Health inspection·December 4, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient preparation and orientation to ensure a safe and appropriate discharge for one of three residents (1) procedures to discharge on e of three residents (1) when: 1. The facility did not follow their policy on, Against Medical Advice (AMA, a patient's decision to leave a healthcare facility or discontinue treatment despite the recommendations of their doctor) when Resident 1 was discharged AMA after he did not return to the facility when he went out on pass (a temporary absence for an inpatient who has received official permission to leave a hospital or care facility but is not being officially discharged ) for several hours.2. The facility did not provide Resident 1 with the discharge notice (a written notice in advance to the resident and the resident's representative in a language and manner they understand and an opportunity to appeal) timely (30 days before discharge or as soon as possible).3. Resident 1 also did not have discharge care plan to include some of his discharge needs such as medication management (the process of ensuring prescription drugs and other medications are used correctly to maximize safety and effectiveness), Home Health (services provided by health care provider to resident after discharge to home) referral , DME (durable medical equipment, is medical equipment that is durable, can be reused, and is prescribed by a doctor for use in a patient's home)needed, etc.).The post-discharge plan of care did not address Resident 1's limitations and his ability to care for himself. 4. Facility did not have any interdisciplinary care team (IDT, interdisciplinary team, a group of professionals from different fields who collaborate to achieve a common goal)meeting to discuss Resident 1's discharge plan /needs, did not identify the location of his discharge, and/or complete a referral to appropriate community agency placement (is the arrangement of an individual with a community-based program or service to meet a specific need, such as for care and housing).5. Resident 1 did not have a discharge summary (is a medical document that provides a comprehensive overview of a patient's hospitalization, including their diagnosis, treatment, procedures, and follow-up care instructions to serve as an important communication tool between healthcare providers, ensuring that the patient's primary care physician or other healthcare professionals have all the necessary information to continue their care effectively) that included assistance needed for him to adjust to his new living environment.6. These failures endangered the health and safety of Resident 1 who was unexpectedly discharged from the facility without proper preparation for appropriate placement and/or home health referral, medication management, medical equipment set up, and follow-up medical appointments. Resident 1's whereabouts was unable to locate. 1. A review of iQIES (Internet Quality Improvement and Evaluation System, is used to manage provider and patient information and ensure quality healthcare for Medicare and Medicaid beneficiaries) complaint received on 10/9/2025, indicated, (Resident 1 called to report that he was discharged from the facility on 10/07/25 because the facility stated that he no longer needed that level of care. On the day (10/6/25) he left the facility to Page 1 of 6 055316 055316 12/04/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few run errands. His car broke down, and he was gone for 5 - 6 hours. When he returned from auto parts store, he was discharged . The facility they did not want to provide medication. After going back and forth for over an hour with the facility some medication was provided . During a review of Resident 1's face sheet (a document that summarizes a patient's key demographic and medical information for quick access) it indicated he was admitted to the facility on [DATE] and was discharged AMA on 10/7/25. He had diagnoses including polyneuropathy (is a condition in which multiple peripheral nerves {A nerve is an organ composed of multiple nerve fibers bound together by sheaths of connective tissue throughout the body become damaged or dysfunctional {means a state of not functioning normally, or a problem that disrupts a system's normal operations}), acute on chronic systolic (congestive) heart failure (a sudden worsening of symptoms in individuals with an existing condition of chronic systolic heart failure {a lifelong condition for heart muscle weakens and difficult for the heart to pump blood effectively}) shortness of breath (SOB, is an uncomfortable feeling of not being able to breathe well enough), chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems), obstructive sleep apnea (is a sleep-related breathing disorder ) and need for assistance with personal care, hypertension (HTN, high blood pressures, a condition where the force of blood against artery walls is consistently too high, making the heart work harder and increasing the risk of heart, brain, and kidney diseases ), pacemaker (is a small, battery-powered device that prevents the heart from beating too slowly), Atherosclerotic cardiovascular disease (ASCVD, is a hardening of your arteries from plaque (a small, abnormal patch of tissue on a body part or an organ) building up gradually inside them to cause cardiovascular diseases ). During a review of Resident 1's minimum data set (MDS, an assessment tool), dated 9/6/25, it indicated his brief interview for mental status (BIMS, is a quick, mandatory cognitive (is relating to or involving the processes of thinking and reasoning ) screening tool used in long-term care to assess a person's orientation, attention, and memory) was intact with score of 15 and his functional abilities (the skills and capacities a person has to perform daily tasks, ranging from basic self-care like dressing and eating to more complex activities such as financial management, communication, and professional work) for self-care (is the practice of deliberately taking actions to protect and improve one's own physical, mental, and emotional health) required setup or clean-up assistance for eating, oral hygiene, toileting, dressing, personal hygiene and putting and taking off footwear. He required supervision or touching assistance (is a level of support where a helper provides verbal cues, steadying, or light physical contact as a person completes an activity) for chair or toilet transfer, car transfer shower transfer or walk 10 feet were not attempted due to medical condition or safety concerns. During a review of Resident 1's Temporary Absence Release form indicated he went out on pass on the following dates and time: 9/11/25 at 15:40 (3:40 p.m.), 9/25/25 at 4:07 p.m., 9/26/25 at 10:22 a.m., 9/30/25 at 11 a.m., 10/2/25 at 11:30 a.m., 10/3/25 at 3:23 p.m., 10/4/25 at 11 a.m. and 10/6/25 at 1:30 p.m. During a review of Resident 1's progress notes, dated 10/6/25 at 9 p.m., it indicated, Patient went out in the morning and had not returned to the unit until late at night. Contacted patient by phone; patient stated he was on the way back. Instructed patient to obtain prior approval before going out and to notify the medical staff if they returning late. Education provided. During a review of Resident 1's progress notes, dated 10/7/25 at 1:17 a.m., it indicated, It is now 1:15 AM, patient hasn't come back yet. Called resident on his personal phone left a message. He called back after a few minutes; he said his car broke down and he was stuck at (store) waiting for it to open. He said he was trying to go to DMV (Department of Motor Vehicles, a state-level government agency responsible for managing driver's licenses, vehicle registrations, and state identification cards) but didn't 055316 Page 2 of 6 055316 12/04/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few make it on time. He said he would come back in the morning. Told him staff was wondering why he didn't come back? asked him if he was safe, he said Oh yes, I'm safe. Will endorse to next shift. Called emergency contact #2, left VM (voice message) to (emergency contact person) Will let supervisor know. During a review of Resident 1's progress notes, dated 10/7/25 at 10 :40 a.m., it indicated, (Resident 1) left facility to go to social security office on 10/6 at 13:30 (1:30 p.m.). Per (Resident 1) he will return within 2 (two) hours. Resident did not return as scheduled. Contact was made at approximately 2230 (10:30 p.m.) with (Resident 1) who informed him would be back at the facility by 2330 (11:30 p.m.). He did not come back to facility and did not establish contact before midnight 10/7 at approximately 1040 (10:40 a.m.) Call placed to (Resident 1) to inform that he has been discharged for AMA, and all personal belongings will be available to pick up with social services. During a review of Resident 1's progress notes, dated 10/7/25 at 2:30 p.m., it indicated, Pt (patient) asked to speak with SS (social service). Writer went outside to speak with them. Writer explained to pt that they did not come back when they said they would and that it was already explained to them (Resident 1) they would be discharged under our system under AMA, which they (Resident 1) already verbalized understanding to. Pt asked, Where am I supposed to go? Writer told pt they should reach out to the placement specialist we placed them with. Pt said, I can't afford that. Explained to pt that they could base off of previous conversations with patient, and they were only choosing not to. Pt said, What about food? Writer explained that the Room and Boards presented to them already provide food and a bed. Writer said, Their food wouldn't be enough for me; it's not enough at this facility anyways. Writer reiterated that it is their decision not to continue to the search for placement and SS has presented all they could to them. Pt said, What about my meds( medications), I can't not take my meds. Writer explained to pt that if they discharge under AMA, they don't receive their medication, and we could give them a list of what they were taking. Pt agreed to wanting the medication list. Writer printed out the list and gave it to PT (patient). Pt kept saying My phone was dead, how do you expect me to call you guys? Writer informed pt that this explanation wasn't a valid excuse due to them being able to answer the phone when our nursing staff called them in the middle of the night. Pt asked to speak with admin, this writer informed supervisor. During a review of Resident 1's AMA release form, dated 10/7/25, it indicated that Resident 1 refused to sign. During an interview on 10/10/25, at 10:40 a.m., with registered nurse A (RN A, the nurse supervisor), she stated Resident 1 had an order for out on pass for four hours and was required to complete the sign in sheet (is a document used to record the names, contact information, and arrival and departure times of individuals attending an event, entering a facility, or participating in an activity), and check in and out with a license nurse.During an interview on 10/10/25, at 12:34 p.m., with licensed vocational nurse B (LVN B), LVN B stated she was working the morning shift on 10/6/25 when Resident 1 went out on pass at 1:30 p.m. LVN B confirmed she was aware Resident 1 went out on pass at 1:30 p.m. of 10/6/25 and Resident 1 in the past always returned on time with no problems. LVN further stated Resident 1 was very independent; alert and oriented and he was short stay (is a temporary period of care, typically lasting from a few days up to several months, for individuals recovering from surgery, illness, or injury) in the facility for rehabilitation (a type of short-term therapy focused on helping a patient regain independence after an illness or injury, often through a coordinated care plan involving multiple therapists). During an interview on 10/10/25, at 1 p.m., with the social service director (SSD), the SSD stated, when Resident 1 did not return after midnight (on 10/6/25), he was already considered discharged from the facility. The SSD also stated, Resident 1 passed the time frame for out on pass; hence, he was discharged from the facility. The SSD further stated that Resident 1 was in 055316 Page 3 of 6 055316 12/04/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transitioning looking for placement they (social services) offered him the placement, but he refused, because he did not want to pay any money. So, on the next day of 10/7/25 when he returned to the facility it was afternoon already and Resident 1 was informed that he had been discharged for AMA in the morning by our assistant director of nursing (ADON). Resident 1 came back to pick up his belongings; we explained to him the reason why he was discharged AMA because he did not return as scheduled. The SSD stated Resident 1's medication list had been printed out and was given to him when he came back to pick up his belongings. During an interview on 10/10/25, at 4:15 p.m., with the director of nursing (DON), the DON stated, Resident 1's remaining medications were given to him on 10/7/25 when he came back to pick up his belongings. The DON explained why the facility discharged Resident 1 AMA, it was because he did not return phone calls from facility staff when his return to the facility was delayed, he only came back in the afternoon of the next day (10/7/25). During an interview on 10/16/25, at 2:48 p.m., with the social service assistant (SSA), the SSA stated Resident 1 did not let us know that his car was broken until after midnight when the night shift nurse called him by phone and found out that his car was broken and could not return to the facility. Resident 1 informed the nurse that he would be back in the morning the next day, but he did not. That's why when Resident 1 did not return as he supposed to be before midnight then he would consider to be AMA discharged . The SSA further stated that at nighttime there was no way to arrange transportation services for Resident 1. He was very alert, independent and carried a cellphone with him, so he could have called for driver services. The SSA stated although Resident 1 did not initiate the request to discharge or intend to leave, he was delayed in returning to the facility and exceeded the allowed hours for being out on pass, then he was considered discharged AMA. During a telephone interview on 10/16/25, from 3:05 p.m.to 3:30 p.m., with the ADON, she stated, Resident 1went out on pass and he did not return before midnight (on 10/6/25), so he was considered discharged AMA from the facility. The ADON further stated she had reminded Resident 1 twice before he left the facility, and on the evening when he did not return before midnight on 10/6/25 that he would automatically be discharged from the facility if he would not return on time. The ADON reviewed the facility's policy on Against Medical Advice- Discharge and verified and admitted that the policy did not indicate any information about discharging a resident automatically AMA when she/he goes out on pass and did not return back to the facility on time during this the temporary leave absence. During a telephone interview on 10/16/25, at 3:32 p.m., with Resident 1's family member (FM), the FM stated she was not able to get hold of Resident 1 after several phone call attempts to his cellphone. The FM also expressed feeling worried about Resident 1's health and safety because his whereabouts could not be determined until this time. During an interview on 10/20/25, at around 9:30 a.m., with the administrator (ADM), the ADM stated Resident 1 returned to the facility at around 2 p.m. on 10/7/25. The ADM confirmed he informed Resident 1 that he was already discharged from their system, and he offered Resident 1 two to three times to be admitted to the hospital across the street of the facility to get authorization (hospital admission to be admitted back to the long-term facility) then he would be able to come back for continued care at the facility. The ADM stated, as long as he goes to the hospital to get authorization then we will be able to get him here, so the only thing he needs to do is going to the hospital across the street, but he refused. He (Resident 1) told us, why would I go to the hospital? I am fine. A review of the facility's undated policy and procedures (P&P) titled, Against Medical Advice (AMA) Discharge Policy-Admission, Transferers and Discharges, the P&P indicated, If a resident or responsible party (RP) chooses to leave AMA, staff will respect their right to self -determination. The attending physician or on-call provider must be notified immediately. The assigned nurse or designee will 055316 Page 4 of 6 055316 12/04/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few document in the medical record including resident's or RP ‘s stated intent to leave AMA. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, revised April 2025, the P&P indicated, 1. Resident are permitted to return to the facility after therapeutic leave. A resident's extended therapeutic leave (in which a resident returns to the facility later than agreed upon) is not grounds for discharge. 2. Upon return, the resident will be assessed for any health consequences of being from the facility longer than expected and provided with any missed medications or treatments. 4. The facility will not discharge the resident unless it has ascertained from the resident or resident representative that he or she does not wish to return.A further review of the facility's undated policy and procedures (P&P) titled, Transfer or Discharge, Resident-Initiated, the P&P indicated, A resident's verbal or written notice of intent to leave against medical advice is considered a resident -initiated discharge. During a review of the Notice of Proposed Transfer or Discharge, dated on 10/7/25, it indicated the notice was completed on 10/8/25 but a copy was not provided Resident 1. During a further review of Resident 1's Medi-Cal (is California's state-r un version of the federal Medicaid program, providing low-cost or no-cost health coverage to low-income Californians, including families, seniors, persons with disabilities, and pregnant women) Long-Term Care Facility admission And Discharge Notification, dated 10/6/25, it indicated, Patient refused signature. During an interview on 10/10/25, at around 1:30 p.m., with the SSD, she confirmed that Resident 1 refused to sign on the Medi-Cal Long-Term Care Facility admission and Discharge Notification form dated 10/6/25 that indicated the date of discharge as 9/20/25. The SSD also indicated, Resident 1 was being transitioned to the community and was looking for placements. 3. During a review of Resident 1's nursing progress notes as late entry, dated 9/5/25, it indicated, Heart failure (HF, a progressive condition where the heart cannot pump blood effectively through the body) clinic called to check up on Resident 1- need daily weight r/t (related to) HF and f/u (follow-up) appointment on 9/9/25 at 2:30 p.m. During a review of Resident 1 skilled nursing facility's encounter notes for History and Physical transition of care dated 9/8/25, it indicated, Resident 1 sent from cardiology clinic presenting with chest pain (CP), SOB and 20 pounds weight gain from the past two weeks. Patient is here for CP and SOB. Reports sore (pain) on [NAME] (left upper chest) s/p (status post, is a medical term meaning after or following a specific event, procedure, or condition ) CRT-D (Cardiac Resynchronization Therapy with Defibrillator, a treatment to help restore the normal rhythm (timing pattern) of the heartbeat.)., s/p TAVR (Transcatheter Aortic Valve Replacement, refers to a minimally invasive procedure used to replace a narrowed or diseased aortic valve in the heart. ) 2022, COPD (chronic obstructive pulmonary disease, refers to a group of lung diseases that cause airflow obstruction and breathing problems), and chronic systolic heart failure (a condition where the heart's left ventricle (main pumping chamber) cannot pump blood effectively . In the ED (Emergency Department, is part of a hospital and provides 24/7 care, access to advanced diagnostics like CT scans, and surgical capabilities) he was found to have uncontrolled hypertension (elevated blood pressure and hypoxemia (a condition in which the blood has lower-than-normal levels of oxygen pressure) with oxygen saturations of 88% on room air. Reports pain over left anterior (front) chest wall at the site of ICD (implantable cardioverter-defibrillator/ a pacemaker, is a small battery-powered device placed in the chest. It detects and stops irregular heartbeats) implantation. During a review and concurrent interview on 10/10/25 at 2:10 p.m. with the DON, the DON confirmed Resident 1's care plans did not include any discharge care plan that would address his discharge needs such as medication management, Home Health referral, DME needed. During a review of Resident 1's social service assessment, dated 9/8/25, it indicated, Resident 1 is anticipated to stay in the facility on a short-term basis. Resident will participate in 055316 Page 5 of 6 055316 12/04/2025 Mountain View Healthcare Center 2530 Solace Place Mountain View, CA 94040

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discharge planning .Resident 1 would like to find placement. Resident 1 needs the following for a successful discharge: HH (home health, is a wide range of health care services that you can get in your home for an illness or injury), REFERRALS FOR SAFE DC DME (discharge durable medical equipment) (IDT). RESIDENT WAS PREVIOUSELY LIVING OUT OF THEIR CAR. UPON DC, RESIDENT WOULD LIKE PLACEMENT. 4. During a record review with SSD on 10/10/25 at 9:40 p.m., she confirmed Resident 1's electronic clinical records indicated no interdisciplinary team (IDT) meeting conducted to address the goal of discharge and planning, and a condition in which the blood has lower-than-normal levels of oxygen facility did not identify the location of his discharge and/or complete a referral to appropriate community agency placement. Resident 1 did not have a discharge summary that would indicate/include the assistance needed for Resident 1 ability to adjust to his new living environment.5. During an interview on 10/20/25, at 9:40 a.m., with the SSD, the SSD confirmed that the IDT meeting or discharge summary and plan for Resident 1 were missing and were not done, because there was no date for him to be discharged from the facility. The SSD further stated that the facility introduced a board and care home to Resident 1 during his facility stay and also upon his return to pick up his belongings, but Resident 1 refused for the referral of board and care home. A review of the facility's policy and procedures (P&P) titled, Discharge Summary and Plan, revised March 2025, the P&P indicated, When a resident's discharge is anticipated, a resident discharge summary is created. Every resident has an individual discharge plan, which begins at admission and is part of the comprehensive care plan. The purpose of the discharge plan is to ensure a safe transition from the facility to the post-discharge setting. The discharge plan is developed by the care planning/ interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the resident's discharge goals and needs that must be addressed before the resident can be safely discharged (e.g., caregiver support and education, rehabilitation, etc.). The discharge plan is re-evaluated based on changes in resident's condition or needs prior to discharge. 055316 Page 6 of 6