Inspection visit

InspectionMarch 10, 2023

THE TERRACES AT LOS ALTOS HEALTH FACILITYCMS #05521021 citations on this visit

21 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 21 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 231's medical record indicated he was admitted on [DATE] with diagnoses including glaucoma (increased pressure in the eye that can lead to loss of vision)). Resident 231's Minimum Data Set (MDS, an assessment tool), dated 2/26/23, indicated he had a brief interview for mental status (BIMS) score of 14 (a score of 13 to 15 indicates cognitively intact). Residents Affected - Few During an observation in Resident 231's room on 3/6/23 at 11:09 a.m., there were two ziplock bags on Resident 231's bed. Each bag contained an eye drop bottle and had a label with resident's name, medication and directions for use. During a concurrent interview with Resident 231, he stated I keep these eye drops with me so I can give them to myself. A review of Resident 231's physician order, dated 2/22/23, indicated Rocklatan (ophthalmic solution to treat elevated intraocular pressure) 0.02%-0.005% eye drops, one drop both eyes daily. An additional order, dated 2/22/23, indicated Dorzolamide 22.3mg (mg- unit of measure)-Timolol 6.8mg/ml (ml-unit of measure) (ophthalmic solution to treat glaucoma) eye drops, one drop both eyes two times daily. There was no physician order indicating Resident 231 could self-administer the eye drops. During an observation and concurrent interview with the interim director of nursing (IDON) on 3/9/23 at 10:50 a.m., she went to Resident 231's room and confirmed he had the above-mentioned eye drops at his bedside. The IDON stated a physician's order should be obtained and a medication self-administration assessment should be done prior to resident's self-administration. The IDON reviewed Resident 231's medical record and confirmed there was no assessment indicating it was safe for the Resident 231 to self-administer medications. She confirmed there was no physician's order for Resident 231 to self-administer medications or to keep medications at the bedside. Review of the facility's policy titled Self-Administration of Medications, revised 2/2021 indicated, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assess each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) on medications self-administration (residents take medications without staff assistance) and bed side medications storage for two out of 12 sampled residents (Resident 1 and Resident 231) when (a) the facility did not determine that residents were clinically appropriate and safe to self-administer medications, (b) the facility did not ensure self-administered medications were stored in a safe and secure place, and (c)The facility did not obtain a physician order to store (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 24 Event ID: 055210 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0554 medications at bedside. Level of Harm - Minimal harm or potential for actual harm These failures had the potential to result in unsafe medication self-administration. These failures also had the potential to result in other residents gaining unapproved access to the medications. Residents Affected - Few Findings: 1. Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE]. Resident 1's Minimum Data Set (MDS-an assessment tool), dated 1/6/2023, indicated she had a brief interview for mental status (BIMS) score of 15 (a score of 13-15 indicates cognitively intact). There was no documented evidence of interdisciplinary team (IDT- a group of healthcare professionals including physician, social worker, director of nursing, dietitian, activity director, physical or occupational therapist, and administrator who work together to provide care for residents in facility) assessment for self-administration of medications. Review of physician orders for Albuterol, and Advair inhalers indicated no order to keep both medications at the bedside for self administration. During a medication administration observation and concurrent interview with licensed vocational nurse A (LVN A) in Resident 1's room on 3/7/23 at 9:30 a.m., there was an undated bottle of Refresh Tears (medication used to lubricate the eyes) eye drops with the pharmacy label attached to bottle, on the resident's tray table next to her bed. During an interview with LVN A, she confirmed the Refresh Tears prescription eye drops bottle on resident's tray table. She further stated eye drops should be kept in a locked box and not on the tray table for the resident to use by herself. During an observation and concurrent interview with Resident 1, in her room, on 3/7/23 at 11:48 a.m., Advair inhaler (medication used to prevent and treat symptoms of asthma [asthma-a condition in which airway narrows, swell, and may produce extra mucus]), Albuterol inhaler (medication used to prevent and treat symptoms of asthma [asthma-a condition in which airway narrows, swell, and may produce extra mucus]) had their pharmacy labels attached to both and were on Resident 1's tray table located to next her bed in and open cardboard box. Resident 1 stated she used albuterol inhalers once or twice a day when she had cough or shortness of breath; and that, she rarely used her Advair inhaler. Resident 1 further stated nursing staff ordered these medications from pharmacy when it was needed for her to use them. She also stated she was not aware of a locked box to keep these medications at her bedside. During an observation and concurrent interview with the LVN A on 3/8/23 at 3:25 p.m., LVN A confirmed Albuterol and Advair inhalers were on Resident 1's tray table in a small cardboard box. She also acknowledged there were no no physician orders to keep either inhalers at the bed side to administer for Resident 1. LVN A further stated both inhalers should be kept in a locked box with a key to access them for this resident. During an interview with the interim director of nursing (IDON) on 3/9/23 at 10:50 a.m., the IDON acknowledged IDT self-administration assessments were not completed. She stated the facility should have completed self-administration of medication assessments for both Resident 1 and Resident 231 by the IDT, and received physician orders to keep these medications at the resident's bed side; and that, medications should be placed in a locked box for residents to use. Review of facility's P&P titled, Self-Administration of Medications, dated February 2021, indicated, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 2 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0554 safe and clinically appropriate for the resident. Self -administered medications are stored in a safe and secure place, which is not accessible by other residents. 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: 055210 If continuation sheet Page 3 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, document that specifies the medical treatments the resident wants to receive during serious illness) was completed for 7 of 17 sampled residents (Residents 17, 21, 25, 26, 232, 329 and 330). These failures could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goals and wishes. Findings: 1. Review of Resident 232's clinical record indicated he was admitted to the facility on [DATE]. Review of Resident 232's POLST form indicated the AD section of the POLST was blank. The POLST form did not indicate if there was an advance directive in place or it was not available. Review of Resident 232's POLST indicated the form was prepared on 2/18/23 and Section D: Information and Signatures was signed by a family member on 2/20/23. There was no physician signature on Resident 232's POLST form. During an interview and concurrent record review with the clinical director (CD) on 3/9/23 at 9:14 a.m., she reviewed Resident 232's POLST form and confirmed there was no physician signature and the AD section of the POLST was blank. The CD stated the admission nurse reviews the POLST form with the resident or their responsible party (RP) and discusses their wishes regarding medical treatment. She confirmed Resident 232's POLST form was incomplete. The CD stated all sections of the POLST forms should be completed and signed by the physician and the resident or their RP. 2. Review of Resident 14's clinical record indicated he was admitted on [DATE]. Further review of Resident 14's clinical record indicated there was no POLST form completed for Resident 14. Review of Resident 19's clinical record indicated she was admitted on [DATE]. Further review of Resident 19's clinical record indicated there was no POLST form completed for Resident 19. During an interview and concurrent record review with the clinical director (CD) on 3/9/23 at 9:14 a.m., she confirmed there was no POLST form in Resident 14's and Resident 19's clinical records and no physician orders for POLST directives for Resident 14 and Resident 19. The CD stated every resident should have a POLST/AD so their wishes can be carried out in the event of an emergency. Review of the facility's policy titled Advanced Directives, revised 9/2022, indicated Information about whether or not the resident has executed an advanced directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff . The director of nursing services (DNS) or designee notifies the attending physician of advanced directives (or changes in advanced directives) so that appropriate orders can be documented in the residents medical record and plan of care 3. (a) Clinical record review of Resident 21 indicated she was admitted to the facility on [DATE]. There was no documented evidence of a POLST form completed for Resident 21. During an interview and concurrent record review with the licensed vocational nurse B (LVN B) on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 4 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3/8/23 at 1 p.m., LVN B confirmed there was no POLST form for Resident 21. She stated nursing should have initiated the POLST form upon the admission. During an interview and concurrent record review with the interim director of nursing (IDON) on 3/8/23 at 3:30 p.m., the IDON stated the POLST form for this resident was not in place. She further stated staff should have initiated the POLST form upon her admission to the facility. 3. (b) Clinical record review of Resident 26 indicated he was admitted to the facility on [DATE]. There was no POLST form completed for Resident 26. During an interview and concurrent record review with the IDON on 3/8/23 at 3:30 p.m., the IDON stated the POLST form for this resident was not in place. She further stated staff should have initiated the POLST form upon his admission to the facility. 3. (c) Clinical record review of Resident 329 indicated he was admitted to the facility on [DATE]. There was no POLST form completed for him. During an interview and concurrent record review with the IDON on 3/8/23 at 3:30 p.m., the IDON stated the POLST form for this resident was not in place. She further stated staff should have initiated the POLST form upon his admission to the facility. 4. (a) Clinical record review for Resident 17 indicated she was admitted to the facility on [DATE]. Review of Resident 17's POLST form indicated a blank AD section. The POLST form did not indicate whether there was an advance directive in place or if it was not available. Review of Resident 17's POLST form indicated it was prepared on 2/2/23. During an interview and concurrent record review with LVN B on 3/8/23 at 1 p.m., LVN B confirmed the advance directive section of the POLST was blank for Resident 17. She stated nursing should have completed all the sections of the POLST form. During an interview with the IDON on 3/8/23 at 3:30 p.m., the IDON confirmed the AD section of the POLST was blank. She stated nursing staff should have completed all sections of the POLST form upon Resident 17's admission to the facility. 4. (b) Clinical record review of Resident 25 indicated he was admitted to the facility on [DATE]. Review of his POLST form indicated a blank AD section. The POLST form did not indicate whether there was an advance directives in place or if it was not available. Review of Resident 25's POLST form indicated the form was prepared on 2/14/23. During an interview and concurrent record review with LVN B on 3/8/23 at 1 p.m., LVN B confirmed the advance directive section of the POLST was blank for Resident 25. She stated nursing should have completed all the sections of the POLST form. During an interview with the IDON on 3/8/23 at 3:30 p.m., the IDON confirmed the AD section of the POLST was blank. She stated nursing staff should have completed all sections of the POLST form upon Resident 25's admission to the facility. 4. (c) Clinical record review of Resident 330 indicated he was admitted to the facility on [DATE]. Review of his POLST form indicated the AD section of the POLST form was left blank. The POLST form (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 5 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some did not indicate whether there was an advance directives in place or if it was not available. Review of Resident 330's POLST form indicated the form was prepared on 3/3/23. During an interview and concurrent record review with the LVN B on 3/8/23 at 1 p.m., LVN B confirmed the advance directive section of the POLST was blank for Resident 330. She stated nursing should have completed all sections of the POLST form. During an interview with the IDON on 3/8/23 at 3:30 p.m., the IDON confirmed the AD section of the POLST was left blank. She stated nursing staff should have completed all sections of the POLST form upon the Resident 330's admission to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 6 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 14's clinical record indicated he was admitted to the facility on [DATE]. Resident 14 was transferred to the acute hospital on 1/27/23 due to a fever and altered mental status and again on 2/24/23 for critically low hemoglobin (protein in red blood cells that carries oxygen in the bloodstream). Review of Resident 280's clinical record indicated he was admitted to the facility on [DATE]. Resident 280 was transferred to the acute care hospital on [DATE] after sustaining a fall resulting in uncontrolled back pain. Review of Resident 280's clinical record indicated he was discharged from the facility on 12/21/22. Resident 280 was discharged home with home health services. Review of Resident 282's clinical record indicated she was admitted to the facility on [DATE]. Resident 282 was transferred to the acute care hospital on [DATE] after sustaining a fall and suffering a right forehead hematoma (a solid swelling of clotted blood within the tissues) Review of Resident 282's clinical record indicated she was discharged from the facility on 1/4/22. Resident 282 was discharged to an assisted living facility. During an interview with the social service designee (SSD) on 03/09/23 at 3:25 p.m., she stated there was no documentation the long-term care Ombudsman was notified for Resident 14's, Resident 280's, and Resident 282's hospitalizations. The SSD further stated there was no documentation the long-term care Ombudsman was notified regarding Resident 280's and Resident 282's discharges from the facility. The SSD stated I did not know that I had to notify the Ombudsman, I do not have any documents for that. Based on interview and record review, the facility failed to ensure notification of resident transfer/discharge was sent to the Office of the Ombudsman for four of four residents (Residents 14, 29, 280, and 282), when no documentation of notification was discovered for those residents who had been transferred to the hospital. This failure had the potential of residents being transferred incorrectly and/or not allowed to return to the facility. Findings: 1. Resident 29 was admitted in 09/2022. A review of Resident 29's electronic record indicated she had a fall on 9/24/22 and was taken to the hospital (GACH). No document was seen for notifying the office of the Ombudsman of Resident 29's transfer to the GACH. During an interview on 3/9/23 at 10:42 a.m. with the social service designee (SSD), she stated I wasn't told that the Ombudsman needs to be notified of transfer/discharge. A notice was not sent to the ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 7 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the admission baseline care plan for one of 12 residents (Resident 10) was developed in a timely manner, when Resident 10's baseline care plan was not developed within 48 hours of their admission. This failure had the potential of the resident not getting the care she needed and thus having a negative impact on their health and well-being. Findings: Resident 10 was admitted on [DATE], during the day, with diagnoses which included sepsis (the body's extreme response to an infection), pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity), acute kidney failure, fracture of medial condyle (located on the inside part of the knee) of left femur (upper leg bone), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 10's care plans, her baseline care plan was not started until 3/25/22, while her admission was on 3/20/22 (that was five days without a plan of care to guide the healthcare workers on how to best care for her). During an interview on 3/9/23 at 3:33 p.m. with the clinical director (CD), CD stated Resident 10 was admitted on [DATE], and her baseline care plans were not started until 3/25/22. A review of the facility's policy and procedure (P&P) titled Care Plans - Baseline, revised 03/2022, indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 8 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 19's medical record indicated she was admitted on [DATE] with diagnoses including history of TIA (temporary blockage of blood flow to the brain), cerebral infarction (damage to tissues in the brain due to loss of oxygen), and venous insufficiency (failure of the veins to adequately circulate blood). Resident 19's Minimum Data Set (MDS, an assessment tool), dated 2/8/23, indicated Resident 19 was cognitively intact and required extensive assistance with one-person physical assist during transfers and mobility. Review of Resident 19's clinical record indicated she had an unwitnessed fall on 2/18/23. Resident 19 was found lying on the floor at the foot of her bed after trying to get up to close the window. Review of Resident 19's clinical record indicated there was no care plan (CP, a written document which provides a means of communication among healthcare providers to achieve health care outcomes) developed after Resident 19's fall. During a concurrent interview and record review with the interim director of nursing (IDON) on 3/7/23 at 1:24 p.m., she confirmed there was no evidence in Resident 19's clinical record that a care plan was developed after the fall on 2/18/23. The IDON stated there should be a care plan after each fall with interventions in place to prevent further falls. A review of the facility's policy titled Care Plans-Comprehensive Person-Centered, revised 10/2022, indicated assessments of residents are ongoing and care plans were revised as information about the resident and the resident's condition change. The IDT (IDT, team members from different departments involved in a resident's care) must review and update the care plan: when there has been a significant change in the resident's condition and when the desired outcome is not met. Review of the facility's policy titled Falls - Clinical Protocol, revised 3/2018, indicated the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why current approach remains relevant. Based on interview and record review the facility failed to develop and implement person centered and individualized care plans for three out of seventeen sampled residents (Resident 16, 329, and 19) when: 1. Resident 16 had a fall; 2. Resident 329 had a fall and an allegation of abuse, and 3. For Resident 19 there was no care developed after a fall. These failures may delay the implementation of the interventions, identification of specific care areas and services to meet the resident's needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 9 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0656 Findings: Level of Harm - Minimal harm or potential for actual harm 1. Review of Resident 16's clinical record review indicated he was admitted to the facility on [DATE] with diagnosis of cerebral infraction (a result of disrupted blood flow to the brain), cirrhosis of liver (a disease in which healthy liver tissue replaced with scar tissue and the liver permanently damaged), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), atrial fibrillation (a heart condition that causes an irregular and often fast heart rate), and malignant neoplasm of prostate (prostate cancer marked by an uncontrolled growth of cells in the prostate gland). Residents Affected - Few Further review of Resident 16's clinical record indicated there was no documented evidence of a person-centered and individualized care plan to address Resident 16's fall that happened on 1/1/23. During an interview and concurrent record review with the licensed vocational nurse B (LVN B) on 3/10/23 at 10:20 a.m., LVN B acknowledged there was no fall care plan for this resident. She further stated nursing should have started and implemented the care plan after his fall on 1/1/23. During an interview with the interim director of nursing (IDON) on 3/10/23 at 11:10 a.m., the IDON stated nursing staff should have initiated and implemented the care plan to address this resident's fall on 1/1/23. 2. (a) Review of Resident 329's clinical record review indicated he was admitted to the facility on [DATE] with diagnosis of aftercare surgery for neoplasm of the bladder (a surgical procedure to treat bladder cancer), malignant neoplasm of trigone of bladder (a disease in which abnormal mass of tissue forms when cells grow, divide and spread into nearby tissues), diabetes type 2 (a chronic condition that affects the way the body processes glucose in blood), hypertension (a condition in which the force of the blood against the artery walls is too high). Further review of Resident 329's clinical record indicated there was no documented evidence of a person-centered and individualized care plan for fall that happened on 3/3/23. During a phone interview with LVN J on 3/9/23 at 3:06 p.m., she confirmed the care plan for fall was not initiated upon Resident 329's fall on 3/3/23. She further stated the care plan for fall should have started after his fall. During an interview and concurrent record review with the clinical director (CD) on 3/9/23 at 3:45 p.m., the CD acknowledged the care plan for Resident 329 was not initiated after his fall. She further stated nursing staff should have started the care plan for his fall. 2. (b) Review of Resident 329's clinical record indicated there was no documented evidence of a care plan for the allegation of abuse that happened on 3/3/23. During a phone interview with the LVN J on 3/9/23 at 3:06 p.m., she acknowledged there was no care plan initiated after the abuse allegation on 3/3/23 for Resident 329. She further stated the care plan should have been started and implemented after the allegation of abuse, but this did not occur. During an interview and concurrent record review with the CD on 3/9/23 at 3:45 p.m., the CD confirmed there was no care plan for the abuse allegation. She further stated nursing staff should have started the care plan to address the allegation of abuse for Resident 329 . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 10 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0656 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy and procedure (P&P) titled, Care plan, comprehensive person-centered, dated March 2022, indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 11 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure to provide care and services according to accepted standards of clinical practice for one of three residents (Resident 25) when: Residents Affected - Few Resident 25's room air oxygen concentrator (RAOC-a machine takes room air and passes it through the filtering system in the machine and converts it to more pure oxygen) was set to deliver oxygen flow at a rate of 3.5 liters per minute (L/min, oxygen flowing into nostrils over a period of one minute) via nasal cannula when Resident 25 had an order for oxygen at 2 liters per minute. This failure had the potential to compromise Resident 25's health and well - being, and not meeting the resident's therapeutic needs or excessive use of oxygen. Findings: Clinical record review indicated Resident 25 admitted to the facility on [DATE] with the diagnosis of acute respiratory failure (a disease or injury affects breathing), pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest cavity), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident 25's physician's orders indicated, oxygen at 2L/min per nasal cannula, dated 2/16/23. During an initial pool observation on 3/6/23 at 9:04 a.m., Resident 25's RAOC was set to deliver oxygen at a rate of 3.5 liters per minute with a long nasal cannula. During second observation on 3/8/23 at 8:40a.m., Resident 25's RAOC was set to deliver oxygen at a rate of 3.5 liters per minute. During an interview and concurrent record review with license vocational nurse A (LVN A) on 3/8/23 at 8:40 a.m., she acknowledged the oxygen rate was set at 3.5 liters per minute for resident 25. She reviewed Resident 25's physician's orders for oxygen and confirmed that Resident 25's oxygen was ordered for 2 liters per minute. She further stated the oxygen should be set at 2 liters per minute as ordered. During an interview with the clinical director (CD) on 3/13/23 at 9:30 a.m., the CD stated staff should have placed oxygen at 2 liters per minute for resident 25, as ordered by his physician. Review of the facility policy and procedure (P&P) Oxygen Administration, dated October 2010, indicated, Verify that there is a physician order for this procedure. Review the physician's order or facility protocol for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 12 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure the controlled substance counting (medications with high potential for abuse or addiction) sign-off sheets for every shift were initialed by license nurses when: Narcotic sign-off sheets were missing initials by licensed nurses for medication carts 1 and 2 This failure had the potential to result in loss, misuse, and accountability for controlled substances. Findings: Review of the facility's forms for controlled substances count for every shift Narcotic Sign-off Sheet (to maintain adequate control and accountability for controlled substances) for the period from 1/31/23 to 3/7/23 (total of 36 days, or 108 shifts) indicated, license nurse's initials were left blank for thirty-one times for medication cart 1. During an interview and concurrent record review with the license vocational nurse B (LVN B) on 3/8/23 at 9:00 a.m., LVN B acknowledged there were several missing nurse's initials for narcotic sign-off sheets. She further stated nurses should have initialed each time when they counted narcotic medications at the beginning and end of their shift. During record review of the facility's form for controlled substances count for every shift Narcotic Sign-Off Sheet, for the period from 2/04/23 to 3/7/23 (total of 32 days, or 96 shifts) indicated, license's nurse's initials were left blank twenty-one times for medication 2. During an interview and concurrent record review with the LVN B on 3/8/23 at 9:30 a.m., she confirmed there were several blanks for nurse's initials for daily narcotic sign-off sheets. She further stated nurses should have initialed each time when they counted narcotic medications at the beginning and end of the shift with another nurse. During an interview and concurrent record review with the clinical director (CD) on 3/13/23 at 12:05 p.m., the CD stated staff should have initialed the narcotic sign-off sheet for the oncoming and outgoing nurses for all three shifts when staff counted the controlled medications each time with another nurse. She further stated the nurse that initialed was accountable for any discrepancies with the controlled medications. She also stated the facility's narcotic sign-off sheet required license nurses' initials of each shift for the oncoming and outgoing nurses, even if the facility's policy did not mention to document nurses' initials on it. Review of facility's policy and procedure (P&P) titled, Controlled Substances, dated April 2019, indicated, Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 13 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 ensure two out of five residents (Residents 12 and 279) were free from unnecessary medication when: 1. Resident 12 had physician orders which did not have an indication for the use of Risperdal, a psychotropic (any drug that affects behavior, mood, thoughts, or perception) medication, there was no monitoring of her behaviors, and there was no informed consent for the Risperdal. 2. Resident 279 had physician orders which did not have an indication for the use of Seroquel, there was no monitoring of her behaviors, and there was no informed consent for the Seroquel. These failures had the potential of residents receiving psychotropic medications without a need for them. Findings: 1. Resident 12 was admitted with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), delirium (a serious change in mental abilities resulting in confused thinking and a lack of awareness of someone's surroundings), and anxiety disorder. During a review of Resident 12's physician orders there were orders for 1. Risperidone 0.5 mg (a dosage) tablet po (by mouth) QD (once daily) at 1500 (3 p.m.) for agitation. Start 2/5/23. and 2. Risperidone 0.5 mg tab po prn (as needed), for agitation. Started 1/28/23. During an interview on 3/9/23 at 8:52 a.m. with the clinical director (CD), she stated, when looking for an indication for it's use, she was unable to find anything, I see psychotic symptoms, I see agitation. Sometimes with a new admission and we don't know them well. We will say psychotic symptoms until we are able to know them better. While looking for an informed consent for Risperidone, CD stated only see a consent for Lexapro, and that is the only consent for psychotropic in this record. During an interview on 3/13/23 at 11:26 a.m. with licensed vocational nurse B, (LVN B), she stated we need family to sign consent before we can give medication. After admission, we need family to sign before we can give medications. 2. Resident 279 was admitted with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), neurocognitive disorder with Lewy Bodies (a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain), and hallucinations (where you hear, see, smell, taste or feel things that appear to be real but only exist in your mind). During a review of Resident 279's physician orders, there was an order for Seroquel 25 mg , Seroquel 25 mg (0.5 tab) po QHS (at hour of sleep), and Seroquel 25 mg (0.5 tab) PRN (as needed) Q (every) 12 hrs, for hallucinations, agitation, when not redirectable. During an interview on 3/8/23 at 3:43 p.m. with the clinical director (CD), while she was looking at Resident 279's electronic record, she stated there was a physician order dated 3/5/23 for Seroquel 25 mg QD (morning) and Seroquel 25 mg (0.5 tab) prn. CD stated I do not see an informed consent for 3/5/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 14 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 During an interview on 3/9/23 a 08:47 a.m. with CD, while looking in Resident 279's electronic record, she stated, for the use of Seroquel QD and PRN, I do not see any monitoring. I do not see an indication for use on this. A review of the facility's policy and procedure (P&P) titled Antipsychotic Medication Use, revised 07/2022, indicated 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others . 6. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident .17. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. A review of the facility's P&P titled Medication and Treatment Orders, revised 07/2016, indicated .9. Orders for medications must include . e. clinical condition or symptoms for which the medication is prescribed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 15 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the facility's medication error rate did not exceed five percent or greater when observation of 30 opportunities during the medication administration resulted in two errors (both for Resident 15). The calculation of medication error rate was 6.67 percent. Residents Affected - Few These failures placed Resident 15 at risk for not receiving the full therapeutic effects of medications when medications were not given according to physician's orders. Findings: Clinical review of Resident 15 indicated, the Resident was admitted to the facility on [DATE] with diagnoses that included cerebral infraction due to embolism of right middle cerebral artery (medical condition that occurs when blood flow from the largest artery of the brain suddenly disrupted), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), congestive heart failure (a serious condition in which the heart does not pump blood as efficiently as it should), and osteoporosis (medical condition in which the bones become brittle and weak from a lifelong lack of calcium). 1. During a medication administration observation for Resident 15 on 3/7/23 at 8:55 a.m., with license vocational nurse A (LVN A), she observed Eliquis (a medication used to treat and prevent blood clots and to prevent stroke) 2.5 mg supply was not available in the medication cart to give for Resident 15. LVN A stated she ran out of this medication for Resident 15, ordered it from the pharmacy yesterday, and that it would be delivered at 1:00 p.m. that day. LVN A verified that the facility's E-kit (contains essential emergency medications) did not contain this medication. Review of Resident 15's physician's orders indicated, Eliquis 2.5 milligram (mg- a unit of measurement equal to a thousandth of a gram) 1 tablet by mouth two times daily at 9:00 a.m. and 5:00 p.m. for cerebral infraction due to thrombosis of right middle cerebral artery, dated 5/6/22. Review of electronic medication administration record (EMAR) for Eliquis 2.5 mg one tablet on 3/7/23 for 9:00 a.m., documented by LVN A, indicated, Medication not available. Called pharmacy to check on refill. Pharmacy indicates it will come today. Not here yet. During an interview with LVN A on 3/8/23 at 3:25 p.m., LVN A confirmed she did not give Eliquis 2.5 mg to Resident 15 on 3/7/23 at 9:00 a.m. She stated this medication's supply should not have run out for the resident. During an interview with the interim director of nursing (IDON) on 3/8/23 at 4:00 p.m., the IDON stated LVN A should not have missed the Eliquis medication. She further stated nursing should have ordered this medication from the pharmacy, as ordered by physician, to make it available for each resident. 2. During a medication administration observation for Resident 15, on 3/7/23 at 8:55 a.m., with the license vocational nurse A (LVN A), she was observed calcium carbonate 400 mg 1 tablet was not given to Resident 15. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 16 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 15's physician's orders indicated, calcium carbonate 400mg chewable one tablet two times daily at 9:00 a.m. and 5:00 p.m. During an interview with the LVN A on 3/8/23 at 3:25 p.m., she acknowledged she did not give calcium carbonate to Resident 15 on 3/7/23 at 9:00 a.m. She further stated should have given this medication to the resident, but mistakenly documented it as given on the EMAR on 3/7/23 at 9:00 a.m. During an interview with the IDON on 3/8/23 at 4:00 p.m., the IDON stated staff should not have missed these doses of medications for resident as ordered by the resident's physician. Review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, medications are administered in according with prescriber orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 17 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medication when: One opened and undated tuberculin purified protein derivative (PPD- a solution used for tuberculin skin test) multi-dose vial was observed in the refrigerator in the medication storage room; This failure had the potential for residents to receive a PPD skin test with reduced potency due to the drug to be potentially past its use-by-date. Finding: During medication room observation and concurrent interview with the interim director of nursing (IDON) on [DATE] at 12:09 p.m., a one fourth full vial of clear solution of PPD multi-dose was opened and undated in refrigerator in the medication storage room. The IDON confirmed this observation. She further stated nursing staff should have labeled the vial with the date for when it was opened. During a phone interview with the facility's consultant pharmacist (CP) on [DATE] at 10:22 a.m., the CP stated nursing staff should have labeled this multi-dose PPD vial with the date when they opened it. She further stated the vial should be expired within 30 days after it was opened. Review of the facility's policy and procedure (P&P) titled, Administering Medications, dated [DATE], indicated, When opening a multi-dose container, the date opened is recorded on the container. The United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle- punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. (CDC.gov/injection safety/providers/provider_faqs_multivials.html.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 18 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: Residents Affected - Some 1. There were opened undated, unlabeled, and outdated food items in the reach-in refrigerator and dry storage areas; 2. Pans and plastic containers used for food preparation and food service were stacked and stored wet; 3. Kitchen staff did not know the proper procedures for testing chlorine (chemical) sanitizer used for dishwashing; 4. The dishwasher sanitizing log was not completed; 5. There were no logs recording weekly calibration of thermometers; 6. The temperature of a food item on the steam table was not checked prior to serving during lunch; 7. A scoop was left inside the flour container; 8. There were dented cans of food in the dry storage area; 9. Open bags of food items were not sealed or closed in the walk-in freezer; and, 10. There were opened undated and outdated food items in the food preparation area. These failures had the potential to cause food contamination and food-borne illness to 24 of 24 residents who received their food from the kitchen. Findings: During an initial kitchen tour on 3/9/23 at 8:40 a.m., accompanied by director of dining services F (DDS F) and the dining supervisor (DS), the following observations were made in the facility's small kitchen (Kitchen A): 1a. In the reach-in refrigerator there was an opened undated gallon container of olive oil dressing and an opened undated partial loaf of gluten-free bread. The DDS F confirmed the 2 items were not dated and stated all food items should be dated with an open date and a good through date. The DDS F stated the olive oil dressing and the bread must be discarded. 1b. In the reach-in refrigerator there were containers of roast beef, low sodium beef base, and American cheese that were labeled good through 3/5/23. There were 2 sticks of butter labeled with a good through date of 3/2/23. The DDS F confirmed the food items were beyond the good through date and stated the roast beef, low sodium beef base, American cheese, and the butter must be discarded. 10a. There was a large container of croutons on the shelf above the food preparation area. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 19 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some croutons were labelled good through 3/4/23. The DDS F confirmed the croutons were beyond the good through date and stated the croutons must be discarded. On another shelf above the food preparation area, there was a large container of 5-Chinese Spices labeled opened 6/15/21. The label indicated a good through date of 6/15 but the year was not legible. The DDS F stated it looks like the date on the label wore away. The DDS D stated spices are good for one year after they are opened. The DDS F stated 5-Chinese Spices must be discarded. 2. There were 14 metal pans of various sizes, observed to be stacked both on a metal wire rack and underneath the steam table. The pans were stacked upside down inside of one another and were wet inside and outside of the pan's surfaces. There were 9 water pitchers with lids observed inside a plastic bin on top of a metal cart. The pitchers were wet on the inside and outside of the containers. The DDS F confirmed the pans and water pitchers were wet and she stated they should have been air dried before being stacked and stored. Review of the facility's undated policy titled Storage of Pots, Dishes, Flatware, Utensils indicated to air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage. Do not stack or store wet. 3. During an observation and concurrent interview in Kitchen A on 3/6/23 at 9:16 a.m., accompanied by DDS F and the DS, the dishwasher (DW) was observed doing dishes from the breakfast service. The dishwasher machine was running at the time and the DS stated the dishwasher machine was currently operating as a low temperature dishwasher. The DW was asked how he checks the chlorine sanitizer solution in the dishwasher machine. Through a translator, [NAME] G, the DW stated he did not know how to check the chlorine sanitizer. The DW stated I have never been told to do that, I don't know how. The DS was asked how often the chlorine sanitizer solution is checked and he stated the chlorine level in the dishwasher is checked 3 times a day during meals when the dishwasher is being used. 4. During an interview and concurrent record review in Kitchen A on 3/6/23 at 9:16 a.m., with the DS and the DDS F, they were asked to produce the logs of the chlorine sanitizer solution checks. They were unable to provide any record of the chlorine sanitizer levels of the dishwasher being checked 3 times a day during the month of March. 5. During a tray line service observation on 3/8/23 at 11:05 a.m., accompanied by the DDS E, the [NAME] G was checking temperatures of food items on the steam table. When asked how often she calibrated the thermometers, she stated several times a week. When asked to see the log of the thermometer calibrations the [NAME] G stated Honestly I do not write that down anywhere. A second cook who was assisting with the tray line, [NAME] H, stated Thermometers are calibrated once a week. [NAME] H stated There is a thermometer verification sheet to log the calibrations. The DDS E, [NAME] H, and [NAME] G were unable to provide any documentation or logs that indicated the thermometers were calibrated weekly. Review of the facility's undated policy Thermometer Verification indicated Pocket digital and thermocouple thermometers must be tested every week in an ice slurry to ensure the readings are accurate (32+/-2F). Complete the Thermometer Verification Sheet. Thermometers that cannot be calibrated, must be replaced. 6. During a tray line service observation on 3/8/23 at 11:38 a.m., accompanied by the DDS E, the [NAME] G was plating food items for the lunch service. A resident's tray card read mechanical ground, so the [NAME] G left the steam table area and went to retrieve the mechanical ground quesadilla that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 20 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was being stored in a warming cart. [NAME] G decanted the mechanical ground quesadilla into a metal container and brought it back to the steam table. [NAME] G then proceeded to use a scoop to serve the mechanical ground quesadilla onto the lunch plates. [NAME] G did not check the temperature of the mechanical ground quesadilla prior to serving it to the residents. [NAME] G confirmed she did not check the temperature of the mechanical ground quesadilla. She stated all foods should be checked before they are served to ensure they have reached the proper cooking temperatures. During a kitchen tour on 3/9/23 at 11:00 a.m., accompanied by director of dining services E (DDS E), the following observations were made in the facility's large kitchen (Kitchen B): 7. There was a large plastic bin containing flour with a scoop inside the bin. The scoop was touching the flour. The DDS E confirmed the scoop was inside the bin of flour and stated the scoop should not be stored inside the bin. 8. There was a dented can of crab meat and a dented can of enchilada sauce in the dry storage area The DDS E confirmed the cans were dented and stated they should not be used and should be removed from the dry storage area. 9. In the walk-in freezer there was an open bag of sweet sausages and an open bag of beef raviolis. The plastic bags containing the sausages and raviolis were open and the food was exposed to the air. There was ice build-up observed on the sausages and the raviolis. The DDS E confirmed the ice-build up and stated the sausage and raviolis must be discarded. 10b. There was a large container of black pepper on the shelf above the food preparation area. The pepper was opened but was not dated. The DDS E confirmed the pepper was not dated and stated all food items should be dated with an open date and a good through date. The DDS E stated the pepper must be discarded. There was a large container of croutons on the shelf above the food preparation area. The croutons were labelled good through 3/5/23. The DDS E confirmed the croutons were beyond the good through date and she stated the croutons must be discarded. Review of the facility's undated policy titled Food and Supply Storage indicated Dry Storage: Scoops may be stored in bins on a scoop holder. The food level must be no closer than one inch below the handle of the scoop. The policy further indicated Maintain designated area for items that are damaged (such as dented cans) that are to be returned for credit. Review of the facility's undated policy titled Food and Supply Storage indicated Frozen Storage: Wrap food tightly to prevent cross contamination. Review of the facility's undated policy titled Food and Supply Storage indicated Procedures: Cover, label, and date unused portions and open packages. Products are good through the close of business on the date noted on the label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 21 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper infection prevention protocols were followed during multiple occasions, when 1. hand hygiene was not performed between glove changes during wound care, 2. proper PPE (personal protective equipment, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was not worn inside of an isolation room, and 3. hand hygiene was not used during medication pass. Residents Affected - Some These failures had the potential of causing personal and wide spread infections, compromising the health and well-being of all residents and staff in the facility. Findings: 1. During an observation and subsequent interview on 3/8/23 at 2:06 p.m., with licensed vocational nurse B (LVN B), while changing a wound dressing on the right posterior thigh/gluteal border MASD (moisture associated skin damage) of Resident 1, LVN B put on gloves and removed the dressing, then changed gloves without using any form of hand hygiene. LVN B cleaned the wound with normal saline (0.9% sodium chloride), then changed gloves, without any hand hygiene. She then put cream on the wound, then took off gloves, did not use hand hygiene. LVN B stated I should have used hand hygiene. I tried, (pulled out a small bottle of hand sanitizer), but it was difficult. I did not use hand hygiene. A review of the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, revised 08/2019, indicated, This facility considers hand hygiene the primary means to prevent the spread of infection . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . c. Before preparing or handling medications . m. after removing gloves. 2. During an observation on 3/6/23 at 10:50 a.m., the interim director of rehabilitation (IDOR) was observed delivering care inside the room of a resident with a confirmed case of Covid-19 (COVID-19, a new strain of virus that can cause mild to severe respiratory illness). The IDOR was not wearing an N95 mask (filtering facepiece device designed to achieve a very close facial fit that filters at least 95% of airborne particles), a gown, gloves, or a face shield while inside the room. Signage was posted on the wall outside of the resident's room indicating Contact Precautions (for diseases spread by direct or indirect contact) and Droplet Precautions (for diseases spread by large particles in the air) with instructions for the type of PPE to be worn when entering the room. There was a table containing N95 masks, gowns, gloves and face shields placed directly below the signage on the wall. During an interview with the IDOR at 11:08 a.m., she confirmed she was not wearing an N95, gown, gloves, or face shield while she was inside delivering care to resident with Covid-19. The IDOR stated I did not see that signage or the table with the PPE, I did not know. She confirmed she should be wearing an N95, gown, gloves and a face shield when caring for a resident who has Covid-19. During an observation on 3/7/23 at 9:08 a.m., LVN D was observed wearing a face mask (a loose fitting disposable device worn over the nose and mouth that creates a physical barrier) when she exited the room of a resident with a confirmed case of Covid-19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 22 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0880 Level of Harm - Minimal harm or potential for actual harm During an interview with LVN D on 3/7/23 at 9:10 a.m., she confirmed she was wearing a face mask while delivering care to the confirmed Covid-19 resident. When asked what precautions are indicated for delivering direct care to a resident who is Covid-19 positive, LVN D stated Full PPE, that includes a gown, gloves, face shield and an N95 mask. When LVN D was asked why she was not wearing an N95 mask she stated The night nurse endorsed to me that it was OK to wear face masks. Residents Affected - Some During an interview with the interim director of nursing (IDON) on 03/07/23 at 9:40 a.m., she stated all staff must wear an N95 mask when entering the room of a Covid-19 positive resident. IDON confirmed face masks should not be worn by staff caring for Covid-19 positive residents. Review of the facility's policy titled Coronavirus Disease (COVID-19) - Using Personal Protective Equipment, dated September 2021, indicated when caring for a resident with suspected or confirmed SARS-CoV-2 (virus that causes Covid-19) use an N95 mask, gown, gloves, and eye protection. 3. During a medication administration observation with licensed vocational nurse A (LVN A) on 3/7/23 at 8:55 a.m., LVN A donned (to put on) gloves on both hands, used a pill cutter to cut a docusate sodium (medication used to soften the stool) 100 milligram (mg- unit of measurement) tablet in half. After she completed cutting the tablet, she placed the pill cutter in medication cart. LVN A doffed (removed) her gloves and discarded them in medication cart garbage bin. LVN A opened the medication cart top drawer and took out an over the counter (OTC) medication bottle without hand hygiene after she removed her gloves. During a medication administration observation with the LVN A on 3/7/23 at 9:05 a.m., LVN A donned gloves, opened a 250 mg capsule of saccharomyces boulardii (a probiotic yeast often used for the treatment of gastrointestinal (GI-relating to stomach) disorders), and poured the contents of this capsule into a medication cup. She then doffed both gloves and discarded them into a medication cart garbage bin. LVN A took a plastic spoon from a container attached to the medication cart without hand hygiene after she removed both gloves. During an observation in Resident 1's room with the LVN A on 3/7/23 at 9:20 a.m., LVN A donned gloves for both hands, administered lovenox (medication used to prevent and treat formation of blood clots) 80mg/08 milliliters (unit of measurement for liquids) subcutaneous injection (shot given into the fatty tissue just under the skin) into the left side of Resident 1's abdomen. She retracted the syringe (needle automatically draw back directly into the barrel of the syringe when the plunger handle is fully depressed to eliminate exposure to the contaminated needle, and risk of needle stick injury), donned both gloves, and discarded her gloves in the garbage bin in the room. The LVN A proceeded with adjusting Resident 1's position in bed, the bed sheet, and pillow under Resident 1's head without hand hygiene after she removed her gloves. During an interview with the LVN A on 3/8/23 at 3:25 p.m., the she acknowledged she did not perform hand hygiene after she removed gloves while preparing medications both times and after she administered an injection to Resident 1 on 3/7/23 during the 9:00 a.m. medication administration period. The LVN A further stated she should have cleaned her hands after she removed her gloves each time. During an interview with the interim director of nursing (IDON) on 3/8/23 at 4:00 p.m., the IDON stated staff should wash their hands after removing gloves each time for infection control purposes. Review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, indicated, Staff follows established facility infection control procedures (e.g., handwashing, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 23 of 24 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 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 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 0880 antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 24 of 24

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Citations

21 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.

0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0161GeneralS&S Dpotential for harm
Use approved construction type or materials.
0554GeneralS&S Dpotential for harm
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
0578GeneralS&S Epotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0623GeneralS&S Epotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0658GeneralS&S Dpotential for harm
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
0726GeneralS&S Dpotential for harm
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0758GeneralS&S Dpotential for harm
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.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0344GeneralS&S Dpotential for harm
Have an alternate power supply for its alarm system.
0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
0511GeneralS&S Dpotential for harm
Have properly installed electrical wiring and gas equipment.
0711GeneralS&S Dpotential for harm
F711 - Physician Visits
Provide a written emergency evacuation plan.
0918GeneralS&S Dpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0923GeneralS&S Dpotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.

FAQ · About this visit

Common questions about this visit

What happened during the March 10, 2023 survey of THE TERRACES AT LOS ALTOS HEALTH FACILITY?

This was a inspection survey of THE TERRACES AT LOS ALTOS HEALTH FACILITY on March 10, 2023. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at THE TERRACES AT LOS ALTOS HEALTH FACILITY on March 10, 2023?

Yes, 21 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

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·March 10, 2023