Health inspection·August 1, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of Resident 111's medical record indicated he was admitted on [DATE] and had diagnoses including depression. Review of Resident 111's Order Summary Report indicated he had a physician's order, dated 7/22/25, for venlafaxine 150 mg one capsule by mouth one time a day for depression AEB voicing sadness. Review of Resident 111's medical record indicated there was no documentation that staff were monitoring for side effects from venlafaxine. During an interview and concurrent record review with Registered Nurse C (RN C) on 7/30/25, at 1:20 p.m., RN C confirmed that for residents taking psychotropic medications, the nurses should monitor for side effects every shift. RN C stated this monitoring should be documented on the medication administration record (MAR) or treatment administration record (TAR). RN C reviewed Resident 111's medical record and confirmed there was no documentation that the nurses were monitoring for side effects of venlafaxine. The facility's P&P titled Psychotropic Medication Use, revised 7/2022, indicated psychotropic medication management includes adequate monitoring for adverse consequences. 3. Review of Resident 118's clinical record indicated Resident 118 was admitted to the facility with diagnoses including essential primary hypertension (high blood pressure with no identifiable underlying medical cause). Review of Resident 118's physician's orders indicated an order, dated 7/23/25, for Trazodone 25 mg give 25 mg by mouth at bedtime for depression AEB inability to sleep. Further review of Resident 118's clinical record indicated there was no monitoring for the target behavior of inability to sleep and there was no side effects monitoring for trazodone. During a concurrent interview and record review on 7/31/25 at 2:32 p.m., with the Director of Nursing (DON), the DON Reviewed Resident 118's clinical record and confirmed there was no side effects monitoring for trazodone. The DON also confirmed there was no monitoring for the target behavior of inability to sleep. The DON stated residents taking psychotropic medications should have monitoring for side effects and target behaviors. The facility's P&P titled Psychotropic Medication Use, revised 7/2022, indicated, 3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes. d. adequate monitoring for efficacy and adverse consequences. The P&P further indicated, 13. Residents receiving psychotropic medication are monitored for adverse consequences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 2 of 18 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 08/01/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the long-term care Ombudsman (resident advocate) was notified of transfers or discharges for two of four residents (Residents 82 and 2). For Resident 2, the facility also failed to ensure a discharge summary was completed. Failure to notify the Ombudsman had the potential to compromise the residents' admission, transfer, and discharge rights. Failure to complete a discharge summary had the potential to compromise the facility's ability to ensure the resident received appropriate care and services after leaving the facility.Findings: 1. Review of Resident 82's medical record indicated he was admitted on [DATE] and had diagnoses including bladder cancer and kidney failure. Review of Resident 82's progress notes, dated 4/15/25, indicated he had a change of condition and was transferred to the hospital. There was no documentation in the medical record that indicated the facility notified the Ombudsman of this hospital transfer. During an interview with the Social Service Designee (SSD) on 7/31/25, at 10:09 a.m., the SSD stated when a resident is transferred to the hospital, the facility is supposed to fill out a transfer form. The SSD further stated this transfer form should be faxed to the Ombudsman as soon as it is filled out. The SSD indicated she would look for documentation indicating the facility faxed a transfer form to the Ombudsman when Resident 82 was transferred to the hospital on 4/15/25. During a follow-up interview with the SSD on 7/31/25, at 11:00 a.m., the SSD confirmed she was not able to find documentation that the facility faxed a transfer form to the Ombudsman for Resident 82's hospital transfer on 4/15/25. 2. Review of Resident 2's medical record indicated he was admitted on [DATE] and had diagnoses including difficulty in walking, muscle weakness, type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), atrial fibrillation (irregular heartbeat that often causes the heart to beat too quickly), asthma (inflammatory disease of the airway that often causes wheezing, coughing, shortness of breath) and Dysphagia (difficulty in swallowing). Resident 2's medical record indicated he was discharged home on 6/16/25. There was no documentation in the medical record that the facility notified the Ombudsman of this discharge. During a concurrent interview and record review with the SSD on 8/1/25, at 2:16 p.m., the SSD confirmed there was no documentation in the medical record that indicated the facility notified the Ombudsman of Resident 2's discharge on [DATE]. The SSD could not provide fax confirmation that the facility notified the Ombudsman. The SSD stated if there was no documentation or fax confirmation about the notification to the Ombudsman, it was not done. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 8/1/25, at 9:14 a.m., the MDSC reviewed Resident 2's medical record and stated there was a physician's order for Resident 2 to be discharged on 6/16/25. The MDSC confirmed Resident 2's Discharge Instructions and Summary, initiated 6/13/25, was incomplete. The MDSC confirmed information was missing to include a recapitulation of the resident's stay, discharge note, nursing discharge assessment, name and signature of the nurse that provided discharge instructions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 3 of 18 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 08/01/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's policy and procedure (P&P) titled Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated for residents who go on emergent leave, notice of transfer is provided to the long-term care Ombudsman when practicable (e.g. in a monthly list of residents that includes all notice content requirements). The P&P indicated, for residents with planned discharges, a notice is sent to the Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. The facility's P&P titled Discharge Summary and Plan, revised 10/2022, indicated when a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge. The discharge summary shall include a description of the resident's current diagnosis, medical history, course of illness, physical and mental functional status, nutritional status, and mental and psychosocial status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 4 of 18 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 08/01/2025 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and transmit the discharge Minimum Data Set (MDS, an assessment tool) for four of seven residents (Residents 46, 76, 105, and 2) . Failure to complete and transmit MDS assessments had the potential to compromise the accuracy of the facility's quality measures (reports that reflect the facility's performance in certain care areas). This could negatively affect the facility's ability to identify areas for improvement and implement interventions accordingly.Findings: Residents Affected - Some 1. Review of Resident 46's medical record indicated he was admitted on [DATE] and discharged on 4/26/25. Resident 46's discharge MDS, dated [DATE], was incomplete and not transmitted. Review of Resident 76's medical record indicated she was admitted on [DATE] and discharged on 4/25/25. Resident 76's discharge MDS, dated [DATE], was incomplete. Review of Resident 105's medical record indicated she was admitted on [DATE] and discharged on 5/13/25. Resident 105's discharge MDS, dated [DATE], was incomplete. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 7/30/25, at 10:46 a.m., the MDSC explained the discharge MDS must be completed no later than 14 days after the resident's discharge date . The MDSC further explained the discharge MDS must be transmitted no later than 14 days after completion. The MDSC reviewed the medical records for Residents 46, 76, and 105 and confirmed the discharge MDS had not been completed and transmitted for these residents. 2. Review of Resident 2's medical record indicated he was admitted on [DATE] and discharged on 6/16/25. Resident 2's discharge MDS, dated [DATE], was incomplete. During an interview and concurrent record review with the MDSC on 8/1/25, at 8:23 a.m., the MDSC confirmed Resident 2 was discharged on 6/16/25 and his discharge MDS was incomplete. The MDSC stated the discharge MDS should have been completed 14 days after Resident 2's discharge. The MDSC confirmed Resident 2's discharge MDS was 32 days overdue. The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS instruction manual), dated 10/2024, indicated the discharge MDS must be completed no later than 14 calendar days after a resident's discharge date , and the discharge MDS must be transmitted no later than 14 calendar days after the completion date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 5 of 18 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 08/01/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 observation, interview, and record review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for one of thirteen sampled Residents (Resident 127). This failure resulted in a delayed plan of care for Resident 127.Findings:Review of Resident 127's medical record indicated he was admitted on [DATE] and had diagnoses including Congestive heart failure (inability of heart to pump enough blood), atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), atrial fibrillation (irregular heartbeat where the heart to beats too quickly) and chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs, making it difficult to breathe).Review of Resident 127's physician's order, dated 7/25/25, indicated Nitroglycerine tablet sublingual (a fast-acting medication used to relieve and prevent chest pain) 0.4 milligram (mg, a unit of measurement) give one tablet sublingually (under the tongue) every five minutes as needed for chest pain. If symptoms are not significantly improved by one dose of nitroglycerine, repeat nitroglycerine every five minutes for a maximum of three doses and call MD if symptoms are not resolved completely. During a concurrent observation and interview on 7/28/25 at 10:56 a.m., with Resident 127, he stated the staff kept a bottle of nitroglycerine tablets at his bedside table since his admission to the facility on 7/24/25.Review of Resident 127's Minimum Data Set (MDS, an assessment tool), dated 7/29/25, indicated he had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates the resident is cognitively intact).Review of Resident 127's medical record indicated there were no baseline care plans for medication self-administration and nitroglycerine sublingual tablets completed within 48 hours of the resident's admission to the facility on 7/24/25.During a concurrent interview and record review on 7/31/25 at 11:43 a.m., with the Minimum Data Set Coordinator (MDSC), the MDSC confirmed the above findings and stated baseline care plans should be initiated and completed within 48 hours of admission.The facility's policy and procedure (P&P) titled Care Plans, Baseline, revised 3/2022, 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. The P&P further indicate, 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 including but not limited to the following: a. initial goals based on admission orders and discussion with the resident/representative . Event ID: Facility ID: 055210 If continuation sheet Page 6 of 18 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 08/01/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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** Based on interview and record review, the facility failed to develop and implement care plans for one of 13 sampled residents (Resident 35) when a care plan for Nystop External Powder (a brand name for topical nystatin, an antifungal medication used to treat skin infections caused by yeast) was not developed. This failure had the potential to not meet the residents' medical, nursing, mental and psychosocial needs.Review of Resident 35's medical record indicated she was admitted to the facility on [DATE] and had diagnoses including difficulty in walking, cellulitis (a skin infection) of left and right lower limbs (lower legs), hypertension (high blood pressure), and chronic venous hypertension (CVH, a condition where the veins in the legs experience elevated, persistent pressure due to impaired blood flow back to the heart) with inflammation of bilateral lower extremities (legs).Review of Resident 35's physician's order, dated 7/21/25, indicated Nystop External Powder 100,000 unit/gm (gm, a unit of weight in the metric system) apply to under-breast topically two times a day for fungal rash under breast.Review of Resident 35's care plans indicated there was no care plan developed to address her rashes under her breast and the use Nystop External Powder as ordered by the physician.During a concurrent interview and record review on 7/31/25 at 10:57 a.m., with the Director of Nursing (DON), the DON reviewed Resident 35's medical record and stated that she could not find a care plan for the rashes under Resident 35's breast. The DON acknowledged that a care plan should have been developed to address Resident 35's under-breast rash and the use of Nystop External Powder. The DON stated the care plan should be individualized and person-centered for each resident.The facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Event ID: Facility ID: 055210 If continuation sheet Page 7 of 18 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 08/01/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure three of 19 residents (Residents 119, 120, and 114) were free from unnecessary medications when:Resident 119 had no side effects monitoring for heparin (an anticoagulant [blood thinner] used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels); 2. Resident 120 had three identical orders for oxycodone (a potent controlled medication for pain); and 3. Resident 114 had no side effects monitoring for Eliquis (an anticoagulant medication used to treat and prevent blood clots).These failures resulted in unmonitored side effects of anticoagulant medications and duplicate orders that had the potential for excessive dose/adverse effects for the residents. Findings:1. Review of Resident 119's clinical record indicated Resident 119 was admitted to the facility with diagnoses including coronary artery dissection (tear in the inner layer of a coronary artery [blood vessel that supplies oxygen and nutrients to the heart muscle]). Resident 119's physician's orders indicated an order, dated 7/26/25, for Heparin Sodium Injection solution 5000 unit/ml (Milliliter, is a unit of volume) inject 0.5 ml subcutaneously (into the tissue layer between the skin and the muscle) three times a day for DVT (Deep Vein Thrombosis, a condition where a blood clot forms in a deep vein). There was no documentation of monitoring for side effects of heparin.During a concurrent interview and record review on 7/31/25 at 2:26 p.m., with the Director of Nursing (DON), the DON reviewed Resident 119's physician's orders and confirmed Resident 119 was on Heparin three times daily. The DON confirmed there was no monitoring for side effects of heparin. The DON stated residents taking anticoagulants should have monitoring for signs and symptoms for bleeding. 2. Review of Resident 120's clinical record indicated Resident 120 was admitted to the facility with diagnoses including chronic pain (pain that persists for three months or longer). Review of Resident 120's physician's orders indicated she had three active identical orders of oxycodone 5 mg with three different order dates, as follows:- Oxycodone 5 mg Give 1 tablet by mouth every 6 hours as needed for severe pain, dated 6/29/25.- Oxycodone 5 mg Give 1 tablet by mouth every 6 hours as needed for severe pain, dated 7/4/25.Oxycodone 5 mg Give 1 tablet by mouth every 6 hours as needed for pain, dated 7/15/25.Review of Resident 120's July 2025 Medication Administration Record (MAR) indicated there were three entries for oxycodone 5mg orders.During a concurrent interview and record review on 7/31/25 at 2:35 p.m., with DON, the DON reviewed Resident 120's July 2025 MAR and confirmed there were three of the same orders for oxycodone 5 mg. The DON stated when the nurses received new orders for oxycodone, they should discontinue the old orders. 3. Review of Resident 114's clinical record indicated Resident 114 was admitted to the facility with diagnoses including paroxysmal atrial fibrillation (A-fib, a type of irregular heartbeat that starts and stops on its own). Physician's orders indicated an order, dated 7/26/25, for Eliquis oral tablet 5 mg give 1 tablet by mouth two times a day for A-fib. There was no documentation of monitoring for side effects of Eliquis.During a concurrent interview and record review on 8/1/25 at 10:48 p.m., with the Director of Staff Development (DSD), the DSD reviewed Resident 114's clinical record and confirmed Resident 114 was on Eliquis 5 mg. The DSD confirmed she did not see anticoagulant side effects monitoring in Resident 114's clinical record. During an interview on 8/1/25 at 1:31 p.m., with the DON, the DON stated residents on anticoagulants should have monitoring for side effects of bleeding.The facility's policy and procedure (P&P) titled Medication Therapy, revised 4/2007, indicated, 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 2. Medication use shall be consistent with an individual's condition . 3. All medication orders will be supported by appropriate care processes . 2. All decisions related to medications shall include appropriate elements of the care process . 3. Upon or Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 8 of 18 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 08/01/2025 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 0757 Level of Harm - Minimal harm or potential for actual harm shortly after admission and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether. b. dosage is appropriate; c. the frequency of administration and duration of use are appropriate; and d. potential or suspected side effects are present. 8. The medical director and consultant pharmacist shall collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 9 of 18 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 08/01/2025 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 Based on observation, interview, and record review, the facility had a medication error rate of 6.9% when two medication errors occurred out of 29 opportunities during the medication administration for two out of 12 residents (Residents 111 and 67) when:1. For Resident 111, Registered Nurse B (RN B) did not follow a physician's order to hold midodrine (medication used to raise blood pressure) for systolic blood pressure (SBP, the top number in a blood pressure reading) greater than 120; and2. For Resident 67, Registered Nurse C (RN C) administered eyedrops and did not wait three to four minutes before instilling a second drop in each eye. These failures had the potential to result in the residents experiencing complications and not receiving the full therapeutic effects of medications. Findings:1. During the medication administration observation on 7/28/2025 at 12:17 p.m., RN B was observed preparing one medication tablet for Resident 111. The medication was midodrine 2.5 milligrams (mg, unit of dose measurement). RN B administered the medication to Resident 111. RN B did not appear to have checked the resident's blood pressure (BP) before administering the midodrine.During an interview and record review with RN B on 7/28/25 at 12:19 p.m., RN B was asked if he checked Resident 111's BP. RN B stated he did check the BP earlier at around 9:30 a.m., and the reading was 142/72. RN B reviewed Resident 111's midodrine instructions, which indicated to hold for SBP greater than 120. During an observation on 7/28/25 at 12:26 p.m., RN B went back to Resident 111 to recheck the BP, and the reading was 147/101. RN B stated he should have held the midodrine.Review of Resident 111's physician order, dated 7/23/25, indicated Midodrine 2.5 mg give 1 tablet by mouth three times a day for hypotension (low blood pressure) hold for SBP > (greater than) 120.During an interview on 7/28/25 at 5:23 p.m., with the Director for Nursing (DON), the DON stated for medications with BP parameters, the BP should be checked prior to giving the medication and the doctor's order should be followed. The DON further stated to hold the medication if the BP is above the parameters.During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised 4/19, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. The P&P further indicated, Medications are administered in accordance with prescriber orders. 2. During the medication administration observation on 7/30/25 at 12:49 p.m., RN C was observed preparing and administering two eye drops to each of Resident 67's eyes. RN C instructed Resident 67 to look up, then pulled the resident's left lower eyelid, instilled two eye drops into the lower conjunctiva (transparent mucous membrane that lines the inner surface of the eyelids and covers the white part of the eyeball), wiped the left eye with Kleenex, and repeated the process on right eye. RN C was not observed waiting 3 to 4 minutes in between drops in each eye, and he did not apply pressure over the point where the lid meets the nose.During a follow-up interview with RN C on 7/30/2025 at 1:13 p.m., RN C stated he give two quick drops to Resident 67's eyes. RN C confirmed he did not wait a few minutes to administer the second drop to the same eye. He stated he should wait about 30 seconds to administer the second drop.Review of Resident 67's physician orders indicated an order, dated 12/20/24, for Refresh Tears (artificial tears used provide relief for dry, burning, irritated eyes) Ophthalmic Solution 0.5% instill 2 drops in both eyes three times a day for dry eyes.During an interview with the DON on 7/31/25 at 2:24 p.m., the DON was asked if the nurse needed to wait a few minutes before administering the second eye drop. The DON stated maybe about 2 seconds. She stated she would follow up.During an interview on 8/1/25 at 10:46 a.m., with the Director of Staff Development (DSD), the DSD was asked if the nurse needed to wait a few minutes when administering two drops of same eye drop. The DSD stated if it was the same eye drop, and there were no directions on the medication box, it was up to the nurse's discretion.During a phone interview on 8/1/25 at 11:29 a.m., with the Consultant Pharmacist (CP), the CP stated she Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 10 of 18 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 08/01/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete would look for the policy. Shortly after, the CP stated if administering another drop of same eye drop, or a different medication, the nurse should wait 3 to 5 minutes. According to American Academy of Allergy Asthma & Immunology's (professional medical organization dedicated to advancing the knowledge and practice of allergy, asthma, and immunology for optimal patient care, https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/eye-drops) Tips For Administering Eye Drops, If more than one drop has been ordered, wait 3 to 4 minutes before putting another drop into the same eye. 8. After inserting the drops, close the eyelids and apply pressure for 1 to 2 minutes over the point where the lid meets the nose. Event ID: Facility ID: 055210 If continuation sheet Page 11 of 18 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 08/01/2025 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 medications were stored properly in one medication cart and for two of 13 sampled residents (Resident 35 and 127) when:1. Two expired bottles of over the counter medication (OTC) medications were not removed from the medication cart;2. A bottle of Nystop External Powder (a brand name for topical nystatin, an antifungal medication used to treat skin infections caused by yeast) was kept on Resident 35's bedside table unattended; and,3. A bottle of Nitroglycerine sublingual tablets (a fast-acting medication used to relieve and prevent chest pain) was kept on resident 127's bedside table unattended.These failures had the potential for unsafe and improper administration of medications. Findings: 1. During an inspection of Medication Cart X on [DATE] at 3:55 p.m., with Registered Nurse D (RN D), there was one opened bottle of Naproxen (medication used to relieve pain, inflammation, and fever) 220 milligrams (mg, unit of dose measurement) that had an expiration date of 6/2025. There was also one opened bottle of Zyrtec (medication used to relieve common allergy symptoms) 10 mg that had an expiration date of 2/2022. RN D confirmed the above medications were expired and stated they should not have been in the medication cart. During an interview on [DATE] at 2:44 p.m., with the Director of Nursing (DON), the DON stated any expired medication should be disposed. The DON further stated if something is expired, it needs to be removed from the medication cart. During a review of the facility's policy and procedure (P&P) titled Medication Labeling and Storage, revised 2/2023, the P&P indicated, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 2. During an initial tour of the facility on [DATE] at 10:40 a.m., a bottle of Nystop External Powder 100,000 unit/gm (gm, a unit of weight in the metric system) was kept on Resident 35's bedside table unattended. During a concurrent observation and interview on [DATE] at 10:43 a.m., with Resident 35, she stated that the facility staff was using the powder to treat her under-breast rashes, and facility staff were keeping the powder bottle on her bedside table. During a concurrent observation and interview on [DATE] at 10:47 a.m., with Licensed Vocational Nurse A (LVN A), LVN A confirmed the above observation and stated the Nystop External Powder was used for Resident 35's under-breast rashes as ordered by the physician. LVN A stated that the bottle of Nystop powder should not have been kept at Resident 35's bedside table. She stated it should have been stored inside the treatment cart. LVN A further stated that self-administration assessment was not done by the facility staff for Resident 35. Review of Resident 35's face sheet indicated she had diagnoses of difficulty in walking, hypertension (high blood pressure) and cellulitis of left lower limb. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 12 of 18 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 08/01/2025 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 Review of Resident 35's MDS dated [DATE], indicated she had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates the resident is cognitively intact). Review of Resident 35's physician's order, dated [DATE], indicated Nystop External Powder 100,000 unit/gm (Nystatin Topical) apply to under-breast topically two times a day for fungal rash under breast. Residents Affected - Few 3. During an initial tour of the facility on [DATE] at 10:05 a.m., a bottle of Nitroglycerine tablet sublingual 0.4 mg. was kept on resident 127's bedside table unattended. During a concurrent observation and interview on [DATE] at 10:43 a.m., with LVN A , she stated that Resident 127 had an order to keep the Nitroglycerine at bedside. LVN A stated there was no self-administration assessment done by the facility staff. During a record review on [DATE] at 12:00 p.m., Resident 127 had no self-administration assessment done by facility staff or interdisciplinary team (IDT, staff from different departments who coordinates the residents care) assessment. During a concurrent observation and interview on [DATE] at 10:56 a.m., with Resident 127, he stated the bottle of nitroglycerine tablets was kept by the staff at his bedside table since he was admitted to the facility on [DATE]. Resident 127 stated the facility staff was not checking on the medication. Review of Resident 127's face sheet indicated he had diagnoses of Chronic systolic (Congestive) heart failure (inability of heart to pump enough blood), atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), permanent atrial fibrillation (irregular heartbeat that often causes the heart to beat too quickly) and chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe). Review of Resident 127's MDS dated [DATE], indicated he had a BIMS score of 15. The facility's policy and procedure (P&P) titled Medication Labeling and Storage, revised 2/2023, indicated the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The facility's P&P titled Self -Administration of Medication, revised 2/2021, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the assessment, IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Self- administered medications are stored in a safe places, which are not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored in a central medication cart or in the medication room. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 13 of 18 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 08/01/2025 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 - Many FORM CMS-2567 (02/99) Previous Versions Obsolete 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 maintain sanitary conditions in the kitchen when:There were whitish substances below the steamer and on a metal cart in front of the steamer; 2. There were whitish-grayish substances on a black cart in the dry storage area that was used to store utensils and food containers; 3. There were whitish substances on the edges of the food warmer cart in the dry storage area; 4. There were two open packs of brown grapes and one pack of raw broccoli that were unlabeled and undated in the walk-in refrigerator; 5. There were whitish substances on the outside surface of the ice machine; and, 6. Nine cutting boards were discolored, worn out, and had deep cuts and scratches.These failures had the potential to result in foodborne illness in a population of vulnerable residents with complex medical conditions.Findings:During a concurrent observation and interview with the Dining Director (DD) on 7/28/25, at 9:32 a.m., the following were observed: 1. There were whitish substances below the steamer and on a metal cart in front of the steamer; 2. There were whitish-grayish substances on a black cart in the dry storage area that was used to store utensils and food containers; 3. There were whitish substances on the edges of the food warmer cart in the dry storage area; 4. There were two open packs of brown grapes and one pack of raw broccoli that were unlabeled and undated in the walk-in refrigerator; 5. There were whitish substances on the outside surface of the ice machine; and, 6. There were nine cutting boards that were discolored, worn out, and had deep cuts and scratches. The DD acknowledged these observations and stated the above items that had substances on them should have been cleaned.During a concurrent observation and interview with the Executive Chef (EC) 7/28/2025, at 9:35 a.m., the EC acknowledged the above observations and stated that kitchen staff would clean the items that had substances on them. The EC also stated the nine cutting boards would be replaced. The EC confirmed the two open packs of brown grapes and one pack of raw broccoli should have been labeled with the date they were delivered to the facility.The Food and Drug Administration's 2022 Food Code indicated equipment, food contact surfaces, and utensils shall be clean to sight and touch . non-food-contact surfaces of equipment shall be kept free of accumulations of dust, dirt, food residue, and other debris . Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.The facility's policy titled Production, Purchasing, Storage, revised 1/2025, indicated, Date foods prior to placing in storage areas. Produce is labeled with the date received. Event ID: Facility ID: 055210 If continuation sheet Page 14 of 18 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 08/01/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for two of 13 sampled residents (Residents 82 and 119) when:For Resident 82, there was a typographical error in his order to monitor urine output; and,For Resident 119, the medical record did not accurately reflect the resident's refusal of a lab test.These failures had the potential to compromise the care and safety of the residents.1. Review of Resident's 82's medical record indicated he was admitted on [DATE] and had diagnoses including bladder cancer, hydronephrosis (swelling of the kidneys caused by a backup of urine), and kidney failure. Further review of the medical record indicated Resident 82 had nephrostomy tubes (small flexible tubes inserted through the skin and into the kidneys to drain urine) in both kidneys. Review of Resident 82's Order Summary Report indicated he had a physician's order, dated 5/31/25, to measure output (amount of urine drained) from the left nephrostomy tube every shift. The order further indicated to record the amount of fluid every 24 hours, and if it was greater than 500 milliliters (ml, unit of measurement), notify the doctor. Further review of Resident 82's Order Summary Report indicated he had the same order for the right nephrostomy tube. During an interview and concurrent record review with the Director of Staff Development (DSD) on 8/1/25, at 9:22 a.m., the DSD reviewed Resident 82's medical record and confirmed there were orders to notify the doctor if the output from the nephrostomy tubes was greater than 500 ml in 24 hours. The DSD reviewed Resident 82's nephrostomy output documentation for the month of 7/2025 and confirmed the output was greater 500 ml on most days. However, the DSD confirmed she was only able to find documentation of doctor notification for two of those days. During a follow-up interview with the DSD on 8/1/25, at 10:23 a.m., the DSD explained Resident 82's physician's orders were supposed to indicate to record the amount of fluid from the nephrostomy tubes every 24 hours and notify the doctor if the output was less than (not greater than) 500 ml. The DSD acknowledged the nurses should have contacted the doctor to clarify the order. The facility's policy and procedure (P&P) titled Charting and Documentation, revised 7/2017, indicated documentation in the medical record will be complete and accurate. The facility's P&P titled Medication and Treatment Orders, revised 7/2016, indicated treatment orders will be consistent with principles of safe and effective order writing. 2. Review of Resident 119's clinical record indicated Resident 119 was admitted to the facility with diagnoses including coronary artery dissection (tear in the inner layer of a coronary artery [major blood vessel that leads to the heart muscle]). Review of Resident 119's physician's orders indicated an order, dated 7/25/25 for, PTT [Partial Thromboplastin Time, a blood test that measures how long it takes for a person's blood to clot] weekly while on heparin [a blood thinner] one time a day every Monday for monitoring, start date 7/28/25. Review of Resident 119's July 2025 medication administration record (MAR) indicated an order, dated 7/21/25, for heparin 5000 unit/ml inject 0.5 ml subcutaneously (into the tissue layer between the skin and the muscle) every 8 hours for blood clotting prevention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 15 of 18 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 08/01/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 119's July 2025 treatment administration record (TAR) indicated an order for PTT weekly while on heparin one time a day every Monday for monitoring, start date 7/28/25. The TAR was documented with a check mark on 7/28/25. The chart code on the TAR indicated a check mark meant the treatment was administered. During a concurrent interview and record review with the Director of Nursing (DON) on 7/31/25 at 2:31 p.m., the DON stated Resident 119 should have had a PTT on 7/28/25. The DON stated she would follow up to see if the PTT was done, or if the resident refused. During an interview with the DON on 8/1/25 at 1:32 p.m., the DON stated she could not find the PTT result for Resident 119. The DON stated she was waiting for the nurse to reply to find out if Resident 119 refused. The DON further stated if Resident 119 refused, there should be documentation and notification to the Medical Doctor. During an interview with the DON on 8/1/25 at 2:17 p.m., the DON stated the nurse said Resident 119 refused the PTT on 7/28/25. The DON confirmed there was no documentation of refusal. Review of the TAR indicated the following under Chart Codes/Follow Up Codes; check = administered.2 = drug refusal. During a concurrent interview and record review on 8/1/25 at 2:33 p.m., the DON reviewed Resident 119's TAR. The DON stated the nurse clicked (checked) the TAR to acknowledge that there were labs that needed to be done. The DON further stated the nurse just put late entry notes today, 8/1/25, for Resident 119. The facility's P&P titled Charting and Documentation, revised 7/2017, indicated, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatment will include care-specific details, including:.e. whether the resident refused the procedure/treatment; f. notification of family, physician, or other staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 16 of 18 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 08/01/2025 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 infection control practices were implemented when:1. A nebulizer machine (device used to deliver medication in the form of a mist for inhalation) mask, chamber (part of the mask that holds the liquid medication), and tubing were stored inside the bedside drawer of resident 127 and the mask was touching the drawer surface;2. An inhaler chamber attachment (device that attaches to an inhaler to make it easier to breath the medication in) had a yellowish substance around the mouthpiece and was stored on top of resident 2's bedside table;3. Garbage and recycle bins were open and exposed while three Residents were eating lunch; 4. A licensed nurse did not wear gloves when holding and cutting a medication; andThese failures could result in the spread of infection and cross-contamination that could affect the 28 residents who reside in the facility.1.During an initial tour of the facility on 7/28/25 at 10:56 a.m., Resident 127's nebulizer machine mask, chamber, and tubing were stored inside the resident's bedside drawer. The nebulizer mask was touching the drawer surface. Residents Affected - Some During a concurrent observation and interview on 7/28/25 at 11:01 a.m., with Licensed Vocational Nurse A (LVN A), LVN A confirmed the above observation and stated Resident 127s nebulizer machine mask, chamber, and tubing should have been stored in a plastic bag to prevent contamination. During an observation on 7/29/25 at 2:48 p.m., Resident 127s nebulizer machine mask, chamber, and tubing were stored inside the bedside drawer. The nebulizer mask was touching the drawer surface. During a concurrent observation and interview on 7/29/25 at 2:50 p.m., with the infection Preventionist (IP), the IP acknowledged the above observation and stated the items should have been cleaned after use and stored in a plastic bag to prevent contamination. The facility's policy and procedure (P&P) titled Administering Medications through a Small Volume (Handheld) Nebulizer, revised 10/2010, indicated to rinse and disinfect the nebulizer equipment according to facility protocol and allow to air dry on a paper towel. The P&P further indicated when the equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 2. During an initial tour of the facility on 7/28/25 at 10:56 a.m., Resident 127's inhaler chamber attachment had a yellowish substance around the mouthpiece and was stored on top of resident 2's bedside table. During an observation on 7/29/25 at 2:48 p.m., Resident 127's inhaler chamber attachment had a yellowish substance around the mouthpiece and was stored on top of resident 2's bedside table. During a concurrent observation and interview on 7/29/25 at 2:50 p.m., with the IP, the IP acknowledged the above observation and stated Resident 127's inhaler chamber attachment should have been cleaned and stored inside a plastic bag to prevent contamination. 3. During a dining observation in the west dining area on 7/28/25 at 12:30 p.m., three residents were eating lunch. There was a medication cart in the dining area with a trash bin attached to it. There was garbage in the medication cart trash bin and the lid was open. During a concurrent observation and interview with the IP on 7/28/25 at 12:34 p.m., the IP confirmed the above observation and stated the trash bin lid should be closed for infection prevention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 17 of 18 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 08/01/2025 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 Residents Affected - Some During dining observations on 7/28/25 at 12:22 p.m. and 12:38 p.m., trash and recycle bins were open and the contents of the bins were not covered in the west dining area. Three residents were eating lunch in the area during these observations. During a concurrent observation and interview on 7/28/25 12:39 p.m., with Certified Nursing Assistant E (CNA E), CNA E confirmed the above observations and stated the trash and recycle bin lids should have been closed at all times to prevent the spread of infection. The facility's (P&P) titled Sanitation and infection Prevention Control-Solid Waste Disposal, revised 1/2025, indicated, Garbage containers are clean, lined and covered at all times. 4. During a medication administration observation on 7/28/25 at 11:42 a.m., with Licensed Vocational Nurse A (LVN A), LVN A did not sanitize hands after holding a key and opening the medication cart. LVN A then prepared medication for Resident 123. Without wearing gloves, LVN A took two tablets of acetaminophen (medication used to reduce pain and fever) 500 milligrams (mg, unit of dose measurement) from the bottle, placed the tablets in her right hand, put the two tablets into a medicine cup, picked one tablet up and placed it into a pill cutter, cut the tablet, and placed half the tablet back into the medicine cup. During an interview shortly after the above observation, on 7/28/25 at 11:51 a.m., LVN A confirmed she did not use gloves when she was holding the two tablets of acetaminophen. She stated she did not wear gloves because she was outside the resident's room. During an interview with the IP on 7/31/25 at 1:30 p.m., the IP was asked if the nurse needed to wear gloves when touching the medication. The IP stated if they need to cut medication, the nurses have to perform hand hygiene and put gloves on when touching the medication. The IP further stated the nurses cannot touch the medication without gloves. During a review of the facility's P&P titled Administering Medications, revised 4/2019, the P&P indicated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for administration of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055210 If continuation sheet Page 18 of 18