Health inspection·December 17, 2021

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 a resident's code status (instructions on what to do if the resident has no pulse and stops breathing) was clearly indicated in the medical record for one of 15 sampled residents (Resident 24). This failure had the potential to result in the facility not acting in accordance with Resident 24's wishes in the event of an emergency. Findings: Review of Resident 24's medical record indicated he was admitted on [DATE]. Resident 24's face sheet (document with basic information) did not specify his code status. The area of the face sheet titled Advance Directive [resident's wishes regarding medical treatment] was blank. Resident 24's undated Physician Orders for Life Sustaining Treatment (POLST, document that specifies the medical treatments the resident wants to receive during serious illness) was reviewed. Most of the POLST was blank, including the section regarding what to do if the resident had no pulse or stopped breathing. During an interview and concurrent record review with the medical records director (MRD) on [DATE] at 3:20 p.m., the MRD stated the resident's code status should be indicated on the physician's orders. The MRD reviewed Resident 24's medical record and confirmed his code status was not specified on the physician's orders. The MRD also confirmed Resident 24's code status was not indicated on his face sheet. After searching Resident 24's record for some time, the MRD found a History and Physical, dated [DATE], that indicated Resident 24 demonstrated capacity (had the ability to make decisions) and was to have a code status of Do Not Resuscitate [allow natural death]. During an interview and concurrent record review with licensed vocational nurse B (LVN B) on [DATE] at 3:37 p.m., LVN B was asked to explain what he would do if Resident 24 had no pulse and was not breathing. LVN B stated he would confirm if the resident wanted CPR (cardiopulmonary resuscitation, a procedure consisting of chest compressions and artificial breaths) by looking at the POLST or electronic health record. LVN B reviewed Resident 24's POLST and confirmed it was blank. He then opened Resident 24's electronic health record and confirmed that the area designated for code status was blank. LVN B then stated that in this situation, he would assume Resident 24 was full code (all resuscitation procedures are to be provided to keep the resident alive) and start CPR. On [DATE] at 4:00 p.m., the MRD presented an untitled document for Resident 24, dated 5/10, that indicated, Do Not Resuscitate. The facility's policy titled Advance Directives, revised 12/2016, indicated Advance directives will be respected in accordance with state law and facility policy. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 2 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident 12's clinical record indicated he was admitted on [DATE] and had diagnoses that included acute respiratory failure (when fluid builds up in the air sacs in the lungs), difficulty in walking, shortness of breath, abnormal posture, exhaustion due to excessive exertion, and need for assistance with personal care. Residents Affected - Some Review of Resident 12's Minimum Data Set (MDS, assessment tool), dated 10/2/2021, indicated he had a Brief Interview for Mental Status (BIMS, a screening tool to assess cognition) score of 13. This score indicates intact cognitive response. Review of Resident 12's current PT (physical therapy) Evaluation and Treatment indicated, Gait: requires contact guard assist [CGA, the assisting person has one or two hands on the resident's body but provides no other assistance to perform the functional mobility task]. During an observation on 12/15/2021 at 10:06 a.m., Resident 12 was walking in the hallway using a front wheel walker (FWW, device that provides additional support to maintain balance or stability while walking). Physical therapist K (PT K) was supporting Resident 12 by the waist with her left hand, and using the other hand for a wheelchair to follow Resident 12 during walking. Resident 12 was also receiving oxygen per nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) via oxygen tank, which was strapped to the back of the wheelchair. No gait belt was observed around Resident 12's waist. During an interview with the PT K on 12/15/2021 at 10:15 a.m., PT K confirmed that Resident 12 was not wearing a gait belt. PT K stated gait belts were used during ambulation for safety. During an interview with the Director of Rehabilitation (DOR) on 12/15/2021 at 3:10 p.m., she stated that a gait belt should be used when assisting residents during therapy for safety. During an interview with Resident 12 on 12/17/2021 at 9:00 a.m., he stated that a gait belt was usually used when walking during therapy for safety because he gets dizzy and nervous sometimes during therapy. Resident 12 further stated he did not know why a gait belt was not used last time he had therapy. Review of the facility's undated policy titled Gait Belts, indicated To promote prevention of patient falls while treatment is being rendered and to reduce injury to staff assisting patients. Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for five of 15 sampled residents (Residents 55, 35, 58, 6 and 12) when: 1. Nursing staff provided ice chips to Resident 55, who had a strict nothing by mouth (NPO, no food or drinks) doctor's order; 2. Nursing staff did not provide Resident 35's right hand carrot orthosis (device used to prevent further stiffening of the hand) as ordered; 3. Nursing staff did not provide a left fifth finger splint to Resident 58 as ordered; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 3 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 0684 4. For Resident 6, the charge nurse signed for a treatment that was provided by the treatment nurse; and Level of Harm - Minimal harm or potential for actual harm 5. The physical therapist did not use a gait belt (device attached to the resident to assist with transferring and walking) while walking Resident 12 when indicated. Residents Affected - Some These failures had the potential to affect the residents' care and jeopardize their health and well-being. Findings: 1. A review of Resident 55's clinical record indicated he was admitted with the diagnosis of dysphagia (difficulty in swallowing) following cerebral infarction (also called stroke). During a concurrent observation and interview on 12/13/21 at 12:11 p.m., with Resident 55's family member, a pitcher of ice chips was on Resident 55's overbed table. Resident 55's family member stated, he can only have ice chips. During an observation on 12/15/21 at 10:15 a.m. inside Resident 55's room, a pitcher of ice chips was observed on top of the overbed table. During a concurrent interview and record review on 12/15/21 at 10:22 a.m., licensed vocational nurse C (LVN C) reviewed resident 55's physician order and did not find an order for ice chips. During a concurrent interview and record review on 12/15/21 at 10:33 a.m., the nurse supervisor (NS) reviewed Resident 55's physician order and confirmed there was no order for the resident to have ice chips. During an interview on 12/16/21 at 12:50 p.m., the director of nursing (DON) stated a physician's order was needed prior to giving ice chips to Resident 55. 2. A review of Resident 35's clinical record indicated she was admitted with the diagnosis of Alzheimer's disease (a condition characterized by memory loss). A review of Resident 35's physician order, dated 12/4/2020, indicated Apply right hand carrot d/t (due to) contractures (stiffness of joints). Check skin integrity for breakdown, every shift. A review of Resident 35's occupational therapy Discharge summary, dated [DATE], indicated Discharge Recommendations: Hand carrot orthosis on right hand. During an observation on 12/13/21 at 9:27 a.m., while Resident 35 was in bed, there was no hand carrot orthosis observed to right hand. During a concurrent observation and interview on 12/14/21 at 10:00 a.m., the treatment nurse (TN) was looking for Resident 35's hand carrot orthosis. The TN stated Resident 35 used a carrot to the right hand for contractures. During a concurrent observation and interview on 12/15/21 at 10:17 a.m., LVN C stated Resident 35 should have the carrot to her right hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 4 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 12/15/21 at 10:44 a.m., the NS reviewed Resident 35's list of care plans and confirmed there was no care plan regarding Resident 35's refusal to use the right-hand carrot orthosis. During a concurrent observation and interview on 12/15/21 at 1:54 p.m., with certified nursing assistant G (CNA G), the carrot was observed on top of Resident 35's overbed table. CNA G stated Resident 35 threw the carrot to the floor. During an interview on 12/16/21 at 12:50 p.m., the DON confirmed she was not aware of Resident 35's refusal to use the carrot orthosis. The DON stated nursing staff should have notified the physician, the family and care planned the refusal of carrot use. 3. During an observation on 12/13/21 at 12:13 p.m., in Resident 58's room, a blue finger brace was found on the floor. Resident 58 did not have a finger brace on his hand. During an interview on 12/13/21 at 1:00 p.m., CNA I stated he did not know whose finger brace it was. CNA I picked up the finger brace and threw it in the garbage, without notifying the charge nurse. During an observation on 12/14/21 at 10:00 a.m., Resident 58 did not have a finger brace on. During an interview on 12/15/21 at 1:52 p.m., LVN C stated Resident 58 had an order to apply a finger brace to the left little finger. During an interview on 12/15/21 at 3:15 p.m., LVN H stated staff could not find the blue finger brace for several days. Reviewed of Resident 58's Electronic Health Record (EHR) indicated Resident 58 had the diagnoses of dislocation of distal interphalangeal joint of left little finger (left little finger out of place) and dementia (a disease with memory loss). Review of Resident 58's physician order, dated 12/9/21, indicated apply finger brace to left little finger at all times. Review of Resident 58's EHR indicated there was no care plan regarding the intervention of applying a finger brace to the left little finger. During an interview on 12/16/21 at 1:45 p.m., the DON stated Resident 58 should have the finger brace on the left little finger at all times. The DON confirmed the nurses should update resident care plans. 4. During a concurrent interview and review of Resident 6's December 2021, Medication Administration Record (MAR) on 12/15/21 at 11:05 a.m., with LVN C, Resident 6's day shift Nystatin cream (a topical ointment for fungal infection) administration was signed off by LVN C. LVN C stated she did not apply any cream for Resident 6 that morning. During an interview on 12/15/21 at 11:12 a.m., the TN stated she applied Nystatin cream for Resident 6 this morning, but did not document. During an interview on 12/16/21 at 1:05 p.m., the DON stated nurses should only document in the MAR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 5 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete or TAR (treatment administration record) if they gave the medication or provided treatment to the resident. The DON acknowledged the TN should have signed for Resident 6's Nystatin cream administration. Review of the facility's policy, Administering Medications, revised December 2012, indicated the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next dose. Event ID: Facility ID: 055517 If continuation sheet Page 6 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 provide services to promote healing of pressure ulcers (damage to the skin and underlying tissue as a result of prolonged pressure) for one of 15 sampled residents (Resident 11) when: Residents Affected - Few 1. The facility did not obtain treatment orders for the resident's multiple pressure ulcers in a timely manner; 2. There was no documentation indicating the facility provided treatments for the resident's multiple pressure ulcers; and 3. The facility did not develop care plans to address the resident's multiple pressure ulcers. These failures had the potential to result in worsening pressure ulcers and the development of new pressure ulcers for Resident 11. Findings: Review of Resident 11's medical record indicated she was readmitted to the facility on [DATE]. Review of Resident 11's Baseline Admission/readmission Screen document, dated 12/12/2021, indicated Resident 11 had one pressure ulcer on her left heel, one on her right heel, four on her back, one on her sacrum (tailbone area), one on her left buttock, and one on her right elbow (nine total pressure ulcers). The pressure ulcers were of different sizes and severities. Review of Resident 11's December 2021, Order Summary Report indicated she did not have orders for treatment of the above pressure ulcers until 12/16/2021 (four days after the resident was noted with pressure ulcers upon readmission). Resident 11's December 2021, treatment administration record (TAR) was reviewed on 12/17/2021. There was no documentation indicating the facility provided treatment for any of Resident 11's multiple pressure ulcers from 12/12/2021 to 12/16/2021. During an interview and concurrent record review with the director of nursing (DON) on 12/17/2021 at 10:42 a.m., she acknowledged that when a resident is noted with pressure ulcers, treatments should be initiated right away. The DON reviewed Resident 11's record and confirmed there were no pressure ulcer treatment orders until 12/16/2021. She also confirmed there was no documentation indicating the facility provided pressure ulcer treatments from 12/12/2021 to 12/16/2021. The DON acknowledged that if the treatments were not documented, they were not done. Further review of Resident 11's medical record indicated there were no care plans to address her multiple pressure ulcers. During an interview and concurrent record review with the DON on 12/17/2021 at 11:29 a.m., she reviewed Resident 11's record and confirmed there were no care plans to address her multiple pressure ulcers. The DON stated the facility was supposed to develop a separate care plan for each individual pressure ulcer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 7 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's policy titled Wound Care, revised 10/2010, indicated Verify that there is a physician's order for this procedure. The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound (weekly). 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. The facility's policy titled Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated the comprehensive person-centered care plan will incorporate identified problem areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 8 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement appropriate new interventions after a fall for one of 15 sampled residents (Resident 9). This failure had the potential to result in Resident 9 experiencing further falls and injury. Findings: Review of Resident 9's medical record indicated she was admitted on [DATE] and had the diagnoses of disorientation (a state of mental confusion), glaucoma (condition that causes gradual loss of sight), and abnormalities of gait (manner of walking) and mobility. Review of Resident 9's Minimum Data Sets (MDS, assessment tools) dated 9/14/2020, 9/30/2020 and 12/31/2020, indicated she had brief interview for mental status (BIMS) scores ranging from 5 to 11 (these scores indicate moderate to severe cognitive impairment). Review of Resident 9's care plan, dated 9/4/2020, indicated she was at high risk for falls and injury related to use of psychotropic medications (medications used to treat mental disorders). The care plan included interventions such as, Encourage resident to use call light and wait for staff assistance prior to transferring and Provide assistance needed with transfer and ambulation [walking]. Review of Resident 9's Progress Notes, dated 1/22/2021, indicated she had a fall while transferring herself from bed to wheelchair. Review of Resident 9's Post Fall Evaluation, dated 1/25/2021, indicated Resident 9 forgot to ask for staff assistance and claimed she could transfer by herself. The Post Fall Evaluation further indicated Resident 1 needed re-education, and the interdisciplinary team (IDT, staff from different disciplines who work together to plan and provide care) recommended to encourage the resident to use the call light to call for assistance. During an interview with the director of nursing (DON) on 12/16/2021 at 8:58 a.m., she confirmed that when a resident falls, the facility should develop and implement a new intervention to try and prevent future falls. During an interview and concurrent record review with the DON on 12/17/2021 at 8:25 a.m., she reviewed Resident 9's record and confirmed that after the resident fell on 1/22/2021, the IDT recommended to encourage the resident to use the call light for assistance. She stated the IDT also recommended to provide assistance during transfers. The DON confirmed these interventions were already in place before Resident 9 fell on 1/22/2021, and the IDT did not develop new interventions. The DON also acknowledged that encouraging and/or providing reminders were not appropriate interventions to prevent future falls for Resident 9 because her cognition was impaired. The facility's policy titled Falls Management Program, revised 1/2019, indicated The Interdisciplinary Team will reassess the risk factors contributing to falls and interventions to minimize recurrence of falls and injury during the initial, quarterly and annual assessment, post fall and when a significant change of condition is identified. The Interdisciplinary Team will review the appropriateness of the interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 9 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident 12's clinical record indicated the resident was admitted with a diagnosis of acute respiratory failure with hypoxia. Residents Affected - Few A review of Resident 12's physician order, dated 10/28/21, indicated Change humidifier bottle every week, every Sunday and as needed (PRN) when empty. During observations on 12/13/21 at 9:17 a.m. and on 9/14/21 at 1:10 p.m., Resident 12 was in bed, with oxygen at six LPM and no humidifier bottle connected to the oxygen concentrator. During a concurrent interview and record review on 12/15/21 at 10:40 a.m., the nurse supervisor (NS) reviewed Resident 12's physician order and confirmed the resident had an order for humidifier. During an interview on 12/16/21 at 12:50 p.m., the DON confirmed Resident 12 did not have an oxygen humidifier when she did her rounds on 12/15/21. Review of the facility's policy titled Oxygen Administration, dated 2/2014, indicated Steps in the Procedure: Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Based on observation, interview and record review, the facility failed to ensure two of 15 sampled residents (Residents 18 and 12) received humidified oxygen while on an oxygen concentrator (medical device that gives extra oxygen). This failure had the potential to affect the residents' health and well-being. Findings: 1. Review of Resident 18's clinical record indicated she was admitted with the diagnoses of acute respiratory failure with hypoxia (not enough oxygen in the blood), chronic pulmonary edema (condition caused by excess fluid in the lungs), and pleural effusion (build up of fluid between the tissues that line the lungs and chest). During an observation on 12/14/21 at 10:30 a.m., Resident 18 was lying in bed and receiving oxygen at two liters per minute (LPM, unit of measurement) per nasal cannula (NC, narrow, flexible plastic tubing used to deliver oxygen through the nostrils) via oxygen concentrator. The NC was not attached to the humidifier bottle (a bottle filled with water connected to the oxygen concentrator, to keep the nostrils moist). During an observation and concurrent interview with licensed vocational nurse C (LVN C) on 12/14/2021 at 10:35 a.m., LVN C confirmed the above observation and stated that the NC was not attached to the humidifier. LVN C immediately attached the NC to the humidifier bottle. During an interview with the director of nursing (DON) on 12/15/2021 at 3:00 p.m., the DON stated that staff should make sure oxygen concentrators are set up properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 10 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to document administration of controlled medications (medications controlled by the government because they may be abused or cause addiction) on the controlled medication accountability sheet (count sheet) for three residents (Residents 6, 11 and 16). This failure compromised the facility's ability to ensure accurate administration of medications. Findings: Review of Resident 11's controlled medication accountability sheet on 12/14/21, indicated the remaining count of Pregabalin (nerve pain medication) 50 milligrams (mg, unit dose of measurement) was 17, but the medication stock count was 16. During an interview with licensed vocational nurse C (LVN C) on 12/14/21 at 10:45 a.m., she stated she gave one dose of Pregabalin 50 mg around 10:00 a.m., today, but did not document it yet. The LVN stated she should have documented it right away. Review of Resident 16's controlled medication accountability sheet on 12/14/21, indicated the remaining count of Metronidazole (antibiotics) 500 mg was 20, but the medication stock count was 19. The controlled medication accountability sheet also indicated the remaining count of Vancomycin (antibiotics) 125 mg was 7, but the medication stock count was 6. During an interview with LVN D on 12/14/21 at 11:15 a.m., she stated she gave one dose of Metronidazole 500 mg and one dose of Vancomycin 125 mg that morning, but did not document yet. The LVN stated she should document when she administered the medications. Review of Resident 6's controlled medication accountability sheet on 12/14/21, indicated the remaining count of Testosterone (major sex hormone in male) 200 mg/milliliter (ml, unit dose of measurement) was 1, but the medication was not in the medication cart. During an interview with LVN D on 12/14/21 at 11:15 a.m., she stated she gave one dose of Testosterone 200 mg/ml this morning, but did not document it yet. The LVN stated she should document when she gave the medication. During an interview with the DON on 12/14/21 at 1:07 p.m., she confirmed the licensed nurses should document administration of controlled medications on the controlled medication accountability sheet when the medications are administered. Review of the facility's policy, Medication Storage in the Facility, Controlled Medication Storage, dated April 2008, indicated, a physical inventory of all controlled medication is documented on the controlled medication accountability record. Review of the facility's policy, Documentation of Medication Administration, revised April 2007, indicated Administration of medication must be documented immediately after it is given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 11 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 one of 15 sampled residents (Resident 50) had the appropriate indication for the use of Nuedexta (medication for pseudobulbar affect). This failure put the resident at risk for receiving unnecessary medication. Residents Affected - Few Findings: Review of Resident 50's clinical record indicated she had the diagnosis of unspecified psychosis (a mental disorder characterized by a disconnection from reality) and did not have the diagnosis of pseudobulbar affect (a nervous system disorder that causes inappropriate involuntary laughing and crying). Review of Resident 50's physician orders, dated 12/04/21, indicated Nuedexta 20-10 milligrams (mg, unit of dose measurement) by mouth two times a day for psychosis manifested by hallucination. During an interview and concurrent record review with the director of nursing (DON) on 12/15/21 at 2:56 p.m., Resident 50's Consultant pharmacist's medication regimen review, dated 10/6/21, indicated Clarify diagnosis for use of Nuedexta. This is only approved for pseudobulbar affect. The DON stated she was aware of the pharmacy consultant recommendation, and verified Nuedexta was approved for pseudobulbar affect, not for Psychosis. During an interview and concurrent record review with the DON on 12/15/21 at 2:56 p.m., Resident 50's physician orders, dated 12/4/21, indicated Psychological/psychiatric evaluation and treatment as needed. The DON confirmed there was no psychological/psychiatric evaluation. During an interview and concurrent record review with the DON on 12/15/21 at 2:56 p.m., she reviewed Resident 50's record and verified the resident was on Nuedexta 20-10 mg for Psychosis manifested by hallucination. The DON stated nurses used an inappropriate indication for Nuedexta. Review of the facility's policy, Medication administration, dated April 2008, indicated If a medication order seems to be unrelated to the resident's diagnosis or conditions, the nurse calls the provider pharmacy for clarification or contacts the prescriber for clarification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 12 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 one of 15 sampled residents (Resident 50) was free of unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when there was no documentation of monitoring for the specific target behavior of paranoid ideation. This failure resulted in lack of adequate behavior monitoring and had the potential for the resident to receive unnecessary psychotropic medications. Findings: Review of Resident 50's clinical record indicated she had the diagnosis of unspecified psychosis (a mental disorder characterized by a disconnection from reality). Review of Resident 50's physician orders, dated 12/4/21, indicated Risperidone [medication for mental/mood disorder] 0.5 milligrams [mg, unit of dose measurement] by mouth at bedtime for psychosis manifested by paranoid ideation. The orders also indicated, Monitor episodes of paranoid ideation and document number of episode(s) every shift. During an interview and concurrent record review with the director of nursing (DON) on 12/15/21 at 2:56 p.m., she reviewed Resident 50's record and confirmed there was no documentation of monitoring for the specific target behavior of paranoid ideation. The DON stated staff should monitor for specific target behavior not general behavior, and the resident's specific target behavior of paranoid ideation was seeing things outside of window. During an interview and concurrent record review with licensed vocational nurse C (LVN C) on 12/15/21 at 3:30 p.m., she reviewed Resident 50's record and confirmed there was no documentation of monitoring for the specific target behavior of paranoid ideation. LVN C stated the specific target behavior of paranoid ideation was someone will hurt her. During an interview and concurrent record review with registered nurse E (RN E) on 12/15/21 at 3:35 p.m., she reviewed Resident 50's record and confirmed there was no documentation of monitoring for the specific target behavior of paranoid ideation. RN E stated the specific target behavior of paranoid ideation was not taking care of her, seeing abnormal things, someone hurting her. During an interview with certified nursing assistant F (CNA F) on 12/15/21 at 3:45 p.m., she stated she was not aware of the resident taking psychotropic medication and was not monitoring any behavior. Review of the facility's policy, Antipsychotic Medication Use, revised December 2016, indicated Staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 13 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 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. Based on observation, interview and record review, the facility failed to ensure: Residents Affected - Few 1. Five expired medications were properly discarded and not stored in the medication cart and/or the medication refrigerator and, 2. Safe storage of medications for two of two treatment carts. These deficient practices had the potential for unsafe and ineffective use of medications being used past the expiration date and risk the misuse of medications because they were unlabeled or improperly labeled. Findings: 1. During a concurrent medication refrigerator inspection for Station J and interview with the director of nursing (DON) on 12/13/21 at 3:45 p.m., the surveyor observed one opened Afluria Quadrivalent (influenza vaccine) 5ml multi dose vial (about half dose remaining) with no open date. The included full prescribing information for the medication indicated, Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. The DON verified there was no open date and no proof that the medication was not expired. The DON stated she would consider it as expired. During a concurrent medication cart inspection for Station J and interview with the DON on 12/13/21 at 3:50 p.m., the surveyor observed one Rhopressa ophthalmic (medication for eye disorder) 0.02 % solution without an open date, which was filled on 10/31/21. The DON stated the medication expires six weeks after opening, per the facility pharmacy. The DON verified there was no open date and no proof that the medication was not expired. The DON stated the medication was expired, and licensed nurses should date when they opened it. During a concurrent medication cart inspection for Station J and interview with the DON on 12/13/21 at 3:55 p.m., the surveyor observed one Latanoprost ophthalmic (medication for eye disorder) 0.005 % solution without an open date, which was filled on 10/31/21 and indicated discard 42 days after opening on the pharmacy sticker attached to the vial. The DON verified there was no open date and no proof that the medication was not expired. The DON stated the medication was expired, and licensed nurses should date when they opened it. During a concurrent medication cart inspection for Station J and interview with the DON on 12/13/21 at 4:00 p.m., the surveyor observed one Ipratropium Bromide and Albuterol sulfate (medication to open the air passages) 0.5-3 mg/3 ml vial in an open foil pouch without an open date, which was filled on 10/22/21, and indicated Once removed from the foil pouch, the individual vials should be used within two weeks on the box. The DON verified there was no open date and no proof that the medication was not expired. The DON stated the medication was expired, and licensed nurses should date when they opened it. During a concurrent medication cart inspection for Station K and interview with licensed vocational nurse C (LVN C) on 12/14/21 at 10:41 a.m., the surveyor observed one Ipratropium Bromide and Albuterol sulfate 0.5-3 mg/3 ml vial in an open foil pouch without an open date, which was filled on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 14 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 11/25/21, and indicated Once removed from the foil pouch, the individual vials should be used within two weeks on the box. LVN C verified there was no open date and no proof that the medication was not expired. LVN C stated she did not know the open date and the medication was expired. Review of the facility's policy, Medication Storage in the Facility, dated April 2008 indicated,Outdated, contaminated, or deteriorated medications are immediately removed from stock. 2. During an observation on 12/15/21 at 11:12 a.m., there was an unlabeled tube of Nystatin cream (a topical ointment for fungal infections) in treatment cart #1. During a concurrent observation and interview on 12/16/21 at 10:35 a.m., there was an unlabeled tube of Lidocaine cream (a topical ointment to numb the skin) in treatment cart #2. The tube of Lidocaine cream also had an expiration date of 11/2021. The treatment nurse (TN) confirmed these observations. During an interview on 12/16/21 at 1:05 p.m., the DON stated medications that come from the pharmacy should all have labels. The DON also stated expired medications should be removed, and put in a locked room for disposal. Review of the facility's Labeling of Medication Containers policy, revised April 2007, indicated that labels for individual drug containers shall include all necessary information, such as: a. the resident's name; b. the prescribing physician's name; c. the name, address, and telephone number of the issuing pharmacy; d. the name, strength, and quantity of the drug; e. the prescription number (if applicable); f. the date that the medication was dispensed; g. appropriate accessory and cautionary statements; h. the expiration date when applicable; and i. directions of use. Review of the facility's Storage of Medications policy, dated April 2008, indicated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 15 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 document review, the facility failed to store and prepare food under sanitary conditions when: Residents Affected - Many 1. There was outdated food in the kitchen refrigerator; 2. There was water leaking from a ceiling vent onto the kitchen freezer; 3. There was a brown substance inside the ice machine; and 4. Dietary staff used expired test strips and improper technique when testing the kitchen surface sanitizer (solution used to kill microorganisms on kitchen surfaces). These failures had the potential to result in foodborne illness (illness resulting from contaminated food) throughout the facility. Findings: 1. During an observation on 12/13/2021 at 8:58 a.m., there was a plastic container of strawberries in one of the kitchen refrigerators. The container was labeled, Use by 12/11. During a concurrent interview with [NAME] A, she confirmed the strawberries in the refrigerator were outdated. The facility's 2018 document, titled Produce Storage Guidelines, indicated strawberries can be stored in the refrigerator for two to three days. 2. During an observation on 12/13/2021 at 9:00 a.m., there was water dripping from a ceiling vent onto one of the kitchen freezers. When the freezer door was open, the water dripped in front of, and into the freezer. During a concurrent interview with [NAME] A, she confirmed the above observation. [NAME] A stated the vent was leaking water onto the freezer because it was raining outside. The facility's policy titled Food Receiving and Storage, revised 10/2017, indicated Food shall be received and stored in a manner that complies with safe food handling practices. The U.S. Food & Drug Administration's 2017 Food Code indicated, Food equipment and the food that contacts the equipment must be protected from sources of overhead contamination such as leaking or ruptured water or sewer pipes, dripping condensate, and falling objects. When equipment is installed, it must be situated with consideration of the potential for contamination from such overhead sources. 3. During an observation on 12/14/2021 at 8:49 a.m., there was a brown substance on the inside of the ice machine, right above the compartment where the ice was stored. The brown substance was near the part of the machine that dropped the ice into the storage compartment. There were also water droplets around the area of the brown substance, which had the potential to drop onto the ice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 16 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 During a concurrent interview with the maintenance director (MD), he confirmed there was a brown substance on the inside of the ice machine. The U.S. Food & Drug Administration's 2017 Food Code indicates that equipment, including ice makers, shall be clean to sight and touch. Residents Affected - Many 4. During an observation on 12/14/2021 at 9:27 a.m., [NAME] A tested the kitchen surface sanitizer. [NAME] A emptied a red bucket and filled it with new sanitizer solution. Without checking the temperature of the sanitizer solution, [NAME] A took a test strip from its container and dipped it in the red bucket. She then checked if the test strip changed to the appropriate color. The test strip container indicated the test strips expired on 11/15/2018 (more than three years prior to this observation). During a concurrent interview with the dietary manager (DM), the DM confirmed the test strips [NAME] A used were expired. The DM also acknowledged that [NAME] A should have checked the temperature of the sanitizer solution to ensure it was within the correct parameters for testing. The DM checked the temperature of the sanitizer solution and stated the temperature was 64 degrees Fahrenheit (F, unit of temperature measurement). The facility's undated instructions for testing the kitchen surface sanitizer, which were posted on the wall in the kitchen, indicated the temperature of the testing solution should be between 65 and 75 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 17 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 implement infection control practices when: Residents Affected - Some 1. Certified nursing assistant L (CNA L) did not perform the COVID-19 (infectious disease caused by SARS-Cov-2 virus) healthcare professional screening prior to entering the facility; 2. The housekeeper (HK) and CNA J did not perform hand hygiene in between tasks; 3. The treatment nurse (TN) did not perform hand hygiene in between tasks and practiced double gloving (wearing of inner and outer gloves) during wound care; and 4. The business office manager (BOM) did not perform the COVID-19 screening assessment prior to entering the facility. These failures had the potential to compromise resident's health and safety in the facility. Findings: 1. During an observation and interview on 12/13/2021 at 8:55 a.m., while in the facility's lobby, CNA L went inside the facility, checked his temperature, but did not perform the employee COVID-19 screening prior to entering the facility. CNA L said he started orientation 3 days ago. During an interview and record review with the front desk receptionist (FDR) on 12/15/2021 at 9:24 a.m., she stated that CNA L was in-serviced (trained) on 12/13/2021 to perform the COVID-19 symptoms self-check before entering the facility. The surveyor reviewed the healthcare/visitor screening log for 12/6/2021, 12/8/2021 and 12/10/2021, and did not see evidence of documentation. During an interview with Infection Preventionist (IP) on 12/16/2021 at 9:00 a.m., the IP stated employees and visitors should self-screen before entering the facility. She further stated the facility will improve on orienting new staff members on screening procedures. 2a. During an observation on 12/13/21 at 10:17 a.m., the HK exited one resident room after cleaning it. The HK did not perform hand hygiene. The HK then entered another resident room and started cleaning the overbed tables, bedside drawers, and bed frames without wearing gloves. The HK then put on a pair of gloves prior to entering the bathroom and started cleaning. During an observation on 12/13/21 at 10:23 a.m., the HK removed her gloves after cleaning the bathroom, and did not perform hand hygiene. The HK stepped out into the hallway, grabbed the floor mop, then went into a resident room and started mopping the floor. During an interview on 12/13/21 at 10:52 a.m., the HK confirmed she should have washed her hands before leaving the resident room, before wearing gloves, and after removing gloves. During an interview on 12/17/21 at 10:03 a.m., the IP stated housekeepers should be wearing gloves when cleaning residents' rooms and bathrooms. The IP added that housekeepers should perform hand hygiene before wearing and upon removal of gloves and when touching dirty to clean surfaces. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 18 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 Review of the facility's policy and procedure titled Handwashing/Hand Hygiene, dated August 2015, indicated All personnel shall follow the handwashing/hand hygiene procedures to help prevent spread of infections to other personnel, residents, and visitors. 2b. During an observation on 12/14/21 at 9:58 a.m., CNA J was performing a bed bath and incontinent care (cleansing areas between thighs to buttocks) for Resident 35 after the resident had a bowel movement (BM). Using only one pair of gloves, CNA J cleansed Resident 35's perineal area (area between thighs to buttocks) with a wet washcloth, turned the resident to the left side, touched the bed control to adjust the bed's height level, went to the resident's bathroom by touching the doorknob, took a roll of toilet paper to wipe Resident 35's buttocks and remove the BM, and wiped resident's upper back with another wet washcloth. Still using the same pair of gloves, CNA J touched the overbed table and applied a clean pad under the resident. CNA J then removed the gloves, and put on a new pair of gloves without performing hand hygiene. During an interview on 12/14/21 at 10:33 a.m., CNA J confirmed touching the bed remote and bathroom doorknob with dirty gloves. CNA J stated she should have performed hand hygiene during Resident 35's bed bath and incontinent care. Review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated August 2015, indicated 7. Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care; 3. During an observation on 12/14/21 at 9:24 a.m., the TN performed a wound treatment in a resident's room, then went out of the room. The TN did not sanitize the scissors and Sharpie pen she used during the wound treatment. She went straight to Resident 35's room. During an observation on 12/14/21 at 10:06 a.m., the TN was performing wound care to Resident 35's sacrum (tailbone area) pressure ulcer (PU, wound caused by pressure). The TN used only one pair of gloves when removing the old/dirty foam dressing, cleansing the wound, picking up scissors from her pants side pocket to cut a piece of silver alginate (a dressing with antimicrobial, use to absorb some drainage), and applying a clean foam dressing to the PU. The TN used the same gloves to apply lotrisone cream (a cream used to treat rashes) to Resident 35's back and neck. The TN removed her right hand glove, replaced it with a new one, touched the bedside drawer to look for a face towel, changed the right hand glove to help reposition resident, then removed both gloves. Without performing hand hygiene, the TN went out of Resident 35's room to get a clean face towel in the linen room. The TN rolled the face towel and applied it to Resident 35's right hand. Without performing hand hygiene, the TN put on a new pair of gloves, took Sani Wipes (wipes used to clean and sanitize surfaces, equipment, etc), started wiping a bottle of Dakin's solution (a liquid solution used to cleanse wounds), a bottle of normal saline, a pair of scissors, and the top of the treatment cart. She then removed her gloves and starting documenting on the laptop, without performing hand hygiene. During an interview on 12/14/21 at 10:18 a.m., the TN stated she used double gloves, but she should have removed her old gloves and performed hand hygiene in between tasks and when touching surfaces. The TN confirmed not sanitizing the pair of scissors and Sharpie pen used during wound treatment. During an interview on 12/17/21 at 10:03 a.m., the IP stated nursing staff and CNAs should perform hand hygiene before donning (putting on) and after doffing (removing) gloves, and when touching dirty to clean surfaces. The IP stated nurses should sanitize materials brought and used inside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 19 of 20 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 055517 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032 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 residents' rooms, like scissors, Sharpie pens, etc. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy and procedure titled Handwashing/Hand Hygiene, dated August 2015, indicated 7. Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: f. Before donning sterile gloves; g. Before handling clean or soiled dressings, gauze pads, etc.; k. After handling used dressings, contaminated equipment, etc. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare- associated infections. Residents Affected - Some 4. During an observation on 12/13/21 at 8:43 a.m., in the facility lobby, the BOM entered the facility without performing COVID-19 screening and started helping to clean up. Review of the facility's Healthcare Professional Screening Log, dated 12/13/21, indicated the BOM was screened on 12/13/21 at 8:51 a.m. During an interview on 12/14/21 at 11:00 a.m., the BOM confirmed the above observation. During an interview on 12/16/21 at 1:05 p.m., the DON stated all staff should answer the screening questions and check their temperature before they start working. Review of the facility's COVID-19 Visitation Policy, revised 8/12/2021, indicated one of the core principles of COVID-19 infection prevention is, Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions about and observations about signs and symptoms), and denial of entry of those with signs or symptoms or those who have had close contact with someone with COVID-19 infection in the prior 14 days (regardless of the visitor's vaccination status). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055517 If continuation sheet Page 20 of 20