Other·April 11, 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 a standard abbreviated survey regarding investigation of a complaint conducted on 3/8/17, 3/9/17, 3/17/17, and 4/5/17. For Complaint CA00524747 regarding Quality of Care/Treatment, a federal deficiency was identified (see F314).

F314, 483.25(b)(1) had a scope and severity of an H, in addition A Class "B" Citation was issued. Inspection was limited to the specific complaint 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.

F314 SS=H TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(b)(1)

F314 (b) Skin Integrity (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and 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: EPM011 Facility ID: CA070000017 If continuation sheet 1 of 11 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 04/05/2017 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 (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement their prevention of pressure ulcers (injury to the skin and the underlying tissue resulting from prolonged pressure on the skin) policy including evaluating and assessing the residents' clinical conditions, implementing interventions, and monitoring and evaluating the impact of the interventions to promote healing, prevent infection, and prevent new ulcers from developing for three of three sampled residents (Residents 1, 2, and 3). These deficiencies resulted in the further development of pressure sores and other injuries. Findings: 1. Resident 1's clinical record was reviewed and indicated he was admitted in 2/2017 for rehabilitation following spinal surgery. His Minimum Data Set (MDS, an assessment tool), dated 2/17/17, indicated he was incontinent (insufficient control) of urine and feces and had Parkinson's disease (a disorder of the central nervous system affecting movement and often including tremors). His admission assessment did not indicate he had any pressure sores. Resident 1's Wound Assessment Report, dated 2/17/17, indicated he had a moisture related excoriation (abrasion or wearing off of the skin) on his coccyx (tailbone) measuring 8 centimeters (cm, unit of measurement) in length and 5 cm in width with a small amount of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EPM011 Facility ID: CA070000017 If continuation sheet 2 of 11 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 04/05/2017 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 serosanguinous drainage (drainage composed of plasma and blood). His nurses' notes, dated 2/17/17, indicated he was subsequently seen by a nurse practitioner (NP) later the same day who staged (classified) the open area on his buttocks as a Stage II (presents as an abrasion, blister or shallow crater) pressure ulcer. The facility's 24 Hour Reports (reports completed each shift to monitor nursing home residents and documenting any changes in the residents' status), dated 2/17/17, 2/18/17, and 2/19/17 indicated there was no documentation regarding Resident 1's pressure sore. The nursing notes, dated 2/18/17, 2/19/17, and 2/20/17 did not document any further assessments of his pressure sore and any evaluation of the impact of the interventions. Resident 1's physician progress note, dated 2/20/17, indicated he developed pressure ulcers on both of his buttocks. His right buttock had a Stage II pressure ulcer and his left buttock had an unstageable deep tissue injury (injury to tissues under the skin) with a larger area of non-blanchable erythema (intact skin with redness in a localized area not affected by light finger pressure). Resident 1's Wound Assessment Report, dated 2/21/17, indicated he had a deteriorated pressure ulcer on his coccyx measuring 8 cm in length by 6 cm in width. His nurses notes, dated 2/21/17, indicated a physician reassessed his pressure sore and determined the wound was unstageable because the base of the ulcer was covered by eschar (dark patch of dead skin on the wound surface). Resident 1's laboratory tests, dated 2/22/17, indicated he had an infection. He was started on antibiotics. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EPM011 Facility ID: CA070000017 If continuation sheet 3 of 11 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 04/05/2017 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 Resident 1's nurses notes, dated 2/23/17, indicated he had an 0.1 cm by 0.1 cm open area draining 120 cubic centimeters (cc, unit of measurement) of fluid, in addition to the pressure sore. His physician progress notes, 2/23/17, indicated the drainage was coming from the base of the scrotum (a pouch of skin containing the testicles). He was transferred to the acute hospital for further evaluation. Resident 1's hospital records, dated 2/23/17, indicated he was taken to the operating room for debridement (removal of damaged tissue) from the buttock wound. On 2/24/17, he returned to the operating room for further debridement. On 2/25/17, he returned again to the operating room for an incision and drainage (minor surgical procedure to release pus or pressure build up under the skin) of a perianal abscess (a collection of pus around the anus) and a colostomy (a surgical operation in which a piece of the intestine is diverted to an artificial opening in the abdomen to bypass the damaged portion of the intestine). During an interview on 3/7/17, at 12:45 p.m., with the director of nurses (DON), she stated Resident 1 had back surgery and was admitted to the facility for rehabilitation. She stated he was up and walking with physical therapy and could walk to the bathroom. During an interview on 3/7/17, at 2:25 p.m., with certified nurse assistant A (CNA A), she stated she provided care for Resident 1 on 2/11/17, 2/12/17, 2/17/17, and 2/18/17. She stated on 2/11/17 and 2/12/17, the skin on Resident 1's buttocks was fine. She stated on 2/17/17, she noted a purple discoloration around his rectum. CNA A stated she called her supervisor, the treatment nurse, and the case manager. She stated the treatment nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EPM011 Facility ID: CA070000017 If continuation sheet 4 of 11 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 04/05/2017 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 applied some cream. During an interview on 3/7/17, at 2:35 p.m., licensed vocational nurse B (LVN B) stated she was the supervisor CNA A called after the purple discoloration was noted on Resident 1's buttocks. She stated she thought Resident 1 had an excoriation around his anus. She stated she called the treatment nurse and the NP. LVN B stated the NP thought he had a Stage II pressure ulcer. LVN B stated Resident 1's physician came in a few days later and said he had a Stage II pressure ulcer on the right buttock and a deep tissue injury on the left buttock. She stated a few days after the physician diagnosed the pressure ulcer and the deep tissue injury, the treatment nurse asked her to look at Resident 1's buttocks. LVN B stated she observed a boil (painful, pus-filled bump under the skin) on his scrotum which was draining fluid in addition to the pressure sore and the deep tissue injury. She stated she called the case manager who called the physician. During an interview on 3/7/17, at 2:45 p.m., with CNA C, she stated she provided care for Resident 1 on 2/13/17, 2/14/17, 2/15/17, and 2/19/17. She stated he walked to the bathroom by himself and on 2/13/17, when she was helping him clean up, she noted he had redness on his buttocks. She stated she reported her findings to the charge nurse, registered nurse D (RN D). She stated she did not know what the RN did after she made her report. During an interview on 3/7/17, at 2:55 p.m., with LVN E, she stated she was one of the treatment nurses who are LVNs. She stated as a LVN, she provided treatment but she did not assess or describe the wound. She stated the RNs were supposed to assess the wound FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EPM011 Facility ID: CA070000017 If continuation sheet 5 of 11 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 04/05/2017 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 every shift for 72 hours after the resident had a change in condition. She stated the discovery of Resident 1's pressure sore on 2/17/17 was a change of condition and there should have been an assessment every shift for the next 72 hours. She reviewed Resident 1's clinical record and stated there were no assessments of Resident 1's pressure sore between 2/17/17 and 2/21/17 and no evaluation of the impact of the interventions. During an interview on 3/17/17, at 1:05 p.m., with LVN F, she stated she was one of the treatment nurses. She stated she performed Resident 1's initial skin assessment when he was admitted and she did not see any discoloration or pressure sores on his buttocks. She stated she was asked to see Resident 1 on 2/17/17 and she saw an excoriation on his buttock. She stated the charge nurse called the case manager and Resident 1 was seen by the NP who thought the resident had a Stage II pressure sore. LVN F stated when a resident has a change of condition, such as a pressure sore, the RN on each shift should chart an assessment of the pressure sore for the next 72 hours. She reviewed the clinical record and stated there was no charting regarding Resident 1's pressure sore for the next three days. During an interview on 3/17/17, at 1:55 p.m., RN D stated she was the nurse who provided care for Resident 1 from 2/12/17 through 2/15/17 and on 2/18/17 through 2/21/17 on the day shift. She stated she has no recollection of anyone telling her Resident 1 had redness on his buttocks on 2/14/17. She also stated she has no recollection of anyone telling her he had a Stage II pressure ulcer on his buttocks on 2/18/17, 2/19/17, and 2/20/17. She stated when a resident has a change in condition, such as a pressure sore, the RN on each shift FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EPM011 Facility ID: CA070000017 If continuation sheet 6 of 11 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 04/05/2017 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 should chart an assessment of the pressure sore for the next 72 hours. She stated she did not assess his pressure sore from 2/18/17 through 2/20/17, because she did not know he had a pressure sore. She also stated there was no documentation on the 24 Hour Report indicating Resident 1 had a pressure sore until 2/20/17. During an interview on 3/17/17, at 2:20 p.m., with the director of staff development (DSD), she stated when a resident has a change in condition, such as a pressure sore, the RN on each shift should chart an assessment of the pressure sore for the next 72 hours and the information regarding the change of condition should be documented on the 24 Hour Report. She reviewed the 24 Hour Reports from 2/17/17 through 2/20/17 and stated there was no documentation indicating Resident 1 had a pressure sore until 2/20/17. 2. Resident 2's clinical record was reviewed and indicated she was admitted in 2/2017 following a cerebral infarction (a lack of blood flow resulting in severe brain damage) with left sided hemiplegia (paralysis), a tracheostomy (a tube inserted in her windpipe to open a restricted airway and enable breathing), a gastrostomy tube (a tube inserted through the abdominal wall into the stomach for the infusion of nutrition and medications), and an indwelling catheter (a tube inserted into the bladder to drain urine). Her initial assessment indicated she was incontinent. No discoloration on her buttocks was noted. A physician order, dated 2/9/17, indicated a barrier cream was to be applied to Resident 2's buttocks every shift as a preventive measure. Her Treatment Administration Record (TAR) indicated the barrier cream was applied only once a day. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EPM011 Facility ID: CA070000017 If continuation sheet 7 of 11 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 04/05/2017 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 Resident 2's nurses note, dated 2/16/17, indicated she had an excoriation on her left buttock with no bleeding or drainage noted. Her Wound Assessment Report, dated 2/16/17, indicated the excoriation was 4 cm by 3 cm and red. Resident 2's nurse's note, dated 2/23/17, indicated the excoriation on her buttock was reassessed and was healing well. Her Wound Assessment Report, dated 2/23/17, indicated her excoriation was 4 cm by 2.7 cm. Resident 2's nurse's note, dated 3/2/17, indicated the excoriation on her buttocks increased in size and the drainage remained the same. Her Wound Assessment Report, dated 3/2/17, indicated her excoriation was 5 cm by 4 cm and had increased in size. Resident 2's nurse's note, dated 3/9/17, indicated the excoriation on her buttocks increased in size and scant sanguineous drainage (fresh blood) was noted. Her Wound Assessment Report, dated 3/9/17, indicated her excoriation was 7.3 cm by 5 cm and the size and the amount of drainage had increased. Resident 2's nurse's note, dated 3/16/17, indicated the DON reassessed the left coccyx wound and noted the 8 cm by 8 cm wound was a suspected deep tissue injury due to a rapid deterioration of the wound with 50% granulation (indication healing taking place) and 50% eschar tissue. Her Wound Assessment Report, dated 3/16/16, indicated she had an unstageable 8 cm by 8 cm pressure sore. The pressure sore was unstageable due to slough (yellow nonviable tissue) and eschar. Resident 2's nurses notes for the 72 hours after FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EPM011 Facility ID: CA070000017 If continuation sheet 8 of 11 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 04/05/2017 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 the excoriation was initially noted on 2/16/17 did not include any documentation of additional assessments performed by each shift. The nurses notes, dated 3/2/17 and 3/9/17, when the excoriation was increasing in size and when there was a change in the drainage, did not document any additional assessments performed by each shift in the following 72 hours. The nurses notes, dated 3/17/17, the day following the documentation of the suspected deep tissue injury, did not indicate any further assessments of her pressure sore were performed. During an interview on 3/17/17, at 2:30 p.m., with the director of staff development (DSD), she reviewed Resident 2's chart and stated there was an order to apply a barrier cream to the resident's buttocks every shift for preventative measures starting 2/9/17. She stated the documentation in the chart indicated the cream was only applied once a day and not every shift. She also stated when a resident has a change in condition, the RN on each shift should chart an assessment of the excoriation or pressure sore for the next 72 hours. She confirmed the nurses notes for the 72 hours after the excoriation was initially noted on 2/16/17 did not include any documentation of additional assessments performed by each shift; the nurses notes, dated 3/2/17 and 3/9/17, when the excoriation was increasing in size and when there was a change in the drainage, did not document any additional assessments performed by each shift in the following 72 hours; and the nurses notes, dated 3/17/17, the day following the documentation of the suspected deep tissue injury, did not indicate any further assessments of her pressure sore were performed. 3. Resident 3's clinical record was reviewed and indicated he was admitted in 2/2017 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EPM011 Facility ID: CA070000017 If continuation sheet 9 of 11 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 04/05/2017 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 following a left total knee revision due to an infected total knee arthroplasty (surgical reconstruction or replacement of a joint). His initial assessment did not indicate he had any pressure ulcers on his heels. Resident 3's nurses notes, dated 2/9/17 through 2/27/17, indicated he had a foot cradle (a wire frame raising sheets, blankets, and covers up above the users feet, keeping the weight off the lower legs and feet) in place. On 2/27/17, his nurses notes indicated he was seen by his physician because his right foot was irritated by the foot cradle and some blanchable redness (loss of all redness when pressed) was noted on his heel. The foot cradle was removed and a longer bed was requested to accommodate his height. Resident 3's nurses notes, dated 2/28/17, indicated he was seen by a NP who assessed his right heel and noted a suspected deep tissue injury. His physician order, dated 2/28/17, indicated he was to wear heel protectors while he was in bed. During an observation on 3/17/17, at 2:50 p.m., Resident 3 was sitting up in bed reading. He was dressed in a hospital gown with a blanket over his legs but not his feet. His feet were exposed and he was not wearing any heel protectors. During an interview and observation on 3/17/17, at 3 p.m., RN D confirmed Resident 3 was not wearing any heel protectors. She stated he was supposed to wear heel protectors while he was in bed. Review of the facility's 2001 policy, revised in 10/2010, "Prevention of Pressure Ulcers", indicated a timely assessment should be performed and pressure sores are made worse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EPM011 Facility ID: CA070000017 If continuation sheet 10 of 11 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 04/05/2017 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 by continual pressure, moisture, and irritating substances on the resident's skin such as feces and urine. A change in the condition of the pressure sore should be recognized, evaluated, reported to the physician, and addressed timely. The condition of the resident's skin should be routinely assessed and documented and signs of a developing pressure ulcer should be immediately reported to the supervisor. Efforts should be made to stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate. Causes of moisture should be addressed, skin should be protected by a skin barrier, and heels should be protected with devices prescribed by the physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EPM011 Facility ID: CA070000017 If continuation sheet 11 of 11