Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of
Resident 3's MDS, dated [DATE], indicated he required extensive assistance (staff provide weight-bearing
support) from two or more people for transfers. The MDS also indicated the bed rail was coded as a
physical restraint for Resident 3.
Residents Affected - Some
During an observation on 8/22/19 at 10:30 a.m., Resident 3 was sitting on his chair in his room. His bed
was equipped with partial bed rails (rails that did not cover the entire length of the bed). He was unable to
move his left arm and left leg.
During an interview with MDSN B and MDSN C on 8/23/19 at 12:43 p.m., they both confirmed Resident 3's
bed rails were not restraints because he could not voluntarily get out of bed, even if the bed rails were not
present.
5. Review of Resident 10's MDS, dated [DATE], indicated she required extensive assistance from one
person for transfers. The MDS also indicated the bed rail was coded as a physical restraint for Resident 10.
During an observation and concurrent interview with Resident 10 on 8/21/19 at 1:56 p.m., Resident 10 was
sitting on her chair in her room. Her bed was equipped with short rails near the head of the bed. Resident
10 stated the short rails helped her move and did not restrain her.
During an interview with MDSN B and MDSN C on 8/23/19 at 12:39 p.m., they both confirmed the short
rails near the head of Resident 10's bed were not restraints. MDSN B and MDSN C also confirmed
Resident 10 could not voluntarily get out of bed, even if the bed rails were not present.
6. Review of Resident 30's MDS, dated [DATE], indicated he required extensive assistance from two or
more people for transfers. The MDS also indicated the bed rail was coded as a physical restraint for
Resident 30.
During an observation and concurrent interview with Resident 30 on 8/21/19 at 8:30 a.m., Resident 30 was
lying in his bed, which was equipped with partial rails. Resident 30 stated the bed rails helped him move
and did not restrain him.
During an interview with MDSN B and MDSN C on 8/23/19 at 12:42 p.m., they both confirmed Resident
30's bed rails were not restraints because he could not voluntarily get out of bed, even if the bed rails were
not present.
7. Review of Resident 42's MDS, dated [DATE], indicated she required extensive assistance from one
(continued on next page)
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
555835
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/23/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at Palo Alto
600 Sand Hill Road
Palo Alto, CA 94304
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
person for transfers. The MDS also indicated the bed rail was coded as a physical restraint for Resident 42.
Level of Harm - Minimal harm
or potential for actual harm
During an observation and concurrent interview with Resident 42 on 8/21/19 at 8:53 a.m., Resident 42 was
lying in her bed, which was equipped with short rails near the head of the bed. Resident 42 stated the short
rails helped her move and did not restrain her.
Residents Affected - Some
During an interview with MDSN B and MDSN C on 8/23/19 at 12:45 p.m., they both confirmed the short
rails near the head of Resident 42's bed were not restraints. MDSN B and MDSN C also confirmed
Resident 42 could not voluntarily get out of bed, even if the bed rails were not present.
Review of the RAI manual indicated a device should be classified as a restraint only when it meets the
criteria of the restraint definition. The RAI manual further indicated, If the resident is immobile and cannot
voluntarily get out of bed because of a physical limitation or because proper assistive devices were not
present, the bed rails do not meet the definition of a physical restraint.
Based on observation, interview, and record review, the facility failed to accurately code the minimum data
set (MDS, an assessment tool) for seven of 12 sampled residents (Residents 16, 19, 41, 3, 10, 30, and 42).
For Resident 16, the facility inaccurately coded the use of a medication. For Residents 19, 41, 3, 10, 30,
and 42, the facility inaccurately coded bed rails as physical restraints. Failure to accurately assess the
residents had the potential for inappropriate care planning and interventions.
Findings:
1. Review of Resident 16's MDS' dated 9/22/18, 12/23/18, 3/25/19, and 6/25/19 under Section M
Medications, indicated Resident 16 received anticoagulant (blood thinner, medication that slows down
clotting).
Review of Resident 16's physician order report indicated an order for Plavix (clopidogrel, antiplatelet
medication that prevents clots from forming and growing) 75 milligrams once a day for stroke prevention.
During an interview with minimum data set nurse B (MDSN B) on 8/23/19 at 10:59 a.m., MDSN B stated
they thought Plavix was an anticoagulant. MDSN B confirmed Resident 19 was not on an anticoagulant but
was an antiplatelet medication.
2. Review of Resident 19's clinical record indicated diagnoses of muscle weakness, difficulty in walking,
restless leg syndrome, and reduced mobility.
Review of Resident 19's MDS dated [DATE] under Section P Restraints and Alarms, indicated the bed rail
was used daily as a physical restraint for Resident 19. Under Section G Functional Status, it indicated
Resident 19 needed extensive assistance with two or more person assist for bed mobility and transfers.
Review of Resident 19's physician orders report dated 7/10/18, indicated an order that Resident 19 may
use quarter side rails as enablers for assistance with transfers, bed mobility and aid in position while at the
facility.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555835
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/23/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at Palo Alto
600 Sand Hill Road
Palo Alto, CA 94304
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an observation and interview on 8/20/19 at 10:07 a.m., Resident 19 was in bed with one side rail up.
Resident 19 stated the side rail was to help her move around in bed. Resident 19 stated she was able to
move around once in the wheelchair but needed help with transferring.
During an interview with the registered nurse supervisor (RNS) on 8/23/19 at 11:37 a.m., the RNS stated
Resident 19 was unable to physically get out of bed by herself and needed two people to physically get
Resident 19 out of bed to a wheelchair.
During an interview with MDSN B and MDSN C on 8/23/19 at 12:31 p.m., MDSN B and MDSN C confirmed
Resident 19 was not able to get out of bed by herself with or without the side rail present.
3. Review of Resident 41's clinical record indicated the diagnoses of hemiplegia (paralysis on one side of
the body) and hemiparesis (weakness on one side of the body), Parkinson's disease (loss of nerve cells in
the brain affecting movement), muscle weakness and difficulty in walking.
Review of Resident 41's MDS dated [DATE] under Section P Restraints and Alarms indicated the bed rail
was used daily as a physical restraint for Resident 41. Under Section G Functional Status, it indicated
Resident 41 needed extensive assistance with two or more person assist for bed mobility and transfers.
Review of Resident 41's physician orders report dated 7/31/19 indicated an order that Resident 41 may use
quarter side rails as enablers for assistance with transfers, bed mobility and aid in position while at the
facility.
During observation and interview on 8/20/19 at 1:46 p.m., Resident 41 was observed lying in bed with two
side rails up on both sides of the bed.
During another observation and interview on 8/23/19 at 8:23 a.m., Resident 41 was lying in bed with two
side rails up on both sides of the bed. Resident 41's family member was also at bedside. Resident 41 stated
the side rail does not restrain me at all. Resident 41 stated he was not able to physically get out of the bed
by himself.
During an interview with registered nurse D (RN D) on 8/23/19 at 11:39 a.m., RN D stated Resident 41 was
not able to get out of the bed by himself and needed at least a two person assist to get out of bed and into
a wheelchair due to Resident 41's condition.
During an interview with MDSN B and MDSN C on 8/23/19 at 12:31 p.m., MDSN B and MDSN C confirmed
Resident 41 was not able to get out of bed by himself with or without the side rail present.
Review of the Minimum Data Set 3.0 Resident Assessment Instrument User's Manual version 1.16 (RAI
manual, MDS coding instructions) dated 10/2019 indicated if the resident is immobile and cannot voluntarily
get out of bed because of a physical limitation or because proper assistive device were not present, the bed
rails do not meet the definition of a physical restraint.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555835
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/23/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at Palo Alto
600 Sand Hill Road
Palo Alto, CA 94304
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview and document review, the facility's pharmacy failed to ensure there was no
expired medication in one of three emergency kits (E-kits). This failure had the potential to result in
residents receiving medication with decreased potency.
Findings:
During an observation on 8/20/19 at 10:30 a.m., the facility's E-kit for intravenous (IV, administered into a
vein) medications was inspected. Inside the E-kit, there was one vial (small cylindrical container) of
Vancomycin Hydrochloride (medication used to treat infection) 1 gram (gm, unit of dose measurement) with
an expiration date of 8/1/19.
During a concurrent interview with registered nurse A (RN A), she confirmed the vial of Vancomycin
Hydrochloride 1 gm was expired. RN A confirmed the expired medication should not have been in the E-kit.
During an interview with the consultant pharmacist (CP) on 8/21/19 at 2:24 p.m., he explained that the
pharmacist who stocked the E-kit before it was sent to the facility was supposed to check the expiration
dates on the medications.
Review of the facility's policy, Medication Storage in the Facility ID1: Storage of Medications, revised 3/4/14,
indicated All expired medications will be removed from the active supply and destroyed in the facility,
regardless of amount remaining.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555835
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/23/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at Palo Alto
600 Sand Hill Road
Palo Alto, CA 94304
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on interview and record review, the facility failed to monitor for side effects of psychotropic
medications (medications capable of affecting the mind, emotions and behavior) for one of eight sampled
residents (Resident 30). This failure had the potential to negatively affect the resident's health and
well-being.
Findings:
Review of Resident 30's clinical record indicated he had the diagnoses of Parkinson's disease (progressive
disorder of the nervous system), dementia (disorder of the mental processes caused by brain disease or
injury) and major depressive disorder (mood disorder that causes persistent feelings of sadness and loss of
interest).
Review of Resident 30's physician's order, dated 7/16/19, indicated he was to receive Seroquel (an
antipsychotic medication) 12.5 milligrams (mg, unit of dose measurement) by mouth at bedtime for
Parkinson's related psychosis (a severe mental disorder) manifested by visual hallucinations (seeing things
that are not really there) and aggression. Resident 30 also had a physician's order, dated 6/27/19, for
Lamotrigine (anticonvulsant medication sometimes used to treat mood disorders) 100 mg by mouth once
an evening for depression manifested by statements of having a low mood. There was no documentation
indicating staff had been monitoring Resident 30 for side effects of Seroquel or Lamotrigine.
During an interview and concurrent record review with minimum data set nurse B (MDSN B) on 8/23/19 at
9:14 a.m., she stated staff should monitor for side effects of psychotropic medications every shift. She
further stated the monitoring should be documented on the medication administration record (MAR). MDSN
B reviewed Resident 30's record and confirmed there was no documentation indicating staff had been
monitoring him for side effects of Seroquel or Lamotrigine.
During an interview with the consultant pharmacist (CP) on 8/23/19 at 10:56 a.m., he stated monitoring for
side effects of psychotropic medications should be documented on the MAR.
Review of the facility's policy, Preparation and General Guidelines IIIA3: Limitations on Psychoactive Drugs,
revised 1/18/18, indicated Interdisciplinary team [IDT, staff from different disciplines who work together to
plan and provide care] will work together to ensure appropriate use, evaluation and monitoring. The policy
further indicated, Facility staff will monitor psychotropic medication use and note adverse effects or
changes in resident behavior and report to provider.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555835
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/23/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at Palo Alto
600 Sand Hill Road
Palo Alto, CA 94304
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility had an eight percent medication error rate
when two medication errors out of 25 opportunities were observed during medication pass for two of five
residents (Residents 20 and 95). These failures had the potential to compromise the health and safety of
the residents.
Residents Affected - Few
Findings:
1. Review of Resident 20's clinical record indicated she had a physician's order, dated 3/16/19, for Klor-Con
10 (potassium chloride, a mineral supplement) extended release (ER, designed to slowly release the
medication in the body over an extended period of time) tablet 10 milliequivalents (meq, unit of dose
measurement) two tablets by mouth once a morning.
During an observation on 8/22/19 at 9:37 a.m., licensed vocational nurse E (LVN E) crushed two tablets of
the above medication, mixed the crushed tablets in applesauce, and administered them to Resident 20.
During an interview with LVN E on 8/22/19 at 9:49 a.m., she confirmed she crushed the two tablets of
potassium chloride ER and administered them to Resident 20.
During an interview with the consultant pharmacist (CP) on 8/22/19 at 9:57 a.m., he stated potassium
chloride ER should not be crushed. The CP explained that crushing the medication could alter its
bioavailability (the degree and rate at which the medication is absorbed).
Review of the facility's policy, Medication Crushing Guidelines, revised 3/4/14, indicated Timed Release
Tablets are designed to release medication over a sustained period, usually 8 to 24 hours. The policy
further indicated these tablets should not be crushed.
The facility's 2019 Do No Crush Medication List was reviewed. Potassium chloride was on the list.
2. Review of Resident 95's clinical record indicated she had a physician's order, dated 8/5/19, for Refresh
Tears (carboxymethylcellulose sodium, lubricating eye drops) 0.5% (concentration of the medication) one
drop to both eyes twice a day.
During an observation on 8/22/19 at 8:20 a.m., registered nurse D (RN D) administered one drop of
artificial tears 0.2-0.2-1% to both of Resident 95's eyes.
During an interview with RN D on 8/22/19 at 8:55 a.m., she confirmed the eye drops she administered to
Resident 95 did not match the physician's order. RN D also confirmed that prior to administering the eye
drops, she did not check to make sure the eye drop concentration matched the physician's order.
During an interview with the CP on 8/22/19 at 9:57 p.m., he explained that Refresh Tears 0.5% and artificial
tears 0.2-0.2-1% were slightly different from each other.
Review of the facility's policy, Preparation and General Guidelines IIA2: Medication Administration-General
Guidelines, revised 3/4/14, indicated Medications are administered in accordance with written orders of the
prescriber. The policy further indicated a triple check of the five rights (right
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555835
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/23/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
VI at Palo Alto
600 Sand Hill Road
Palo Alto, CA 94304
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
resident, right drug, right dose, right route and right time) is recommended in the process of preparation of
a medication for administration.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555835
If continuation sheet
Page 7 of 7
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
FAQ · About this visit
Common questions about this visit
What happened during the August 23, 2019 survey of VI AT PALO ALTO?
This was a inspection survey of VI AT PALO ALTO on August 23, 2019. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VI AT PALO ALTO on August 23, 2019?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure medication error rates are not 5 percent or greater."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.