Health inspection·August 17, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of one of 3 residents (Resident 1) when Resident 1 did not receive her Hydromorphone (a potent controlled medication for pain) Hydrochloride (HCL - acid salt mixed in the medication) in timely manner as prescribed by the physician. This failure had the potential to result in unnecessary pain. Findings: Review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility with diagnoses including aftercare following joint replacement surgery, presence of left artificial knee joint, other chronic pain and dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling). Review of Resident 1's clinical record titled, Order Summary Report, dated 05/17/2023, indicated, HYDROmorphone HCL Oral Tablet 2 MG (milligrams - unit of measurement) Give 4 mg by mouth every 3 hours as needed for severe pain 7-10. The medication was ordered on 5/14/2023. Review of Resident 1's admission Note, dated 5/14/2023, it indicated Resident 1 was admitted on [DATE] at 1:49 p.m. Review of Resident 1's clinical record titled, Progress Notes, dated 5/15/2023, it indicated Resident 1 complained of pain at 12 midnight, but her medications were not delivered yet. The licensed vocational nurse A (LVN A) assigned to Resident 1, called the facility's pharmacy to obtain the Cubex code (authorization provided by the pharmacist) to get the Hydromorphone HCL from the Cubex (automated dispensing cabinet for medication supply) machine. When LVN A spoke to someone at the facility's pharmacy, he was told they were on lunch break. LVN A tried to call after 10 minutes but nobody answered his call. Further review of the progress note indicated Resident 1 called 911 at around 2:30 a.m. due to severe pain and medications were still not available. During a phone interview with LVN A on 8/17/2023 at 1:50 p.m., LVN A stated when Resident 1 complained of pain, he tried to offer Tylenol (Brand name of acetaminophen - non-narcotic pain reliever) but Resident 1 refused. LVN A further stated he called the facility's pharmacy several times to get the Cubex code but phamacy staff were on their lunch break. LVN A confirmed Resident 1 called 911 due to severe pain. LVN A stated he finally got the Cubex code at 3:00 a.m. (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 2 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 08/17/2023 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)