Other·January 6, 2020

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 1/2/20. For Complaint CA00668716 regarding Quality of Care/Treatment, a federal deficiency was identified (see F758) and a state deficiency was identified (see Section -72313(a)(2)) A Class "B" Citation was also 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: 38087, Health Facilities Evaluator Nurse.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- 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: 7MQ811 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 01/02/2020 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 §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure Resident 1 was free from unnecessary psychotropic drugs (medication capable of affecting the mind, emotions, and behavior) when Resident 1 received a psychotropic medication without a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MQ811 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 01/02/2020 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 physician's order. This failure placed Resident 1 at risk for side effects of the unnecessary medication. Findings: Review of Resident 1's clinical record indicated she was admitted on 9/17/19 with diagnoses including altered mental status, anemia (deficiency of red blood cells), chronic kidney disease (kidneys are damaged and cannot filter water and waste out of the blood), diabetes mellitus (abnormally high levels of sugar (glucose) in the blood), hypertension (abnormally high blood pressure), and history of falling. During an interview with licensed vocational nurse A (LVN A) on 12/31/19 at 2:00 p.m., she stated on 12/4/19 during the evening shift she was being oriented by licensed vocational nurse B (LVN B). LVN A further stated 12/4/19 was her third day of orientation in the facility. LVN A stated LVN B observed her prepare the 9:00 p.m. medications for Resident 1. She then entered Resident 1's room and administered two medications. LVN A further stated LVN B was not present in Resident 1's room when she administered medication to Resident 1. LVN A stated a family member was present at Resident 1's bedside and inquired about the medication LVN A administered to Resident 1. LVN A stated she referred to Resident 1's medication administration record (MAR) and discovered the two medications she had administered to Resident 1 were not listed on the MAR and were not prescribed for Resident 1. LVN A stated she administered sinemet (medication to treat Parkinson's disease (disorder of the central nervous system that affects movement) 50-200 milligrams (mg, unit of measure) and Seroquel (antipsychotic medication used to treat schizophrenia, bipolar FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MQ811 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 01/02/2020 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 disorder and depression) 25 mg to Resident 1. During an interview on 12/31/19 at 3:20 p.m., LVN B stated on 12/4/19 he was orienting a new employee [LVN A], and accompanied her during the evening medication pass. LVN B stated LVN A informed him that she had given two medications to Resident 1 that were not prescribed to her. He confirmed LVN A administered medications to Resident 1 when he was not present. LVN B stated during medication pass orientation, LVN A should not have administered any medication unsupervised. During an interview with the director of nursing (DON) on 12/31/19 at 1:45 p.m., she confirmed LVN A administered medications to Resident 1 which was not prescribed to her. The DON further stated licensed nurses who are being oriented during medication pass should not have administered any medications without direct supervision. Review of the facility's policy, "Administering Medications", revised December 2012, indicated highlights labeled "Supervision of New Personnel": The charge nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7MQ811 Facility ID: CA070000017 If continuation sheet 4 of 4