Health inspection·April 5, 2023

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. Based on observation, interview and record review, the facility failed to implement their Policies and Procedures (P&P) related to administering and storage of medications. Upon a random, initial tour round, a medicine cup with six pills was observed on Resident's 2 overbed table while he was asleep. In addition, a opened bottle of Acetaminophen (Tylenol, a pain medication) was on top of a medication cart with no nursing staff nearby and a resident sitting near the medication cart. These failures had the potential to cause harm by allowing other residents the opportunity to access unattended medications. Findings: 1. On 4/5/2023 at 9:25 a.m., during initial tour rounds, two clear medicine cups were observed on Resident 2's overbed table while he had his eyes closed. One medicine cup had six different color medications in it and one medicine cup had a small amount of white fluid in it. At 9:29 a.m., RN A entered the room and told Resident 2 she needed to take his blood pressure. When she was asked the reason Resident 2's medications where left unattended on his overbed table, she stated the resident was in the shower when she placed the medication cups on his overbed table. RN A stated the medications should have not been left on Resident 2's overbed table if he was not available to administer the medications. Clinical record review for Resident 2 was initiated on 4/5/2023. Resident 2 was admitted to the facility with diagnoses including Metabolic Encephalopathy (damage or disease that affects the brain) and Dysphagia (swallowing difficulty). Review of Resident 2's Minimum Data Set (MDS, an assessment tool) dated 2/17/2023 showed a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). Review of Resident 2's physician orders from 2/12/2023 - 4/5/2023, showed no order to leave his medications at his bedside. Review of Resident 2's care plan problems indicated the following: a. impaired swallowing related to dysphagia (revised date 2/12/2023); b. altered thought process related to short term memory problem-cannot recall after 5 minutes and periods of forgetfulness (revised date 2/21/2023); and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055517 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 04/05/2023 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)