Health inspection·May 28, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 service provided to meet professional standards for two of three residents (1 and 2) when their fall risk assessments were not done quarterly. This failure resulted in the residents' fall risk and fall prevention not updated to the residents' conditions to prevent the residents from falling. Residents Affected - Some Note: The nursing home is disputing this citation. Findings: Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE] with respiratory disorders and difficulty in walking diagnoses. Review of Resident 1's clinical record indicated he did not have any quarterly fall risk assessment. Review of Resident 1's Change in Condition Evaluation, dated 2/17/25, indicated Resident 1 slid down from the commode in his restroom and layed on the floor. Review of Resident 2's admission Record indicated she was admitted to the facility on [DATE] with dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) diagnosis. Review of Resident 2's clinical record indicated she did not have quarterly fall risk assessment done in 5/2024. Review of Resident 2's Change in Condition Evaluation, dated 8/7/24, indicated Resident 2 was found sitting on the floor next to the edge of her bed. Resident 2 stated that she tried to ambulate self to bedside commode, felt weak, and sat down to the floor. During an interview with the director of nursing (DON) on 5/14/25, at 4 p.m., she reviewed Resident 1's and Resident 2's clinical records and confirmed that Resident 1 did not have any quarterly fall risk assessment, and Resident 2 did not have quarterly fall risk assessment done in 5/2024. The DON stated the residents' fall risk assessment should be done every quarter. Review of the facility's policy, Fall Prevention Program, dated 3/1/23, indicated . 5. g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. Page 1 of 3 055316 055316 05/28/2025 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** Based on interview and record review, the facility failed to ensure the residents received the necessary care and services Residents Affected - Some 1. For one of three residents (3) when Resident 3's order from the acute care was not followed; and Note: The nursing home is disputing this citation. 2. For three of three residents (3, 4, and 5) when the licensed nurses did not administer Resident 3, 4, and 5's blood pressure medications as ordered by the physician. These failures could negatively impact the residents' health and well-being. Findings: 1. Review of Resident 3's admission Record indicated he was admitted to the facility on [DATE] with benign prostatic hyperplasia (enlarged gland in the male reproductive system) and obstructive and reflux uropathy (a blockage in the urinary tract, preventing normal urine flow, and urine flows backward from the bladder instead of exiting the body) diagnoses. Review of Resident 3's clinical record indicated he had a Foley catheter (a soft and flexible tube inserted into the bladder to drain urine). Review of Resident 3's acute care Interagency Discharge Summary and Orders, dated 2/6/25, indicated that Resident 3 had a urology referral (a formal direction from a primary care physician or other healthcare provider for specialized care related to the urinary system), and his void trial (a clinical procedure involves removing the urinary catheter and monitoring the patient's bladder emptying capabilities) would be under supervision of urology (a part of health care that deals with diseases of the urinary tract) on 2/10/25. However, review of Resident 3's Nurses Progress Note, dated 2/12/25, at 7 a.m., indicated Resident 3's void trial was performed at the facility without supervision of urology. His Foley catheter was removed. Review of Resident 3's Progress Note, dated 2/12/25, at 3:27 p.m., indicated Resident 3's post-void residual (PVR, the amount of urine remaining in the bladder after a person has urinated) was 780 milliliters (ml, a metric unit of volume). The licensed nurse attempted to empty Resident 3's bladder with straight catheter (a flexible tube used to drain urine from the bladder on a temporary basis) three times but was unsuccessful. Resident 3 had discomfort with the procedure performed of emptying the bladder via straight catheter and was sent out to acute care for Foley catheter placement. During an interview with the director of nursing (DON) on 5/14/25, at 4:35 p.m., she reviewed Resident 3's 2/6/25 acute care Interagency Discharge Summary and Orders and stated that Resident 3's void trial should be performed under supervision of urology. Review of the facility's policy, Medication Orders, dated 7/1/23, indicated . 5. c. Written Transfer Orders (sent with a resident by a hospital or other health care facility) - Implement a transfer order without further validation, if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned, or signed by another physician, or the date is other than the 055316 Page 2 of 3 055316 05/28/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Note: The nursing home is disputing this citation. date of admission, the receiving nurse should verify the order with the current attending physician before medications are administered. The nurse should document verification on the admission order record, by entering the time, date, and signature. 2a. Review of Resident 3's admission Record indicated he was admitted to the facility on [DATE] with hypertension (HTN, high blood pressure) diagnosis. Review of Resident 3's physician order, dated 3/6/25, indicated he had an order for hydralazine (used to treat HTN) 25 milligrams (mg, a metric unit of mass) every 8 hours as needed for systolic blood pressure (SBP, it measures the pressure the blood is pushing against the artery walls when the heart beats) greater than 160. Review of Resident 3's medication administration record (MAR), dated 3/2025, indicated the licensed nurse administered hydralazine 25 mg to Resident 3 on 3/11/25 when his SBP was 151, and the licensed nurse did not administer hydralazine 25 mg to Resident 3 on 3/7/25, 3/14/25, and 3/15/25 when his SBP was 172, 175, and 165. 2b. Review of Resident 4's admission Record indicated she was admitted to the facility on [DATE] with HTN diagnosis. Review of Resident 4's physician order, dated 4/23/25, indicated she had an order for hydralazine 25 mg every 6 hours as needed for SBP greater than 160. Review of Resident 4's 5/2025 MAR indicated the licensed nurse did not administer hydralazine 25 mg to Resident 4 on 5/6/25 when her SBP was 162. 2c. Review of Resident 5's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 5's physician order, dated 3/4/25, indicated she had an order for losartan potassium (used to treat HTN) 25 mg every day for HTN, hold for SBP less than 110. Review of Resident 5's 4/2025 MAR indicated the licensed nurse administered losartan potassium 25 mg to Resident 5 on 4/19/25 when her SBP was 105. During an interview with the director of nursing (DON) on 5/14/25, at 4:20 p.m., she reviewed Resident 3's 3/2025 MAR, Resident 4's 5/2025 MAR, and Resident 5's 4/2025 MAR and confirmed that the licensed nurse administered hydralazine 25 mg to Resident 3 on 3/11/25 when his SBP was 151, and the licensed nurse did not administer hydralazine 25 mg to Resident 3 on 3/7/25, 3/14/25, and 3/15/25 when his SBP was 172, 175, and 165; the licensed nurse did not administer hydralazine 25 mg to Resident 4 on 5/6/25 when her SBP was 162; and the licensed nurse administered losartan potassium 25 mg to Resident 5 on 4/19/25 when her SBP was 105. Review of the facility's job description, Registered Nurse (RN), dated 5/2022, indicated . Resident Care Functions: . Administer medications according to practitioner orders . 055316 Page 3 of 3