Other·June 15, 2018

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 facility reported incident conducted on 6/13/18. For Facility Reported Incident CA00586347 regarding Quality of Care/Treatment, Resident Safety/Falls, a federal deficiency was identified (see F689) with scope and severity of "G". A Class "A" Citation was also issued. Inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 37686, Health Facilities Evaluator Nurse.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. 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: R43W11 Facility ID: CA630006021 If continuation sheet 1 of 6 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: _______________ 555835 (X3) DATE SURVEY COMPLETED 06/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VI AT PALO ALTO 600 Sand Hill Rd Palo Alto, CA 94304 (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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow their policy and plan of care for one of three sampled residents (1). On 5/9/18 Resident 1 was transferred using a Hoyer lift (equipment used to transfer residents using a sling) with only one staff. This failure resulted in Resident 1's fall, hospitalization, left humerus fracture (broken bone in the left upper arm), subdural hemorrhage (bleeding into the space directly outside the brain), subarachnoid hemorrhage (bleeding into the protective lining surrounding the brain), intraparenchymal hemorrhage (bleeding within the brain), and intracranial hemorrhage (bleeding inside the skull). Findings: Review of Resident 1's clinical record indicated he was admitted on 3/10/17 and had the diagnoses of dementia (mental disorder caused by brain disease or injury), muscle weakness, difficulty in walking, hemiplegia (one side of the body is paralyzed), and repeated falls. A fall risk assessment tool, dated 3/20/18, indicated Resident 1 was at high risk for falls. A Minimum Data Set (MDS, an assessment tool), dated 3/20/18, indicated Resident 1 required extensive assistance (staff provide weight-bearing support) from two or more people for transfers. A risk for falls care plan edited on 3/21/18, indicated Resident 1 required Hoyer lift transfers for safety. A decreased functional mobility care plan edited on 3/21/18, indicated Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R43W11 Facility ID: CA630006021 If continuation sheet 2 of 6 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: _______________ 555835 (X3) DATE SURVEY COMPLETED 06/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VI AT PALO ALTO 600 Sand Hill Rd Palo Alto, CA 94304 (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 required a Hoyer lift and maximum assistance from two people for transfers. A progress note dated 5/9/18, indicated Resident 1 "took a fall in his room during transfer." The progress note further indicated Resident 1 complained of pain in his left arm and the facility sent him to the acute hospital for evaluation. During an interview with the director of nursing (DON) on 5/11/18 at 1:20 p.m., she confirmed certified nursing assistant A (CNA A) was the one who transfered Resident 1 when he fell on 5/9/18. The DON explained she did not witness the fall herself, but she received a statement from CNA A about what happened. According to the DON, CNA A stated she put the sling underneath Resident 1 while he was in bed and attached the sling to the Hoyer lift. The legs of the Hoyer lift got stuck underneath Resident 1's bed and CNA A tried to pull the lift to free the legs, but was unsuccessful. CNA A used the bed controls to raise Resident 1's bed so she could free the legs of the Hoyer lift. As CNA A was raising the bed, the Hoyer lift tipped over and Resident 1 fell to the floor. The DON confirmed CNA A used the Hoyer lift without assistance from another staff member. A post-fall assessment dated 5/15/18 indicated when Resident 1 fell on 5/9/18, he hit his head and complained of severe pain in his left arm. The post-assessment further indicated, "Staff person was transferring resident alone". Review of a discharge summary from the acute hospital dated 5/9/18 to 5/14/18 indicated Resident 1 arrived at the hospital after falling while being lifted at the facility. Resident 1 was found to have a fracture of the left humerus, a subarachnoid hemorrhage, and a subdural hemorrhage. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R43W11 Facility ID: CA630006021 If continuation sheet 3 of 6 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: _______________ 555835 (X3) DATE SURVEY COMPLETED 06/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VI AT PALO ALTO 600 Sand Hill Rd Palo Alto, CA 94304 (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 During an interview with CNA B on 5/11/18 at 2:45 p.m., she stated the facility has conducted in-services (training sessions) on proper use of the Hoyer lift in the past. CNA B stated two staff members must be present at all times when the Hoyer lift is being used. CNA B stated, "I cannot touch the patient until another person is there to help." During an interview with the director of rehab (DOR), on 5/11/18 at 2:58 p.m., she stated, "It's a must that Hoyer lift transfers be performed by two people." The DOR stated two people must be present from the beginning to the end of a Hoyer lift transfer. During an interview with licensed vocational nurse C (LVN C) on 5/15/18 at 11:31 a.m., she confirmed she was the nurse in charge of Resident 1 when he fell on 5/9/18. LVN C stated she heard CNA A call for help and ran to Resident 1's room. LVN C stated she saw Resident 1 on the floor with the sling still underneath his body and attached to the Hoyer lift. LVN C confirmed CNA A was the only staff member in Resident 1's room during the time of the incident. LVN C acknowledged two staff members must be present at all times when a Hoyer lift is being used. An "In-service Cover Sheet," dated 1/6/17, indicated the facility conducted a lecture, discussion and demonstration on how to properly use a Hoyer lift. The cover sheet indicated, "Two persons to use Hoyer lift." A sign-in sheet dated 1/6/17, indicated CNA A attended this in-service. A personnel file review indicated CNA A also completed training on lifting and transferring residents on 3/14/14, 6/5/15, 9/21/16, and 10/7/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R43W11 Facility ID: CA630006021 If continuation sheet 4 of 6 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: _______________ 555835 (X3) DATE SURVEY COMPLETED 06/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VI AT PALO ALTO 600 Sand Hill Rd Palo Alto, CA 94304 (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 Review of a letter from the facility to California Department of Public Health, dated 5/14/18, indicated Resident 1 "received injuries during a transfer from his bed to the wheelchair. The CNA was transferring the resident unassisted. The legs of the lift were caught under the bed and when the CNA attempted to free the lift, it became off balance and tipped to the side causing the resident to fall to the floor while in the sling." The facility's policy,"No-Lift Transfers," revised 6/2012, indicated, "Two staff members are present whenever a lift is being used." Resident 1's clinical record indicated he returned to the facility on 5/14/18. A physical therapy assessment dated 5/15/18, indicated Resident 1 had a "plaster slab splint" on his left arm and complained of "severe pain on lt UE [left upper extremity] on movement." A progress note, dated 5/18/18, indicated Resident 1 had blood in his urine, an elevated temperature and elevated heart rate. The progress note indicated the facility called 911 and paramedics took the resident back to the acute hospital. Review of an Emergency Department Provider Note dated 5/18/18, indicated "Multiple critical illnesses, specifically severe anemia requiring blood transfusion, severe sepsis from a likely urinary source, and critical hypokalemia [low potassium] and hypocalcemia [low calcium] ...Subarachnoid hemorrhage ..." Review of an Internal Medicine Progress Note dated 5/19/18 indicated, "worsening intracranial hemorrhage and labs showing UTI [urinary tract infection] ...Sepsis ...will treat with only comfort measures." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R43W11 Facility ID: CA630006021 If continuation sheet 5 of 6 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: _______________ 555835 (X3) DATE SURVEY COMPLETED 06/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VI AT PALO ALTO 600 Sand Hill Rd Palo Alto, CA 94304 (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 Review of a discharge summary from the acute hospital, dated 5/18/18 to 5/21/18, indicated Resident 1 presented to the hospital with decreased alertness and fever. A computerized tomography scan (CT scan, procedure used to view internal components of the body) showed a subdural hematoma and intraparenchymal hemorrhage with new midline shift (shift of the brain past its central line). The discharge summary indicated Resident 1 passed away on 5/21/18. The discharge summary stated the principal diagnosis at time of death was intracranial hemorrhage. The discharge summary stated Resident 1 also had a positive urine culture [bacteria growing in his urine], but "antibiotics were held". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R43W11 Facility ID: CA630006021 If continuation sheet 6 of 6