Other·February 8, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey regarding investigation of three complaints conducted on 1/19/17, 1/20/17, 2/1/17, and 2/2/17. For Complaints CA00517443 and CA00520482 regarding Admission, Transfer, and Discharge Rights, a federal deficiency was identified (see

F206). For Complaint CA00517408 regarding Quality of Care/Treatment, the Department did not substantiate a violation of federal or state regulations. A Class "B" Citation on Permitting Resident Return to the Facility was issued for F206. Inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 29259, Health Facilities Evaluator Nurse.

F206 SS=D POLICY TO PERMIT READMISSION BEYOND BED-HOLD CFR(s): 483.15(e)(1)(2)

F206 (e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKNF11 Facility ID: CA070000017 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055316 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MOUNTAIN VIEW HEALTHCARE CENTER 2530 Solace Pl Mountain View, CA 94040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. (e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to readmit one of one sampled resident (Resident 1) following a hospitalization during a seven-day bed hold period and to follow the Department of Health Care Services' Administrative Appeals' order to readmit the resident. These failures violated the resident's right to readmission as required by law. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKNF11 Facility ID: CA070000017 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055316 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MOUNTAIN VIEW HEALTHCARE CENTER 2530 Solace Pl Mountain View, CA 94040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Resident 1's clinical record was reviewed and indicated she was admitted to the facility in 7/2016. Her Minimum Data Set (MDS, an assessment tool), dated 10/20/16, indicated she was cognitively intact. A physician order, dated 7/14/16, indicated she was capable of making healthcare decisions. Resident 1's progress note, dated 7/13/16, indicated the resident refused to sign the Standard Admission Agreement. Resident 1 deferred to a family member and he also refused to sign the agreement. There was no documentation indicating the family member was the responsible party (RP, individual designated to make medical decisions) or had power of attorney. Numerous attempts were made by the facility to have the Standard Admission Agreement signed, but to no avail. Resident 1's progress note, dated 12/28/16, indicated she had a fever and a headache. Her physician was called and a chest X-ray and laboratory tests were ordered. The family member refused to allow the laboratory tests to be drawn. Resident 1's progress note, dated 1/2/17, indicated she vomited. Her physician was called and visited on 1/3/17. A physician order, dated 1/3/17, indicated she was to be transferred to the hospital for further evaluation. The Bed Hold Request Form, dated 1/3/17, indicated the resident consented to a sevenday bed hold. During interviews with the administrator (ADM) on 1/19/17, at 11 a.m., and 2/1/17, at 1:15 p.m., she stated Resident 1 refused to sign any documents and never produced any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKNF11 Facility ID: CA070000017 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055316 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MOUNTAIN VIEW HEALTHCARE CENTER 2530 Solace Pl Mountain View, CA 94040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE documents indicating her family member was the RP or had power of attorney. She stated when the hospital called on 1/9/17 to transfer the resident back pursuant to the bed hold, the facility refused unless the Standard Admission Agreement was signed. The ADM stated a hearing was held before the State of California, Department of Health Care Services on 1/19/17 and the hearing officer ordered the facility to take back Resident 1. She stated the facility refused to take back the resident, and she was transferred to another facility on 1/20/17. The ADM further stated Resident 1 became ill at the other facility and was transferred to the hospital six days later. She stated the resident needed surgery and remained hospitalized. During an interview with the hospital social worker (HSW) on 2/2/17, at 10:30 a.m., she stated Resident 1 was transferred to the hospital on 1/3/17 for treatment of pneumonia. She stated while the resident was a patient in the hospital she refused to sign any papers as did her family member. The HSW stated the facility refused to take back the resident so the resident was transferred to another facility where she also refused to sign any papers. She stated after Resident 1 became ill at the other facility on 1/26/17, she was transferred back to the hospital where she remained hospitalized. The HSW stated Resident 1's physician thought the resident needed surgery but the resident would not consent. Review of the Department of Health Services' Administrative Appeals Final Decision and Order, dated 1/30/17, indicated the facility must immediately readmit Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UKNF11 Facility ID: CA070000017 If continuation sheet 4 of 4