Health inspection·March 17, 2023

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide and/or document restorative nursing assistant (RNA) treatments for one of five sampled residents (Resident 26). This failure had the potential to result in functional decline for Resident 26. Findings: Review of Resident 26's medical record indicated he was admitted on [DATE] and had the diagnoses of atrial flutter (a condition in which the upper chambers of the heart beat too quickly), chronic obstructive pulmonary disease (COPD, a condition of the airways that causes difficulty breathing), and Parkinson's Disease (a nervous system disease that causes muscle rigidity and tremors). During an interview with Resident 26's family member (FM) on 3/14/23 at 12:34 p.m., the FM stated staff have provided Resident 26 with RNA treatments, but the treatments were sporadic. Review of Resident 26's Order History indicated he had a physician's order for RNA treatments from 9/15/22 to 12/15/22. The order indicated the RNA was to ambulate (walk) Resident 26 in the hallway and perform active range of motion exercises (activity meant to improve joint movement) to both arms and both legs for 15 to 30 minutes, three to five times a week. During an interview with restorative nursing assistant A (RNA A) on 3/15/23 at 8:53 a.m., she stated that when she performs RNA treatments with a resident, she must document the treatments in the electronic health record (EHR). RNA A further stated that if a resident refuses an RNA treatment, she must still document in the EHR and indicate that the resident refused. Review of Resident 26's Point of Care History, dated 9/15/22 to 12/15/22, indicated there were five weeks for which there was no documentation that RNA treatments were either provided as ordered or refused. During an interview and concurrent record review with the director of nursing (DON) on 3/16/23 at 3:52 p.m., the DON reviewed Resident 26's medical record and acknowledged there were several weeks for which there was no documentation that RNA was either provided as ordered or refused. The DON stated, If it's not documented, it was not done. Review of the facility's document titled Restorative Care Protocol, revised 10/2017, indicated RNA responsibilities include providing restorative treatments to assigned residents and documenting daily on the designated flow sheets, including dates of treatment and number of minutes for each (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 8 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 03/17/2023 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)