's catheter use every shift. Residents Affected - Some During a review of Resident 51's Care Plan Report dated 11/19/24 indicated, Focus: The resident is on (EBP) Enhanced Barrier Precautions to reduce MDRO transmission/due to increased risk of MDRO transmission indwelling medical device. Interventions: Follow Enhance Barrier Precautions (glovers/gown) during high-contact care activities. Place a sign for (EBP) near entrance of the room . During a concurrent observation and interview on 5/21/25 at 10:15 a.m. with the Infection Prevention Nurse (IP) outside Resident 51's room, the IP confirmed that there was no EBP signage posted on the door or wall near the entry of Resident 51's room. The IP stated, Resident 51 has a foley catheter and should have an EBP sign posted outside the room. During a review of facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions revised April 2025, the P&P indicated, .17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required . 4. During an observation on 5/19/2025 at 8:20 a.m., inside Resident 109's room, MRA was observed holding on to a clipboard to her left hand and wore gloves to her right hand. MRA moved Resident 109's overbed table with the gloved hand, then removed the used gloves and MRA offered to shake the surveyor's hand without hand hygiene. During an interview with MRA on 5/20/2025 at 9:28 a.m., the MRA confirmed above observation and stated she should have performed hand hygiene after removal of used gloves. During an interview with IP on 5/22/2025 at 1:20 p.m., IP stated staff should perform hand hygiene prior to donning of gloves and upon removal of gloves. During a review of the facility's policy and procedure titled, Hand Hygiene, dated 7/1/2023, indicated, The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 5. Review of Resident 45's clinical record titled, admission Record, dated 5/22/2025, Resident 45 was admitted to the facility with diagnoses including dementia (a progressive state of decline in mental abilities), neuromuscular dysfunction of bladder (a condition where the bladder's function is impaired due to a problem with the nerves controlling it, like damage to the brain, spinal cord, or peripheral nerves), and quadriplegia (a condition in which all four limbs (arms and legs) are paralyzed). Review of Resident 45's order summary report, dated 5/22/2025, indicated an order, (EBP) Enhanced Barrier Precautions during high contact activities secondary to Foley catheter [a thin, flexible tube inserted into the bladder through the urethra to drain urine] use every shift. During an observation on 5/19/2024 at 9:28 a.m., inside Resident 45's room who had an EBP signage by the door, Resident 45 was in bed, unable to move all extremities, with foley catheter in placed. 055316 Page 63 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some CNA entered the room with gloves on, did not wear a gown and assisted Resident 45 in repositioning in bed. CNA K had to move Resident 45's extremities one at a time, and CNA K's clothing had touched Resident 45's beddings, and used pillows. During an interview with CNA K on 5/19/2025 9:39 a.m., CNA K confirmed above observation and stated she should have donned a gown prior to repositioning a totally dependent resident on EBP. During an interview with IP on 5/22/2025 at 1:20 p.m., IP stated staff should wear gown, gloves, and mask/face shield (as needed) whenever they had a prolonged contact with residents on EBP. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, date revised 4/2025, indicated, EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .providing bed mobility. 055316 Page 64 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0881 Implement a program that monitors antibiotic use. 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 implement their antibiotic stewardship program (program intended to prevent overuse of antibiotics) for one of two sampled residents (Resident 21) when: Residents Affected - Few Note: The nursing home is disputing this citation. 1. Resident 21 received several antibiotics (medications used to treat bacterial infections) for pneumonia and chronic bronchitis but no documentation that Resident 21 meet all the criteria that needed to be present for antibiotic use; 2. The prescriptions for antibiotics did not specify the duration and indication for use; 3. No documentation of monitoring antibiotic use; and 4. No documentation related to the program maintained by the Infection Preventionist (IP). These failures had the potential to increase the prevalence of multi-drug resistant organisms in the facility. Findings: Review of Resident 21's clinical record, indicated, Resident 21 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), pneumonia (infection of the lungs), bronchiectasis (condition where the airways are damaged, widened, and thickened making it harder to clear mucus), pseudomonas (a type of bacteria that can cause infections) as the cause of diseases. Review of the physician's order, indicated Resident 21 was on Azithromycin (used to treat bacterial infections) tablet from 6/5/23 to 10/13/24 for prophylaxis chronic bronchitis, 10/28/24 to 11/6/24 for prophylaxis, 11/14/24 to 12/12/24 for prophylaxis, and 12/13/24 to 4/19/25 for pneumonia prophylaxis; Meropenem (used to treat bacterial infections) intravenous (administering medications into a vein) solution from 11/8/24 to 11/14/24; and Vancomycin (used to treat infections caused by bacteria) intravenous solution from 10/13/24 to 10/26/24, and 11/8/24 to 11/14/24. During a concurrent interview and record review on 5/22/25 at 3:57 p.m., with the Infection Preventionist (IP), the IP confirmed that the Azithromycin order did not specify the indication for use and that the order was not complete. The IP stated there should be an indication for use and not just write For Prophylaxis. The IP further stated that he does not fill out the McGeer Criteria (a set of guidelines used to identify and track infections) for any resident in the facility that was on antibiotic. The IP stated the Azithromycin order for Resident 21 was from the hospital and does not need to be reviewed if it was appropriate or not. The IP was not able to provide documentation for surveillance monitoring of antibiotic use. During an interview on 5/23/25 at 9:16 a.m., with the Consultant Pharmacist (CP), the CP stated there was a possibility that Resident 21 can develop multi-drug resistance. During a concurrent interview and record review on 5/23/25 at 1:10 p.m., with the IP, the IP stated he has not seen or used the facility's policy and procedure titled Antibiotic Stewardship Program, dated 5/29/24. The IP stated he did not review the Medication Regimen Review (MRR, a review of all 055316 Page 65 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. prescribed medications) of Resident 21. The IP further stated he does not have any documentation of tracking and monitoring of antibiotic use for all residents on antibiotics in the facility. During a concurrent interview and record review, on 5/23/25 at 1:13 p.m., with the IP, the facility's antibiogram report, dated 1/2024 to 4/2025, did not include the antibiotic Azithromycin. The IP stated he does not know why Azithromycin was not in the report. Review of the physician's order, dated 4/19/25, indicated Resident 21 was on Azithromycin tablet 250 milligrams (mg, unit of measurement) one time a day every Monday, Wednesday, Friday for Chronic Bronchitis. The physician order does not have an end date (stop date). During a concurrent interview and record review on 5/23/25 at 1:03 p.m., with the CP, the CP stated the physician's order for Azithromycin, dated 4/19/25, did not have an end date. The PC stated she should have asked the physician for the end date. During a concurrent interview and record review on 5/23/25 at 2:27 p.m., with the Director of Nursing (DON), the DON stated antibiotic program was created to make sure that the appropriate antibiotic for the residents was prescribed and not just the physician prescribing without justification. The DON stated the McGeer Criteria should be followed when the physician orders an antibiotic. The DON further stated there was no indication that the MRR for Resident 21 was reviewed by the IP. During a review of the facility's policy and procedure (P&P), titled Antibiotic Stewardship Program, dated 5/29/25, indicated 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols .iii. The facility uses the (CDC's NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections .v. All prescriptions for antibiotics shall specify the dose, duration, and indication for use .b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotics is still indicated or adjustments should be made (e.g., antibiotic time-out). ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. iii. Antibiotics orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. iv. Monitor during each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic or any antibiotic regimen review .vii. A review of the facility's antibiogram will be performed every 18-24 months to guide development or revision of antibiotic use protocols or prescribing practices .11. Documentation related to the program is maintained by the Infection Preventionist . 055316 Page 66 of 67 055316 05/23/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility did not ensure the steam table was maintained in a safe operable condition according to manufacturer's guidelines and facility policy. Residents Affected - Some This failure had the potential to impact the ability of dietary staff to prepare and serve food in a safe and sanitary manner. 124 residents are receiving food from the kitchen. Note: The nursing home is disputing this citation. During an observation of the lunch trayline meal service on 5/21/25, [NAME] V (CK V), CK V was observed checking the food temperature placed in steam table. She checked the food which included puree biscuit, puree beef, and BBQ sauce then she asked the Dietary Aide (DA) to reheat those food. The steam table was observed missing one out of six switch knobs from the right and missing red light indicator that is on. During a concurrent observation and interview on 5/22/25 at 10:15 a.m., with [NAME] T (CK T), CK T confirmed the switch knob and red light was missing, she stated when turn on right is high, left is low, when it's flat is off. CK T further stated the steam table switch should be fixed and should have a switch knob. During a concurrent observation and interview on 5/22/25 at 10:34 a.m., with the Facility Services Manager (FSM), the FSM checked the steam table switch knob, and he confirmed one of six switch knobs is missing. During an interview on 5/22/25 at 10:52 a.m., with the Registered Dietitian (RD), the RD stated the steam table missing knob should be fix. The RD further stated kitchen equipment should be working properly. During a review of the facility policy titled Sanitation dated 2023 indicated, The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order . 6.Employees are to alert the FNS Director immediately to any equipment needing repair.7.The FNS Director (and/or cook in their absence) will report any equipment needing repair to the maintenance man . 055316 Page 67 of 67

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Citations

26 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Epotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0554GeneralS&S Dpotential for harm
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
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.
0605GeneralS&S Dpotential for harm
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
0656GeneralS&S Epotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Epotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0676GeneralS&S Dpotential for harm
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0695GeneralS&S Epotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0700GeneralS&S Dpotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0745GeneralS&S Dpotential for harm
F745 - The facility must provide medically-related social services to attain or
Provide medically-related social services to help each resident achieve the highest possible quality of life.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Epotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0757GeneralS&S Epotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0804GeneralS&S Epotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0808GeneralS&S Dpotential for harm
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0842GeneralS&S Epotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0881GeneralS&S Dpotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0908GeneralS&S Epotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.

FAQ · About this visit

Common questions about this visit

What happened during the May 23, 2025 survey of MOUNTAIN VIEW HEALTHCARE CENTER?

This was a inspection survey of MOUNTAIN VIEW HEALTHCARE CENTER on May 23, 2025. The surveyor cited 26 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MOUNTAIN VIEW HEALTHCARE CENTER on May 23, 2025?

Yes, 26 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed July 6, 2026. If you believe any information is inaccurate, report it here.

Health inspection·May 23, 2025